ODs provide better care with the use of injections, despite resistance

In the ongoing legislative struggle to reach an appropriate optometric scope of practice, injection privileges have all too often become a casualty of political compromise, according to private practitioner Christopher Quinn, OD.

“Optometry has been prescribing medications for many years now, and as part of political compromise to pass legislation expanding scope of practice, we’ve often traded away the ability to administer medications via any route of delivery,” Quinn, an American Optometric Association trustee, told Primary Care Optometry News. “So, because in years past there were very few ophthalmic medications that were administered by injection, the compromise was to give up injections in favor of other privileges that were more relevant to daily optometric practice.”

Since then, the political landscape may not have changed dramatically, but the therapeutic landscape has. With many important medications now best administered through an injectable route, injectable privileges have become a legitimate need for modern patient care. Yet currently, only 13 of the 50 states allow optometrists to administer therapeutic injections to patients.

“It’s strange; optometry is pretty unique in that we’ve battled for diagnostic drugs and then therapeutic drugs, which is, in itself, an artificial distinction. We’ve compromised on classes of drugs,” Quinn said, “and ultimately, now, use of medications in optometric practice is being further parsed by the route of administration, which is, again, an artificial distinction.”

Types of injections

An optometric practice that aims to address a wide variety of ocular conditions has various scenarios in which injections are necessary for optimum patient care, according to David K. Talley, OD, a practitioner at West Tennessee Eye and past president of the Tennessee Association of Optometric Physicians.

“There are lots of reasons an optometrist would want to do injections,” he said in an interview with PCON. “The main reason is that some eye diseases simply will not respond to topical or ophthalmic eye medications or orals. In such cases, the appropriate standard of care would be to treat that eye disease through the use of injectable medications.”

The most frequent usage of injections is for therapeutic purposes, Talley said. He cited examples of some common indications.

“Chalazia are very common, and intralesional injection of steroids is one of the standards of care for treating them,” he said.

In addition, a subconjunctival injection would be administered on the conjunctival tissue to treat recalcitrant anterior uveitis patients with severe rheumatoid arthritis who cannot administer drops, he said.

A second category of injection is the type administered for diagnostic purposes, such as fluorescein angiography, Talley said.

“Even though optical coherence tomography and scanning lasers have revolutionized how optometrists diagnose and treat conditions of the eye, there are plenty of times you simply want to know if something is leaking in the back of the eye, and to what extent it is leaking,” he said. And fluorescein is the way we do that.”

A third type of injection would be for administering preoperative anesthesia, which would be indicated when a patient presents with a lump or bump on the eyelid that needs to be surgically removed, Talley said.

“You can either numb it with a cream or you can give a small injection of anesthetic around the eye area prior to removing it,” he said.

In Tennessee, where Talley practices and where injections have been legal for optometrists to perform for 20 years, there is a caveat in the language of the legislation in that it does not specifically address injectable anesthesia, he said.

“When treating a disease of the eye or eyelid, we can perform any injection; however, when it comes to surgery, the law does not specifically say we can use an injectable anesthetic,” he said. “It says we can do surgery through a topical anesthetic, so one of the things we’re in the process of doing is clarifying that law. We currently have legislation pending that would clean up that quirk and allow us to do injectables specifically prior to performing a procedure.”

Pushback from ophthalmology

In what they viewed as a simple afterthought process of trying to tidy up the semantics of the existing law, Talley and his colleagues in Tennessee optometry learned quickly that opposition from ophthalmology is significant.

“We thought this was a no-brainer, and so did the legislators,” he said. “We’ve been performing injections to the eyeball and eyelid for 20 years; we’ve been cutting these lumps and bumps off and cleaning out clogged oil glands surgically. We were just going to do a tidy-up bill to clarify the issue.

“Well, organized ophthalmology has drawn a line in the sand,” he continued. “They don’t want optometrists doing injections.”

According to the Tennessee Academy of Ophthalmology website, “This bill posed a dangerous risk to patient safety and quality surgical care for Tennessee citizens.”

The website said that expertise in managing the types of complications that may occur from injections “is achieved through years of medical school, surgical residency and clinical training. It cannot be obtained in the current optometric curricula or in an ‘add-on’ training course.”

In his role as former chairman of the Tennessee Board of Optometry, Talley testified in front of the House and Senate health subcommittees in support of the bill. He informed the legislators that in the 20 years Tennessee optometrists have been performing injections, not a single negative incident was reported.

“Their [ophthalmology’s] argument was the same one they used 20 years ago; they said we’re not qualified,” he said. “The difference now is that we’ve been doing this for 20 years with no problems.”

The legislation is currently tabled until 2014, Talley said.

The ‘fear factor’

The fear propagated by opponents to injectable legislation taps into an intrinsic human fear – that of having a sharp object inserted into the eye.

“It’s a scary thought and legitimate fear,” Quinn said. “But that fear is separate from the issue of whether optometrists are qualified to do it. There are many MDs who might not be comfortable administering medications into the eye with a needle, but they’re able to make that judgment as to the limits of their competency.”

In actuality, Quinn said the mechanics of administering injections are not particularly challenging.

“In reality, the technical skill of administering an injectable medication is not complex; it doesn’t add in any significant way to the complexity of managing a particular disease state,” he said. “It sounds scary, but the truth is, it’s very straightforward.”

Quinn emphasized that any medical procedure carries a risk of complications, but a trained practitioner should be able to do it safely.

“You wouldn’t want anyone who is poorly trained to put a needle in your eye,” he said, “whether they are an optometrist or an ophthalmologist.”

Concerning optometric training for injections, Quinn said there currently is a “Catch-22” in many optometry schools.

“Because medications are frequently injected into the eye, this is something that optometry training exposes students to extensively,” he said. “The Catch-22 is that if you’re in a state where injections by optometrists aren’t permitted, how do you train a student? They can watch it done a hundred times, but they can’t easily get the hands-on training.”

Training for injections

Martin Bucharowski has firsthand experience with the Catch-22 described by Quinn. As a third-year optometry student at the State University of New York School of Optometry, he is getting his optometric education in a state where injections by optometrists are not permitted. Bucharowski said although his externship might enable him to expand his skills, he does not feel qualified to give injections at this point in his education.

“As a first semester, third-year student in a state where injections aren’t allowed, I have only been taught how to perform a subconjunctival injection,” he told PCON. “If I extern at a site where injections are allowed, if I learn how to use them, practice and attain a state license from said state, then, yes, I would feel qualified to administer injections.”

He said he feels that optometrists should have the option of pursuing training in administering injections.

For students who take the injectable course taught by James L. Fanelli, OD, at Salus University in Elkins Park, Pa., the picture is different.

“I teach a variety of injectable techniques, from intradermal to subcutaneous, to eyelid injections to intramuscular injections, to botulinum toxin, to sub-Tenon injections, to subconjunctival injections,” he said in an interview. “The course is elective, so those who take it are well trained in injections. Those who choose not to take it get only a cursory description.”

Although the course is elective, Fanelli said some states, such as his home state of North Carolina, require that students take an injectable course before they sit for the state boards.

“So, if you go into practice in North Carolina, it does assure that an optometrist who is licensed in that state has had adequate training,” he said. “It varies from state to state, though.”

Bucharowski said all optometrists should be able to decide the extent to which they want to learn and practice injections – and, likewise, they should respect the choices of others. He cited a recent conversation he had with David A. Cockrell, OD, president-elect of the American Optometric Association.

“I admire Dr. Cockrell, and I agree with him on optometric scope of practice issues,” Bucharowski said. “The optometrists’ scope of practice should not be artificially limited based on political battles from state to state. As an optometrist, if all you want to do is refract and fit glasses/contacts, then such is your prerogative. But do not oppose other optometrists who wish to educate themselves and practice to a wider level of care.”

The Oklahoma experience

As AOA president-elect and a practitioner in the state with the broadest legislative privileges for injections, Cockrell has a unique vantage point from which to consider this particular issue. He said although many optometrists primarily administer injections for lid lesions or surgical excision, he does not believe ODs should be restricted to these uses.

“I think the line should be drawn the same way it is for medicine,” he told PCON. “We should be authorized to the extent of our capability and our training.”

Cockrell pointed out that despite the controversy over optometrists giving injections, various non-MD health care practitioners administer them on a daily basis.

“The interesting thing about the hullabaloo over injections on some people’s part is that injections are given by many practitioners throughout the U.S., from nurses to Certified Occupational Therapists to pharmacists,” he said. “Wherever you live in the U.S., you can probably go to a local drugstore and get a flu shot from the pharmacist. So I don’t see that the fact that it’s an injection is the problem; it’s who is doing the injection that is the problem for ophthalmology.”

He said that although, for example, he does not have an extensive retina practice and, therefore, does not perform fluorescein angiography, an optometrist who does have the inclination and training to do so should be permitted under the law.

“It should come down to the level of training the individual optometrist has,” he said, “because if an optometrist isn’t doing the injection, it will frequently be a technician doing it.”

Cockrell said in his state, optometrists have been able to administer injections for more than 2 decades. Some choose to exercise this privilege, and some do not.

“We have four optometrists in our office, and we all do injections as called for, depending on the procedure,” he said. “Injections are widely used throughout the state. And to my knowledge, there has been no report of harm to any patient.”

Injectable treatments expand

Quinn said as science and technology evolve, optometrists should have access to the most effective delivery methods for treating conditions they have already been treating.

“Up until recent years, very few conditions were treated with drugs administered to the eye via injections,” he said. “Today, there’s been an explosion in growth of medications that are much more effective when administered by injection. So, patients with age-related macular degeneration and those with diabetic eye disease can all benefit from medications being administered directly into the eye.”

Quinn said medications intended for the posterior segment of the eye are generally not absorbed well when given orally or topically.

“The eye is very well protected,” he said. “If you deliver a medication directly into the back of the eye, we can get great concentrations into the eye. And we have great drugs now that are very effective in helping these patients.”

Fanelli agreed that some conditions cannot be effectively treated without injections.

“There are certain situations where injectable medications are the primary treatment option, such as gonococcal conjunctivitis, and intravitreal medicines are best administered via injection,” he said. “Emergency anaphylaxis care is administered and best treated by injectable medications, and there are other cases where injectable medications are adjunctive therapy for treating certain conditions.”

Quinn added that an injection from a well-trained optometrist just makes better sense in terms of optimizing time, cost and convenience to the patient.

“In today’s age of looking for efficiency and high-quality care, it really doesn’t make sense for someone to have an examination, be diagnosed and then be referred to another practitioner who will repeat the exam and the diagnosis and then administer the treatment,” he said, “especially when the treatment is pretty clear and not complicated.”

Fanelli said while some optometrists might prefer not to utilize injection privileges, this does not eliminate the overall need for them.

“Some optometrists feel as though there is no need for injectable medications, because they personally don’t use them,” he said. “To which I say: If you don’t want to use them, don’t. But don’t stand in the way of progress.” – by Jennifer Byrne

Disclosures: No products or companies are mentioned that would require financial disclosure.