Oklahoma ODs welcome back their laser privileges

Issue: June 1998

TULSA, Okla. - One month after Gov. Frank Keating (R) signed legislation that restored optometry's right to perform certain laser procedures, the Board of Examiners of Optometry prepared to review its current laser credentialing process and ophthalmology began looking for ways to challenge the new law.

Senate Bill 1192 was signed March 16 and goes into effect Nov. 1. Oklahoma ODs who complete certification through the Board of Examiners of Optometry are permitted to perform laser surgery including, but not limited to, Nd:YAG capsulotomy, argon laser trabeculoplasty and photorefractive keratectomy (PRK).

The bill prohibits the state's 480 licensed optometrists from performing laser in situ keratomileusis, retina surgery and cosmetic lid surgery.

Restoration of rights

SB 1192 does not represent a brand new privilege, however. Before a judge ruled last July that the Oklahoma Board of Examiners of Optometry did not have the authority to grant ODs laser privileges, some optometrists had been performing certain anterior segment laser procedures for nearly 10 years.

"There were thousands of procedures performed during this period, and not one complaint was made against an optometrist performing a laser procedure," said Jack W. Melton, OD, president of LExES Panel of Doctors here. "Many of these procedures were performed in rural Oklahoma, where optometry was the primary care provider of eye health and vision services."

The issue of ODs using lasers gained more attention with the development and introduction of the excimer laser in the early 1990s, and soon the state medical board in Oklahoma challenged the authority of the Board of Examiners of Optometry through a lawsuit.

Following the judge's ruling last July, Oklahoma's optometrists decided to answer by going directly to legislators with a bill to reinstate their laser privileges. ODs here also had the support of thousands of patients, according to state optometry leaders, who called and faxed the governor's office in favor of SB 1192.

In the meantime, the demographics of Oklahoma continued to favor optometrists as primary eye care providers. Oklahoma has a population of approximately 3.2 million people: 1.2 million live in the two largest cities, Oklahoma City and Tulsa, and the remaining 2 million residents are spread throughout the Midwestern state.

Optometrists practice in 73 of the 77 Oklahoma counties. The state's 155 ophthalmologists practice in 23 counties and are clustered in Oklahoma City and Tulsa. In this state, optometrists outnumber ophthalmologists three to one.

Steve Carter, vice president of advocacy for the American Academy of Ophthalmology (AAO), said the AAO disagrees with SB 1192 and will attack it through a referendum, through regulation and possibly through litigation.

"We intend to do whatever we can do to see that it is not implemented," Mr. Carter said. "If you choose to have elective surgery performed, it's not difficult to find an ophthalmologist. For something as potentially dangerous as surgery on your eyes, it doesn't have to be somebody in your hometown, and you shouldn't go to someone who's not qualified simply for convenience."

Thomas E. Eichhorst, director of the state government relations center at the American Optometric Association, said optometry's conservative and conscientious track record in the use of diagnostic and therapeutic agents served the profession well with regard to lasers. is a tremendous credit to optometrists in Oklahoma that the legislators restored their privilege to use lasers for certain procedures," Mr. Eichhorst said.

Ophthalmology filed suits challenging the constitutionality of the first diagnostic pharmaceutical agent law (Rhode Island) and the first therapeutic pharmaceutical agent law (West Virginia), but both laws were upheld. "If ophthalmology now attacks the Oklahoma laser law, its efforts are doomed to fail," said Mr. Eichhorst, "as optometrists throughout the country will again rally to defend optometry law advances."

Excimer experience

David Eldridge, OD, is one of only two optometrists in Oklahoma who have performed excimer laser procedures. He and Jeff Miller, OD, performed PRK procedures from December 1996 to July 1997.

Both Drs. Eldridge and Miller completed the training, protocol and mini-fellowship program established by the Board of Examiners of Optometry to use the excimer laser. Both were also proctored and certified by Visx trainers before performing PRK on their own patients.

"Those cases went perfectly, and we had very happy patients," said Dr. Eldridge, executive vice president of TLC The Laser Center, the largest provider of laser vision correction with 45 centers in North America. Dr. Eldridge said he will continue performing PRK following the legislative victory.

Dr. Miller, center director at TLC Tulsa, said, "I'm obviously ecstatic about the legislation. I performed PRK procedures prior to receiving the order from the board that the judgment from the lawsuit was not in our favor. I was, however, very pleased with the results of these procedures."

Most of the laser procedures Dr. Miller and other ODs here have performed were not refractive in nature; the procedures were designed for therapeutic purposes to preserve a patient's vision. "I have personally done hundreds of argon and YAG procedures including capsulotomies, iridoplasties, peripheral iridotomies and laser trabeculoplasties," he said.

Like Dr. Eldridge, Dr. Miller plans to continue performing these procedures in addition to excimer laser procedures.

Perhaps the most convincing argument Oklahoma ODs presented to state legislators, Dr. Eldridge said, was the fact that optometrists had been performing laser procedures for nearly a decade before the judge's ruling.

"Why should patients in small towns have to see a doctor they don't know who is an hour away when their doctor has been providing that service for almost a decade?" Dr. Eldridge said. "It was not a hypothetical issue or abstract idea - optometrists had performed laser procedures for the past 8 years."

MD-OD relationships

While it may be difficult to gauge how the new law will affect OD-MD relationships, Dr. Melton believes they will maintain what has been a good relationship between the two professions. "We work closely together, but when it came down to this issue, I know there was a division of what people felt was right," he said.

Dr. Melton plans on becoming credentialed to use the excimer laser. "I think the majority of optometrists will probably go through the certification, but, realistically, a smaller group will actually become active in performing laser procedures," he said. "For example, we have 10 ophthalmologists at our center, but only four of them perform the majority of procedures."

The bottom line, Dr. Melton said, is that "optometry, just like medicine, is not going to do anything it doesn't feel 100% comfortable doing."

At his laser center in Tulsa, Dr. Miller said his relationship with the 13 active surgeons at the facility has not changed. "Most of them stayed neutral on this issue," he said. "Obviously, there is a group of ophthalmologists who feel very strongly about this, but it is typically a group that does not comanage or work with optometrists, nor understands their training."

Credentialing to be reviewed

David Cockrell, OD, vice president of the Board of Examiners of Optometry in Oklahoma, said the board will re-evaluate credentialing requirements in light of SB 1192. "Any optometrist who is already credentialed for these procedures won't have to be recredentialed," he said. "The court ruling in 1997 addressed only the board's right to grant that certification. It did not invalidate the certification."

The credentialing process currently in place represent two sets of requirements, Dr. Cockrell explained, one for performing anterior segment procedures and another for performing excimer laser procedures. The board will re-evaluate both sets of requirements so any changes made are in place and published before the law takes effect Nov. 1.

Current guidelines require optometrists who wish to apply for laser privileges to hold an Oklahoma license to practice optometry, pass national boards before sitting for the Oklahoma board, demonstrate they have received training in lasers and pass both a written and clinical exam demonstrating use of individual laser procedures.

For Your Information:

Correspondent Ryan DuBosar contributed to this article.

Steve Carter can be reached at the American Academy of Ophthalmology, P.O. Box 7424, San Francisco, CA 94120-7424; (415) 561-8500.

David Cockrell, OD, can be reached at 1711 West 6th St., Stillwater, OK 74076; (405) 372-1715.

Thomas E. Eichhorst can be reached at the American Optometric Assoc., 243 N. Lindbergh Blvd., St. Louis, MO 63141; (314) 991-4100.

David Eldridge, OD, and Jeff Miller, OD, can be reached at TLC Tulsa, 1323 E. 71st St., Ste. 210, Tulsa, OK 74136; (918) 491-6009. Dr. Eldridge is executive vice president of TLC The Laser Center Inc. Dr. Miller is center director at TLC Tulsa.

Jack W. Melton, OD, president, LExES Panel of Doctors, can be reached at 1800 Canyon Park Circle, Ste. 303, Edmond, OK 73103; (405) 330-2360.