Restrictions on ODs at ophthalmology meetings may harm comanagement

The board of the American Academy of Ophthalmology announced in 2004 a decision to prohibit optometrists from attending its annual meeting. The policy still stands in 2018, still limits optometrists’ access to education and may be affecting comanagement relationships, some sources say.

“In this day and age, it seems unusual to put a prohibition on learning,” PCON comanagement blogger Ami Halvorson, OD, of Pacific Cataract and Laser Institute in Portland, Ore., told Primary Care Optometry News. “It is the sentiment behind the attendance restriction that is unfortunate.”

“The restriction reflects badly on the American Academy of Ophthalmology. It feels punitive from something that is inevitable,” Marc Bloomenstein, OD, FAAO, a PCON Editorial Board member who practices at the Schwartz Laser Eye Center in Scottsdale, Ariz., said in an interview.

As previously reported in PCON, Allan D. Jensen, MD, then president of the American Academy of Ophthalmology (AAO), said the decision stemmed from a recommendation from the council representing the group’s membership.

The council discussion was prompted, in part, by the April 2004 signing of HB 2321 in Oklahoma, which clarified Optometry’s Practice Act to include the word “surgery,” as reported in PCON. The bill was introduced in response to an earlier opinion issued by the state attorney general and was intended to re-establish the ability of optometrists to perform basic procedures such as punctal occlusion or epilation of lashes.

Richard L. Lindstrom, MD, a PCON Editorial Board member who practices at Minnesota Eye Consultants, said in an interview that the decision came about because of a few instances where optometrists were “using attendance at American Academy of Ophthalmology meetings as the basis for surgical credibility.”

He explained that the AAO cited incidents where an Oklahoma optometrist performed laser surgery at the VA in Wichita, Kan., and another optometrist at the Kansas facility cited his attendance at a Maine educational course in ophthalmology as the basis for surgical credibility.

Of note, a 2004 memorandum from then-acting undersecretary for health for the VA, John R. Pierce, MD, which was provided by the American Optometric Association (AOA), stated that 35 laser procedures (32 YAGs and three peripheral iridotomies) performed by optometrists in the Veterans Health Administration were reviewed, and the overall outcomes were acceptable, with no significant complications.

ASCRS policy

Several months after the AAO announced the restriction on ODs attending its meeting in 2004, the American Society of Cataract and Refractive Surgery (ASCRS) announced in a press release that meeting registration would be “limited to those optometrists directly employed by ophthalmologists or by ophthalmic industry entities.”

“At ASCRS, optometrists who work with ophthalmologists are welcome attendees of the meeting; we embrace that,” Eric D. Donnenfeld, MD, past president and ASCRS executive committee member, medical director of TLC Laser Eye Centers and the Lions Eye Bank for Long Island, and a founding partner of Ophthalmic Consultants of Long Island and Connecticut, told PCON.

He said the demographics of eye care are rapidly changing.

“It has become very well known that optometry sees the great majority of patients who require eye care,” Donnenfeld said. “The number of ophthalmologists is actually declining, and with Baby Boomers entering the age where they are seeking more eye care, now is the time to work together in a collaborative way.”

Feedback on the ASCRS policy has been positive from its members, Donnenfeld said.

“We’ve polled ASCRS members, and over 50% of them work with optometry and support their education,” he said. “It’s in the best interest of everyone for optometry and ophthalmology working together to be trained in the best way possible.”

Donnenfeld noted that optometrists who do not work with an ophthalmologist are not currently invited to the meeting, but this is being discussed at the highest level at ASCRS.

He said he is also in favor of ophthalmology learning from optometry, such as ophthalmologists attending optometry meetings.

American Optometric Association view

AOA President Christopher J. Quinn, OD, provided a statement to PCON on the restrictions on attendance by optometrists at ophthalmology meetings.

“Organized ophthalmology’s antiquated guidelines ... have been an embarrassing failure,” said Quinn, who practices in New Jersey and is a PCON Editorial Board member.

“The American Academy of Ophthalmology’s discriminatory and exclusionary meeting policy, which has been singled out for criticism even by the leadership of the NEI, is isolating them from the health care mainstream and increasingly defining them as an out-of-touch organization more interested in economic self-interest than expanding knowledge and advancing patient care,” he continued.

“In 2018, the AAO’s exclusion policy is more indefensible and outdated than ever,” Quinn stated. “It sadly attempts to deny, in the educational arena, that ODs and MDs are equal partners in the delivery of the highest quality care, and it ought to be immediately withdrawn. An OD or MD who accepts anything less is undermining the true progress our patients need while doing damage to their own profession.”

It begins at the state level

Lindstrom noted that the issue first presents at the state level.

“In our state, optometrists don’t come to the Minnesota Academy of Ophthalmology meeting, and, other than to lecture, most ophthalmologists don’t participate in the Minnesota Optometric Association meetings,” Lindstrom said. “I think the perspective comes from the state societies who are continuously battling over scope of practice issues.”

Lindstrom believes restricting optometry, “bubbles up from the state to the AAO, whose members are very active in state politics. Those involved at the state level in scope of practice issues would prefer that the AAO not have a large participation by optometry.”

Lindstrom said he is considered, “an advocate of integrated education.” He sees the consensus as slowly moving toward favoring it.

“Based on the fact that so many of us are, every day, working side by side with optometric colleagues, we need to be collaborative and collegial,” he said. “We want our optometric colleagues to be well educated, because they help take care of our patients.”

David McCullough, MD, president of the Connecticut Society of Eye Physicians, has a different opinion on collaborative care.

“Although there are integrated models where ophthalmology and optometry work as a single system of care, the vast majority of eye care practices, both ophthalmology and optometry, are independent practices that do not share electronic medical records on patients and communicate only by referral letters,” he told PCON.

Despite a general movement to collaborate care to improve quality, coordination and efficiency, “ophthalmology and optometry are still lagging in these integrated models,” McCullough said.

One optometrist’s story

Like many optometrists, Sondra Black, OD, a PCON Editorial Board member, works in the refractive surgery space, handling all preoperative and postoperative care, surgical planning and IOL calculations for patients at Crystal Clear Vision in Toronto, Canada.

She told PCON that the AAO annual meeting is one of the few places she can meet the proper vendors and receive the education needed to perform her job at the highest level of care. Black has attended the meeting for about 13 years, registered as a guest or exhibitor, along w0ith her comanaging surgeon, Jeff Machat, MD, FRCSC, DABO, without conflict, she said.

PCON sister publication Ocular Surgery News published a video perspective with Black as part of its meeting coverage from the 2017 AAO annual conference, which went live on Healio.com in mid-January. Soon after, Black received an email from an ophthalmologist inquiring where it was filmed. Then, on Jan. 25, Black received an email from the AAO outlining its annual meeting guidelines and stating the restricted access for optometrists.

The qualification to use the “spouse/guest” category was described as available only to those attending on a social basis. Further, a co-worker or an associate within the industry may not use the guest registration category, according to the email.

Additionally, AAO cited parameters that have been mandated by its board for optometrist attendance:

• Only optometrists who are members of the American Academy of Optometry and who have been selected for presentation may attend AAO annual meetings.
• If optometrists included on an accepted abstract are not members of the American Academy of Optometry, they may not attend AAO annual meetings.
• Optometrists may not attend Subspecialty Day.

“It’s an archaic way of thinking,” Black said. “The thing that really got me was that the video was on collaborative care between optometry and ophthalmology – the goal we are trying to achieve in the industry. There are articles and research on this left and right, and we are trying to work together to enhance the patient experience.”

She added that ophthalmology is getting more of its patient base from optometrists, as 85% of general eye exams are provided in optometric practices, and more optometrists are working in the refractive surgery space.

“How do we stay up-to-speed and work with ophthalmologists in the way we have to without getting the proper education in the right setting?” she asked.

Black said that Machat received an email from AAO as well, saying he could no longer have her as a guest at the meeting.

She added that some ophthalmologists are “stuck in the past, in the older way of thinking that we are fighting over the same patient base. But optometry is primary eye care, where ophthalmology is a surgical specialty.”

Black said she has attended other ophthalmology meetings without issue.

“I was told to tread lightly, but the issue is out there, and people need to know it’s not appropriate,” she said.

Lindstrom believes ophthalmologists’ opinions on whether AAO – or any ophthalmology society – should allow optometrists to attend their meetings are mixed.

“The naysayer would say that AAO is for ophthalmologists, and that is who should be primarily teaching and learning unless there is a special situation, like presenting a coauthored paper,” he said.

There are other national and regional meetings that provide optometric education, he added.

“Ophthalmologists don’t want to dilute the educational experience for the ophthalmologist by worrying about creating a program that is appropriate for optometrists,” Lindstrom continued.

McCullough agrees.

“The AAO courses are tailored by ophthalmologists for ophthalmologists,” he said. “These medical and surgical courses are designed by instructors who know that the attendee has a certain core knowledge or prerequisite surgical knowledge. The courses are meant to enhance and further this core knowledge.”

American Academy of Optometry program

The meeting attendance restrictions have, “caused a little bit of a fire in the optometric education realm,” Bloomenstein said.

Previously, there was little emphasis on bringing ophthalmologists into optometry meetings to talk about surgical options, comanagement, emerging research and technology, he said.

“In the last decade, ASCRS, as well as the American Academy of Optometry, has jumped on the bandwagon, to focus on making sure we have surgical and medical research-type courses available for optometrists who want to learn.”

A joint education program with the AAO and the American Academy of Optometry has been presented for the past 3 years at the optometry academy meeting, American Academy of Optometry President Joseph P. Shovlin, OD, FAAO, who practices at Northeastern Eye Institute in Pennsylvania and is a PCON Editorial Board member, said in an interview.

Shovlin said the joint symposia is a testament to the optometry academy’s hallmark mission of education.

“It highlights collegiality between the two groups and emphasizes that the team approach works exceedingly well in patient care,” he said.

After the 2004 restriction by AAO, Shovlin said optometrists who relied heavily on that meeting for up-to-date information found other ways to stay current.

Halvorson agreed, saying, “At the end of the day, I think it probably has had very little effect on practicing optometrists,” who have access to dozens of other educational opportunities.

“However, I do happen to love the intricacies of comanagement and would love more opportunities to learn about surgical cases so I can become more adept at managing postop complications,” she added.

AAO President Keith D. Carter, MD, FACS, commented on the joint AAO-American Academy of Optometry program in a statement provided to PCON.

“So far there are three strong symposia,” he said.

The same year the joint symposia began at the optometry academy meeting, the AAO decided to allow American Academy of Optometry member optometrists who are co-authors of papers or courses at the AAO annual meeting to attend and present, Carter said.

“We are looking to continue the symposia offered at our annual meetings,” he said.

“The academy believes that the two professions will be benefited by strong patient-centered relationships with the American Academy of Optometry,” Carter said. “Potential areas for collaboration include clinical guidelines, scientific policy, eye and vision research, and public health initiatives. As these interfaces mature, it will be only natural that we will intermingle more at each other’s meetings in service to our patients.”

Donnenfeld noted that if optometrists who work with ophthalmologists are not exposed to the best opportunities to learn, it ends up having a negative influence on patient care.

Lindstrom said, “Our profession needs well-trained professionals to work together to care for patients, including well-trained optometrists, certified ophthalmic medical technicians, physician assistants and opticians.

“We all need to work collegially to take care of patients, and all colleagues need to be well educated,” he added.

Lindstrom, who entered the profession 40 years ago, said that today nearly 50% of ophthalmologists currently employ an optometrist.

“If I go back to the early years, less than 1% of ophthalmologists employed optometrists,” he said. “The integrated eye care model, what we favor at Minnesota Eye Consultants, is becoming more dominant.

“I think separate but equal education is going to slowly move toward integration and collaboration, but it won’t happen overnight,” Lindstrom continued. “It is slowly moving in that direction.”

A challenge with that changing tide is that the associations need to respond and create educational experiences that are appropriate for the optometrist who works with an ophthalmologist, he said.

Bloomenstein added: “They need to bring optometrists into their programs so that this notion of us against them – this Cold War – is melted, because it’s all about getting patients the very best care.” – by Abigail Sutton

• References:
• Byrne J. OD ban from AAO meeting viewed as unnecessary, damaging. https://www.healio.com/optometry/regulatory-legislative/news/print/primary-care-optometry-news/%7b823ffe03-9f63-48a3-9cea-06e828e373ac%7d/od-ban-from-aao-meeting-viewed-as-unnecessary-damaging. Posted April 30, 2004. Accessed: April 16, 2018.
• Pierce JR. Memo to medical inspector. Dec. 10, 2004.

• For more information:
• Sondra Black, OD, is vice president and clinical director at Crystal Clear Vision, Toronto, and a PCON Editorial Board member. She can be reached at: drsblack@yahoo.ca.
• Marc Bloomenstein, OD, FAAO, practices at the Schwartz Laser Eye Center in Scottsdale, Ariz., and is a PCON Editorial Board member. He can be reached at: mbloomenstein@gmail.com.
• Keith D. Carter, MD, FACS, is president of the AAO and has 30 years of experience as a physician educator on issues such as access to care and quality enhancement. He can be reached at: jchurchill@aao.org.
• Eric D. Donnenfeld, MD, is an executive committee member and past president of ASCRS. He is the medical director of TLC Laser Eye Centers and the Lions Eye Bank for Long Island, a founding partner of Ophthalmic Consultants of Long Island and Connecticut, and clinical professor of ophthalmology at New York University. He can be reached at: ericdonnenfeld@gmail.com.
• Ami Halvorson, OD, practices at Pacific Cataract and Laser Institute in Portland, Ore. She can be reached at: ami.halvorson@pcli.com.
• Richard L. Lindstrom, MD, a PCON Editorial Board member and past president of ASCRS, practices at Minnesota Eye Consultants. He can be reached at: rllindstrom@mneye.com.
• David McCullough, MD, is president of the Connecticut Society of Eye Physicians. He can be reached at: davideyemd@aol.com.
• Christopher J. Quinn, OD, is president of the AOA and a PCON Editorial Board member and practices at Omni Eye Services in New Jersey. He can be reached at: quinn@omnieyeservices.com.
• Joseph P. Shovlin, OD, FAAO, is president of the American Academy of Optometry and a PCON Editorial Board member and practices at Northeastern Eye Institute, in Scranton, Wilkes-Barre and Hazelton, Pa. He can be reached at: jpshovlin@gmail.com.

Disclosures: Black is a consultant for Johnson & Johnson, AcuFocus, Labtician Ophthalmics Inc. and Vision Group Holdings Canada. Bloomenstein is on the speakers’ panel for Alcon, Allergan, Bausch + Lomb, Johnson & Johnson and TearLab and a consultant for J&J, Akorn, Allergan, BioTissue, Reichert, OcuSoft and TearLab. Carter reported a relationship with Research to Prevent Blindness. Donnenfeld, Halvorson, McCullough and Quinn report no relevant financial disclosures. Lindstrom reported a financial interest in Imprimis, Ocular Therapeutix and ForSight Vision5 and he is a consultant for Allergan, Bausch + Lomb, Imprimis and Novartis. Shovlin is on the global advisory panel for Allergan, Johnson & Johnson Vision and Shire.