‘Optometrists should not be performing invasive surgery’

Issue: December 2004

ByLouis J. Catania, OD, FAAO

Louis J. Catania [photo]
Louis J. Catania

Somebody in optometry has to say this, even though it may wind up costing some friendships and, for sure, causing some heated exchanges. But I guess I’m old enough to deal with that, and I’m certainly experienced enough in the “game” of clinical care and professional politics to know when enough is enough.

I believe optometry should neither be performing invasive surgery nor legislating to obtain the authority to do it. Please understand, I’m talking about “real” eye surgery, not primary care procedures such as corneal foreign body removal, punctal plugs, epilation, draining a cyst and those types of things. As long as we’re not playing political games, we all know what real eye surgery is. It’s intraocular procedures, invasive lasers and, I guess, most current forms of refractive surgery.

Let’s not lay blame on states like Oklahoma and others that are embroiled in political battles to protect optometry’s rights to continue to provide primary care procedures that might fall under “surgical” codes. But let’s not allow those noble efforts to lead us into faulty strategies to legislatively obtain invasive surgery privileges. That would be an injustice to our profession, to the public health and — for what it’s worth — towards any hope of a better working relationship with ophthalmic surgeons and the medical community at large. I personally believe such relationships are important, not necessarily for our profession but simply for our ability to do a better job for our patients.

The view of political bodies?

I believe my views represent the feelings of the vast majority of practicing ODs, if not the political bodies that represent us. As this whole issue heats up to the boiling point and “lines begin to be drawn in the sand,” ODs are going to have to stand up and be counted for what they see as the future of our profession.

For many reasons, some good and some not so good, our political representatives will probably hang back and wait for a vocal majority to speak. If that majority speaks up, I believe (as I’ve said) it will not support invasive surgery as part of optometry’s future. And that position by no means is a compromise or a step backward. Rather, I believe that some of our colleagues’ and academic institutions’ obsession with medical eye care and surgery have caused our profession to fall behind as new vision technologies such as wavefront aberrometry and nonsurgical, higher-order correcting devices are exploding in the field. That void being created by optometry’s fading interest in vision care is not going unnoticed. The hottest area in ophthalmology is rapidly becoming vision care – both surgical and nonsurgical.

There’s something askew when we make vision care a secondary issue in optometry while most of our patients view us as the vision care specialist in the health care system. Our expansion into primary medical eye care should never have changed our emphasis, but it has. Now, it seems we may face the risk of further distraction from what people need and want from us: vision care and primary medical eye care.

Unique training required

Let’s face the facts. Invasive surgery for optometry is wrong for many reasons. First and foremost, procedurally oriented care such as invasive surgery and the management of its associated complications requires a unique educational process and philosophy that no optometric academic institution or training program provides.

Furthermore, the only way you become competent in a procedurally oriented skill such as invasive surgery is to do lots of it. No optometric training program currently nor for the foreseeable future will be able to provide adequate numbers to produce a competent optometric surgeon. The best we could hope for as a profession would be to turn out mediocre surgeons. Is that what we really want as our future or our legacy? Indeed, is that the kind of surgeon to whom you would refer a patient? Is that the kind of professional you would want to do surgery on you or your loved ones?

No need for more surgeons

My second point: the last thing our health care system needs is more eye surgeons. If we’re willing to honestly think about the global picture and what is best for the future of the public health, surgery is the last thing a nonsurgical profession should be moving towards.

Indeed, a more aggressive approach — educationally and practically — towards the increased use of technology and trained ancillary personnel is what the future of health care and optometry needs. It is technology and appropriate use of health professionals and technical personnel that will most effectively address the health care needs of our youth and aging population over the coming decades.

Not worth the risk

My third point is one of which many ODs may not be aware. Unless you are a fairly high-volume surgeon who owns your own surgery center (an unlikely scenario for most optometrists), the financial return and time:benefit ratio is far better in vision care and dispensing glasses and contact lenses (and the risk:benefit ratio far less) than in eye surgery – maybe not as glamorous, but we’re just trying to look at the facts. No wonder so many ophthalmologists are introducing and expanding dispensaries in their practices.

Optometry: a nonsurgical profession

And finally, call it philosophy, psychology or just plain reality, but optometry is the nonsurgical eye care profession. Our expansion into pharmaceuticals (with appropriate education and a demonstrated need) did in fact change our “drugless” heritage, but not our general philosophy, psychology and reality as a primary care giver and point-of-entry provider. Invasive surgery changes all of that. It moves us from our primary role into a secondary provider category. And that category is already oversupplied in eye care by ophthalmology.

The bottom line is evident. If optometry does indeed want to move into invasive surgery, there just isn’t enough room. So the real question becomes: “Does optometry want to replace or take over ophthalmology?” If so, OK. But let’s have our political leaders tell us that and let’s democratically decide if that is what the profession wants. I personally cannot believe that a majority of optometrists think that is realistic or good for anybody — optometry, ophthalmology and, mostly, our patients.

Do MDs recognize the logic?

Now, a final word about ophthalmology. The logic I have tried to articulate in this discussion is not rocket science. Anyone in the health professions understands this, and, hopefully, a majority of my profession will agree. I also believe our colleagues in ophthalmology also recognize this logic and have enough respect for optometrists’ motives, if not our intelligence, to know that a majority of educated optometrists feel similarly.

If my premise is correct, that is, ophthalmology respecting the motives and intelligence of the vast majority of our profession, then I have a question and a dilemma. How can ophthalmology (its political organizations and an apparent majority of its practitioners) be so narrow-minded, mistrustful and unreasonable to proceed to stereotype our entire profession on the basis of an infinitesimally small number of ODs that may want to do invasive surgery? How can ophthalmology be so unfair, shameless and arrogant to withhold their education from optometrists (and the patients we serve) to support their undocumented, unsubstantiated and paranoid fears about what they have errantly concluded to be optometry’s goals?

I’ve risked this discussion because, sadly, I see it as a dilemma. Any use of the thoughts I have shared here by ophthalmology against the profession of optometry deserves about as much respect as ophthalmology’s fear that optometry would use attendance at their educational meetings to defend an expansion into invasive surgery. But such aberrant thinking seems to be reducing this sad state of affairs down to a dilemma. Is there no room left for respect, reason and some trust between two professions whose goals should be mutually beneficial to themselves and to their patients?

We can only hope some common sense on both sides might lead to reasonable discussion and help resolve this dilemma.

For Your Information:

Louis J. Catania, OD, FAAO, is a member of the Editorial Board of Primary Care Optometry News. He can be reached at Nicolitz Eye Consultants, 1235 San Marco Blvd., Suite 301, Jacksonville, FL 32207; (904) 398-2720; fax: (904) 398-6408; e-mail: lcatania@bellsouth.net.