Optometrists seek surgery rights in more states after Kentucky victory

Optometrists are stepping up their fight to expand their scope of practice after the enactment of a Kentucky law this year, making it the second state to let optometrists perform certain surgeries.

Lawmakers in Nebraska, South Carolina and Texas are considering optometry legislation to allow surgery-related scope expansions.

Oklahoma was the first state to enact such a law in 1998. Similar legislation has been considered in 25 states since, but none passed until this year, said Daniel Briceland, MD, secretary for state affairs for the American Academy of Ophthalmology.

The Better Access to Quality Eye Care Act was signed into law by Kentucky Gov. Steve Beshear on Feb. 24. It lets optometrists perform a range of new procedures, including Yag capsulotomy -- postcataract surgery -- and argon laser trabeculoplasty and selective laser trabeculoplasty -- both forms of glaucoma surgery.

Several physician organizations, including the American Medical Association, the American College of Surgeons and the AAO, have opposed such efforts, saying optometrists lack adequate medical education and training to perform surgeries and deal with potential complications. In Oklahoma, some patients have been harmed because of botched procedures by optometrists, said Cynthia Bradford, MD, AAO senior secretary for advocacy.

"It's a very significant patient safety issue," Dr. Briceland said.

But proponents argue that optometrists have a strong safety record and that the Oklahoma and Kentucky laws expand needed services to people living in medically underserved areas.

"We must commit to redoubling our efforts," American Optometric Assn. President Joe E. Ellis, OD, said in a statement to members on the organization's website. "Now is the time for optometry to build upon this most recent victory and fight to ensure that our message ... is heard loud and clear in the nation's capital and in the statehouses across the country: ODs have the training and education to provide much-needed treatment now, but outdated laws and discriminatory practices are holding back greater patient access to quality optometric care."

American Optometric Assn. officials did not respond to multiple requests to be interviewed for this article. The Oklahoma Assn. of Optometric Physicians declined to comment.

A new precedent in Kentucky

The bills being considered in Nebraska and Texas would allow optometrists to remove skin lesions from eyelids and do some laser procedures, including capsulotomies and trabeculoplasties. The bills also would authorize optometry schools in those states to perform and teach such procedures.

The bills in Nebraska and Texas and legislation in South Carolina would enable optometrists to make injections into the eyelid. The proposals in each state have been referred to legislative committees.

The Kentucky law sets a new precedent, Dr. Briceland said. In addition to expanding optometrists' scope of practice, it gives the Kentucky Board of Optometric Examiners full oversight to determine what training will be required of optometrists who want to perform laser surgeries.

"It's like the fox guarding the henhouse to have your regulation and discipline done by the same board" that also determines types of procedures and training guidelines, said Woodford VanMeter, MD, an ophthalmologist and president of the Kentucky Academy of Eye Physicians and Surgeons.

Opponents of the Kentucky legislation argued that they weren't given fair opportunity to debate it before passage.

"We are greatly concerned ... that SB 110 was pushed through the Kentucky House and Senate with barely more than a few hours of debate," AMA Executive Vice President and Chief Executive Officer Michael D. Maves, MD, MBA, said in a Feb. 22 letter to Kentucky's governor. "There has been more discussion of SB 110 on the radio and in newspapers."

In his March 2 statement, Ellis, of the American Optometric Assn., said the Kentucky law would expand access to essential health and vision services. "Importantly, it also allows the Board of Optometric Examiners sole authority to determine what constitutes the practice of optometry. Anti-optometry forces will have no power to define our profession," he said.

Optometrists are located in 106 out of 120 Kentucky counties while ophthalmologists practice in only about 40, said Ben Gaddie, OD, president of the Kentucky Optometric Assn.

"We have worked for decades in concert with ophthalmologists in the pre- and postsurgical care of patients, including the identification and monitoring of surgical and laser complications. We now will be able to fully utilize our training to the benefit of Kentucky patients," he said.

But Dr. VanMeter said there is no merit to the access-to-care argument, because there are enough ophthalmologists to meet demand. There's no waiting time for eye surgeries in the state, he said.

Dr. Bradford, of the American Academy of Ophthalmology, said quality of care should not be compromised for convenience.

Patient confusion adds to debate

Many people don't understand the difference between optometrists and ophthalmologists, physicians say. An AMA survey of 850 U.S. adults in 2010 found that 54% believe optometrists are medical doctors.

Ophthalmologists have four years of medical or osteopathic education followed by three to seven years of residency and fellowship training, including surgical training. A doctor of optometry degree requires four years of doctoral-level study concentrating on the structure, function and disorders of the eye, according to the American Optometric Assn. website.

In Oklahoma, optometrists gained the ability to perform certain laser procedures under the 1998 law, with exceptions including laser-assisted in situ keratomileusis (LASIK), retina procedures and cosmetic lid surgeries. They can perform some scalpel surgeries, under provisions added to a pharmacy bill passed in 2004, said Dr. Bradford, who also is past president of the Oklahoma Academy of Ophthalmology.

Despite the scope expansions, Dr. Bradford said not many Oklahoma optometrists are performing surgeries, but there have been problems. In one case, an optometrist gave a patient multiple injections for a bump on her eyelid he mistook as a chalazion, or cyst, but it turned out to be a malignant skin cancer that was diagnosed too late, she said.

In another case, a patient experienced vision loss after an optometrist performed photorefractive keratectomy even though she was not a good candidate for the surgery. The patient sued, and the case was later settled.

"Once a law is passed, it's very hard to undo it," Dr. Bradford said. "We as physicians need to realize that nonphysicians are going to seek the right to practice medicine, and they're going to turn to legislation to do that."