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ODs with proper training, legislation can implement their suturing skills
While practice scope legislation in a number of states bars optometrists from performing surgical procedures in which sutures are required, many optometrists have sufficient education and skill to suture effectively.
“I don’t see any reason why optometrists should not be able to perform these procedures. Optometrists have the appropriate training in the anatomy and the necessary skills to do the procedure,” said Cliff Caudill, OD, a practitioner in Chattanooga, Tenn. “But they need to have that training in their schools first. Currently, some schools have injectables courses. This way, when the scope of practice changes, these optometrists will have that option.”
In Tennessee, Dr. Caudill is not permitted to suture without the supervision of an MD. But Oklahoma, where he received his training, allows the use of injectables and anesthetics. “So in that state, optometrists are allowed to suture,” he said.
When to suture
Dr. Caudill said the decision of whether to suture a patient with a lid laceration depends largely on the length and depth of the laceration.
“If the laceration is just on the epidermis, sometimes a butterfly bandage will do fine,” he said. “But if it has penetrated the dermis, then you will have to suture it together or it will not come together properly, and it will leave a severe scar.”
Sutures would also be warranted after chalazion removal or the removal of any other kind of lesion, such as a large papilloma, Dr. Caudill said.
Tammy Than, OD, FAAO, a professor at the University of Alabama, Birmingham, agreed with Dr. Caudill. “In general, the purpose of suturing is to bring about skin apposition while the tissue is healing,” she said. “Optometric physicians would use them following the removal of a large flat-based papilloma or other skin lesion, after chalazion incision and curettage if performed using a transcutaneous approach, and for lid laceration.”
The suturing process
Most optometric applications require only a few simple or interrupted sutures, according to Dr. Than.
The first step is to anesthetize the lid, using either lidocaine 1% or 2%, she said. “The lidocaine may come with or without 1:100,000 epinephrine,” she said. “This epinephrine causes vasoconstriction, which increases the duration of action, minimizes side effects and reduces bleeding.”
Dr. Caudill also uses lidocaine with epinephrine to anesthetize the eye. “I would anesthetize with a subcutaneous infiltrative injection,” he said. “So, basically, I would use the lidocaine with epinephrine to control bleeding.”
The type of suture material used would largely depend upon the type of laceration involved, Dr. Caudill said.
“If the laceration is very deep and you have to close the dermis first, then you have to use the dissolvable suture, because you can’t go back in and remove the suture once you have stitched over top of that,” he said. “But, in most cases, you can choose between a dissolvable and non-dissolvable type, usually 5-0 to 6-0 is appropriate.”
Dr. Than said sutures are made of either absorbable or non-absorbable materials. “Non-absorbable materials are often used, and common materials include nylon (polyamide), prolene (polypropylene) and silk,” she said. “Sutures for periocular skin applications are usually 6-0.”
Kathy Yang-Williams, OD, FAAO, of Northwest Eye Surgeons, said that for superficial lid lacerations, she would generally use a dissolvable suture material. “I would use a material like vicryl,” she said. “These sutures generally dissolve in 1 to 2 weeks.”
Suturing privileges
Because few states permit optometrists to use anesthetics and injectables, suturing is not a part of daily practice for a majority of optometrists.
“A few states allow it,” Dr. Caudill said. “But, currently, I would say that the percentage of optometrists suturing and using injectable anesthetics is extremely low.”
Dr. Williams said in addition to performing chalazion removal and lesion excision, optometrists in these authorized states would also be involved in suture removal after procedures such as penetrating keratoplasty or trabeculectomy.
Dr. Caudill believes that optometrists with adequate training and the desire to perform these procedures should be permitted to do so. “I think it is reasonable, with proper training, like anything else,” he said. “It is especially valuable in rural practices. If a patient comes in and needs to have a chalazion excised, he or she shouldn’t have to drive 100 miles to go see the ophthalmologist.”
For Your Information:
- Cliff Caudill, OD, can be reached at 1807 Taft Highway, Suite 9, Signal Mountain, TN 37377; (423) 886-7252.
- Tammy Than, OD, FAAO, can be reached at 1716 University Blvd., Birmingham, AL 35294-0010; (205) 975-5235; fax: (205) 934-6758.
- Kathy Yang-Williams, OD, FAAO, can be reached at 10330 Meridian Avenue N., Suite 303, Seattle, WA 98133; (206) 528-6000; fax: (206) 528-0014.