Legislators in several states considering bills to expand scope of optometry

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Legislators in New Hampshire held a hearing this week on Senate Bill 440, which would make various amendments to the regulation of optometry in the state.

Legislatures in Missouri and West Virginia also are making a move to join the states considering similar legislation.

Lawmakers in New Hampshire held a hearing and if the measure is approved, it would grant optometrists the authority to perform delicate surgery on and around the eye with lasers and scalpels. The bill was introduced in the New Hampshire State Senate on January 3.

The bill would make various amendments to the regulation of optometry, including changing the board's name to the Board of Optometry, definitional changes to include what constitutes the "practice of optometry," repealing the joint credentialing committee, modifying the rulemaking authority of the board, and modifying the prescribing authority of optometrists.¹

The legislation also lists several ophthalmic surgery procedures that would be prohibited by optometrists, except for preoperative and postoperative care, including retina laser procedures; penetrating keratoplasty or corneal transplant, administration of general anesthesia; laser or non-laser procedures into the vitreous chamber of the eye to treat macular or retinal disease; surgery requiring full thickness incision or excision of the cornea or sclera, except in emergencies requiring immediate reduction of pressure inside the eye; surgery requiring incision of the iris and ciliary body, retina, vitreous, extraction of the crystalline lens and surgical intraocular implants, surgery of the eyelid, bony orbit or pterygium surgery; and surgery requiring full thickness conjunctivoplasty with a graft or flap.

Kimberly Licciardi, MD, a board-certified ophthalmologist and president of the New Hampshire Society of Eye Physicians and Surgeons, penned an op-ed article for the NH Journal noting that optometrists play a crucial role as respected members of the eye care team.²

“Their significance lies in conducting comprehensive eye examinations and vision assessments, as well as prescribing corrective lenses and identifying specific eye irregularities,” she wrote in the article. “In collaboration with an ophthalmologist, they also possess the authority to prescribe a restricted range of oral medications for eye care, including antibiotics and glaucoma medications. However, one thing is clear: they do not have the necessary level of education and training to safely perform ophthalmic surgery. While SB 440 contains a short list of “prohibited” surgeries, optometrists would be authorized to perform any other eye-related surgery not listed—potentially hundreds of surgical procedures.”

Licciardi also wrote that the surgical procedures that involve the eye and its surrounding regions require meticulous attention and expertise, as any mistakes can have severe consequences.

“Prior to confirming whether an eyelid lesion is cancerous, it is imperative to send a sample for a biopsy, as there is no certainty without this diagnostic procedure,” she wrote in the article. “I also need to know when a patient really needs surgery. Underlying medical conditions unrelated to the eye can pose as eye diseases. Misdiagnosis or unnecessary treatment could have serious consequences for a patient. My foundational understanding of the human body and medicine has prepared me to identify the unexpected.”

Moreover, Licciardi pointed out that supporters of the legislation maintain that allowing optometrists to perform surgeries will lead to reduced costs and improved accessibility to care in the state, noting that it is important to address issues of accessible healthcare options in rural areas.²

“However, granting optometrists the authority to conduct surgeries with negligible training utilizing surgical tools, such as scalpels, to remove potentially cancerous skin lesions and lasers to perform glaucoma and post-cataract surgery is not the solution New Hampshire citizens need or deserve,” she wrote.

Lawmakers in Missouri, South Dakota and West Virginia also are among the states currently pursuing or planning to pursue legislation to expand the scope of practice for optometrists.

The Missouri Optometric Association is offering its support for Senate Bill 956 and House Bill 1963, measures under consideration by legislators that would amend the state’s optometric scope of practice — something that has already been done successfully in nearly a dozen other states.

Mark Curtis, an optometrist who treats patients in Warrensburg, Concordia and Richmond, Missouri, and the volunteer public relations chair of the Missouri Optometric Association, wrote in an op-ed article in the Kansas City Star that the proposal is long overdue.⁶

“More than 8 in 10 Americans already trust their primary eye health care to an optometrist,” he wrote in the article. “At a time when half of ophthalmologists are closer to retirement than training, the optometric workforce is projected to grow 1.4% annually.”

Curtis also noted in the Kansas City Star that the proposed legislation just makes good sense to ensure access to care in the state.

“Doctors of optometry are highly educated, skilled and licensed professionals who play a critical role in protecting eye and vision health care. The bottom line,” Curtis continued. “With more doctors of optometry geographically accessible, particularly in underserved areas, expanding their scope of practice makes good sense.”

In West Virginia, Kayla Campbell, OD, president of the West Virginia Association of Optometric Physicians, and an optometrist at Bailey Eye Care in Barboursville, told Coal Valley News the state must amend optometry laws in an effort to attract new optometrists to the state.⁷

“Optometrists provide indispensable primary eye care that encompasses a broad spectrum of services, extending well beyond the realm of glasses and contacts,” she said. “Our expertise lies in managing eye conditions related to systemic diseases like diabetes, lupus, hypertension, high cholesterol, MS, various cancers, and autoimmune disorders. Additionally, we help provide management and treatment options for a multitude of eye diseases, including but not limited to cataracts, macular degeneration, glaucoma, dry eye, conjunctivitis, and foreign body removals.”

Campbell noted that by aligning West Virginia’s regulations with contemporary standards, the state can create an environment where optometrists can thrive professionally, ultimately enhancing the lives of our residents.

Charles Francis, MD, MS, an ophthalmologist practicing in Hurricane, West Virginia, who serves as AAO Councilor for the West Virginia Academy of Eye Physicians and Surgeons, countered, claiming in a separate op-ed that weakening eye surgery laws would place patients at risk.

“Eye surgery is commonly performed to treat cataracts, glaucoma, tumors on the eyelid, and many other eye-related conditions,” he wrote in Lootpress. "Many of these surgeries employ lasers which can cut, blast, and burn human tissue.”

Francis wrote that the surgeries are advanced and delicate, requiring careful placement of laser energy into the eye.⁸

“For example, YAG lasers turn liquid into gas by heating the tissue to 3,000 degrees for 4 nanoseconds,” he said. “If not aimed carefully, it can have devastating results.”

Francis added that there is good reason our state required those performing eye surgery to go to medical school and residency.

“Unfortunately, some optometrists and their lobbyists want to circumvent this time-honored safety measure and convince the legislature to change existing law, empowering the Board of Optometry to police and approve their ability to do surgical procedures,” he said. “The optometry board and their lobbyists will attempt to chip away year after year asking the legislature to grant them more surgical powers, not through proper training, but through legislation.”

According to a survey conducted by the American Medical Association, there is much public confusion about the difference between ophthalmologists and optometrists. Nearly 47% of respondents thought an optometrist was a medical doctor.

“It is imperative that we do not compromise the safety of patients in New Hampshire by diluting surgical safety standards,” Licciardi concluded in the article. “Enabling optometrists to perform surgery without the extensive clinical training and education provided by medical school, hospital internship, and surgical residency programs is a perilous decision that jeopardizes the level of care Granite Staters rightfully anticipate and deserve.”

The American Academy of Ophthalmology continues to address physician and staff shortages and protect patient safety at a time when nonphysicians are trying to expand their scope of practice into eye surgery, which it noted in a press release this month will be a priority as Jane C. Edmond starts her term as the 128th president of the AAO.

Edmond noted the ophthalmology community finds itself in a critical place: a growing senior population and limited expansion of residency programs point towards a potential shortage of ophthalmologists over the next decade.⁵

“This comes at a time when declining reimbursements, pre-authorization requirements and an overall staffing shortage make our jobs as physicians even more challenging,” Edmond said in the AAO news release. “However, there’s also so much passion and drive in the ophthalmology community, and we have lobbied hard for the safety of our patients these past several years. Together, I believe we can build upon this momentum and make an even greater push for serving our patients, educating our members and inspiring future generations of ophthalmologists.”

The issue is being tackled by lawmakers in each state because any changes to optometrists' scope of practice must be explicitly spelled out in law. Physicians, on the other hand, possess a medical license, which grants broad leeway to diagnose patients, prescribe medications, and — in the case of ophthalmologists and other surgeons — remove or repair tissues and organs.

As a result, the issue has been debated in several states in recent years.

In 2022, California Gov. Gavin Newsom vetoed similar legislation, citing insufficient optometry education and training for surgical procedures. After undergraduate studies, ophthalmologists must complete eight or more years of medical school and specialized clinical training, compared with four years of specialized education and training for optometrists. That didn’t end the debate in California.

Since 2021, nearly a dozen state legislatures have granted expanded contemporary optometric authority including laser procedures to doctors of optometry.

Last year in Florida, Gov. Ron Desantis vetoed a bill that threatened to strip optometrists of their ‘physician’ title. More scope of practice expansions allowing optometrists to perform minor laser procedures, remove styes and skin tags, and expand their vaccination and prescribing authority may also be on the horizon with bills weaving their way through the New Jersey and Ohio state legislatures.

Moreover, studies have tried to provide answers to questions raised in the debate, including whether optometrists have worse outcomes than ophthalmologists when performing the same laser procedures.

In a 2016 study published in JAMA Ophthalmology that reviewed laser trabeculoplasty,¹ researchers analyzed Medicare claims data on 891 patients with glaucoma who received laser trabeculoplasty between 2008 and 2013 in Oklahoma, where optometrists have been offering this treatment for more than two decades. According to the study, patients who saw an optometrist for laser treatment were about twice as likely to have to undergo additional laser procedures in the same eye, compared with patients whose initial procedure was completed by an ophthalmologist.³

A 2021 review found that optometrists had worse scores than ophthalmologists in Medicare’s payment incentive program rewarding physicians based on quality metrics.⁴

References:

1. State.nh.us. Published 2016. Accessed January 15, 2024. https://gencourt.state.nh.us/bill_status/legacy/bs2016/billText.aspx?sy=2024&id=2116&txtFormat=html

2. Licciardi K. LICCIARDI: SB 440 Puts Surgical Eye Safety at Risk and Should be Rejected. NH Journal. Published January 14, 2024. Accessed January 15, 2024. https://nhjournal.com/licciardi-sb-440-puts-surgical-eye-safety-at-risk-and-should-be-rejected/

3. Stein JD, Zhao PY, Andrews C, Skuta GL. Comparison of Outcomes of Laser Trabeculoplasty Performed by Optometrists vs Ophthalmologists in Oklahoma. JAMA Ophthalmology. 2016;134(10):1095. doi:https://doi.org/10.1001/jamaophthalmol.2016.2495

‌4. Neil Sheth, BA, Dustin French, PhD, Angelo Tanna, MD. Merit-Based Incentive Payment System Scores in Ophthalmology and Optometry. Ophthalmology. Published September 11, 2020. Accessed January 15, 2024. DOI: https://doi.org/10.1016/j.ophtha.2020.09.015/S0161-6420(20)30897-6/fulltext

5. 2023 President-Elect Nominee: Jane C. Edmond, MD - American Academy of Ophthalmology. www.aao.org. Accessed January 13, 2024. https://www.aao.org/about/governance/elections/jane-edmond

6. Missouri has an eye health care crisis. Let optometrists do what they’re trained for. Kansas City Star. Published January 12, 2024. Accessed January 19, 2024. https://www.kansascity.com/opinion/readers-opinion/guest-commentary/article284123423.html

7. Kayla Campbell: WV must revise optometry laws to attract new optometrists. The Coal Valley News. Published January 17, 2024. Accessed January 19, 2024. https://www.coalvalleynews.com/opinion/kayla-campbell-wv-must-revise-optometry-laws-to-attract-new-optometrists/article_d8f5ae9d-a4d9-56b2-98c8-6800b4614234.html

8. Ed O. OP ED: Weakening Eye Surgery Laws Place WV Patients in Jeopardy. Lootpress. Published January 18, 2024. Accessed January 19, 2024. https://www.lootpress.com/op-ed-weakening-eye-surgery-laws-place-wv-patients-in-jeopardy/