California physicians sue over glaucoma treatment by optometrists

California physicians are challenging new regulations that allow optometrists to treat certain types of glaucoma.

The rules, established by legislation, do not call for enough instruction for optometrists to perform such treatments, compromising patient safety, the California Medical Assn. said in a lawsuit filed Jan. 11 against the California State Board of Optometry.

"Let's be clear: These new regulations are not up to snuff and in fact jeopardize the quality of eye care Californians deserve," CMA President James Hinsdale, MD, said in a statement. "Failing to require certification that includes treating actual glaucoma patients is the equivalent of handing out driver's licenses to people who have read a driving manual and attended a class but have never driven a car."

The optometry board argues that the regulations were approved through the proper channels. It would not comment on the lawsuit.

The new rules, which took effect Jan. 8, require optometrists to complete two of three prerequisites before they can treat glaucoma:

• A 16-hour case management course or lecture, which can be completed live, online or by remote.
• A grand rounds program consisting of 16 hours examining live patients but not treating them.
• A preceptorship program in which each patient initially must be evaluated by the licensee and co-managed with a certified optometrist or ophthalmologist.

Previously, the certification process required treatment of 50 glaucoma patients over two years under the supervision of a board-certified ophthalmologist. But under two of the new regulations, there is no supervised patient treatment, the CMA said.

"This is a step backward in a time when we're looking at increased emphasis on standards of education and clinical training," said Cindy Bradford, MD, an Oklahoma ophthalmologist and senior secretary for advocacy at the American Academy of Ophthalmology. "It's a quality-of-care issue."

Optometry board spokesman Russ Heimerich said the purpose of the new rules is to improve patient access to glaucoma treatment. About 7,000 optometrists practice in California compared with 3,000 ophthalmologists, he said.

"A lot of rural areas do not have access to ophthalmologists," he said.

The standards do not allow optometrists to diagnose glaucoma but lets them treat three types of the condition, Heimerich added. In many cases, the optometrist will continue to refer patients to an ophthalmologist, he added.

Adoption of rules questioned

Patient safety is not the only reason for the lawsuit. The CMA and the California Academy of Eye Physicians and Surgeons, co-plaintiffs in the suit, said the regulations were not established properly.

A committee of optometrists and ophthalmologists convened to develop the new rules, but Dr. Kliger said they could not agree, and cooperation deteriorated. Instead of submitting one report, the committee ultimately turned in two reports to the California Dept. of Consumer Affairs, according to the lawsuit. The suit also questions the expertise of an outside optometrist who was brought in as a consultant to help with the process.

Optometrists had complained that the old regulations were too difficult to comply with, said Craig H. Kliger, MD, executive vice president of the California Academy of Eye Physicians and Surgeons. They cited a lack of ophthalmologists willing to oversee their training and difficulty finding and retaining 50 patients to treat over two years, as required.

The California Optometric Assn. said "economic interests" of ophthalmologists are the driving force for the lawsuit, said spokeswoman Rachel Pitts.

"This was a transparent process," she said. "There was completely open communication at all levels."

California is the latest state to see scope-of-practice changes in eye care. Arizona enacted legislation to allow optometrists to prescribe oral antiviral medications. Optometrists in Iowa, Kansas, New Hampshire and New Jersey have been allowed to prescribe therapeutic contact lenses containing pharmaceuticals.

Oregon recently reversed rules that let optometrists treat glaucoma, Dr. Bradford said.