Optometrists want a slice of the eye surgery pie in North Carolina. Ophthalmologists, who are medical doctors, don’t want them to cut in on the eye surgery business. They say allowing them to have that slice puts patient safety at risk.
Optometrists assert that they can perform advanced procedures safely. Others would say that consumers should have a choice, and that ultimately the free market will prevail.
Per definitions found at Harvard’s Digital Journal of Ophthalmology, an ophthalmologist is a specialist who is qualified by lengthy medical education, training and experience to diagnose, treat and manage all eye and visual systems and is licensed by a state regulatory board to practice medicine and surgery. An ophthalmologist is a medically trained specialist who can deliver total eye care: primary, secondary and tertiary (i.e., vision services, contact lenses, eye examinations, medical eye care and surgical eye care), diagnose general diseases of the body and treat ocular manifestations of systemic diseases.
Optometrists are specifically educated and trained by an accredited optometry college in a four-year course, but have not attended medical school. They are state licensed to examine the eyes and to determine the presence of vision problems. Optometrists determine visual acuity and prescribe spectacles, contact lenses and eye exercises.
Rep. Justin Burr (R-Stanly) has filed HB 36, “Enact Enhanced Access to Eye Care Act.” The bill would allow optometrists to perform certain surgical procedures on the eyes, with the exception of 17 procedures listed in the bill. (As of this writing, Burr has not responded to a telephone inquiry seeking his thoughts about the bill, or his motivation in filing it).
Dr. Cynthia Bradford is president of the American Academy of Ophthalmologists. The organization is opposed to the bill and the expansion of services allowed to be performed by optometrists that includes surgery. Bradford said, “There’s a difference in training between the MD DOs [Doctors of Ophthalmology] and optometrists.”
Bradford pointed out that ophthalmologists are medical doctors. They go through medical school and an internship. Also, they go through three years of ophthalmology training learning medical and surgical diseases of the eyes. In addition to the base training, ophthalmological specialists have additional training focusing on specific diseases or surgical needs related to the eyes.
While optometrists do receive a Doctor of Optometry degree, after completing at least three years of undergraduate work and four years of optometry school, the key difference is that they are not medical doctors who have been trained to perform surgical procedures. Bradford said, “To replace it with a weekend course, saying ‘you can learn how to do this [surgery] in just a short period of time,’ is not reasonable.”
Diagnosis, treatment, risks and managing possible complications are all parts of the process in evaluating patients with advanced eye care needs. Bradford said, “In optometry school they see a lot of healthy people, they don’t see a lot of disease at all.”
Patient safety is the chief concern expressed by Dr. Sara Stoneburner, an ophthalmologist in Greensboro, NC, and President of the North Carolina Society of Eye Physicians and Surgeons. During an appearance on the “What Matters in North Carolina” podcast on April 19, Stoneburner said that even a non-surgical procedure such as having an injection into the eye, carries the risk of complications such as infection, and believes that ophthalmologists are better trained to deal with those possibilities than are optometrists.
Both Bradford and Stoneburner referred to optometrists attending “weekend courses” to obtain the training necessary to perform surgeries and other advanced eye care procedures. There is not mention of training requirements in HB 36.
Stoneburner said that this is what has taken place in other states that have passed similar bills. For example, a quick search on Google produces lengthy results showing 32-hour classes in advanced procedures offered to optometrists in places such as Oklahoma.
In response to a request to be interviewed for this story, Dr. Jill Bryan, President of the NC Optometric Society instead sent answers via email to questions that have been raised about the bill.
Regarding patient safety, Bryan’s answer stated, “HB 36 will allow North Carolina to replicate other states’ successful efforts to expand access to eye care services. HB 36 is modeled on bills from Oklahoma, Kentucky, and Louisiana. In those states, optometrists have performed more than 33,000 laser procedures. There have been only two formal patient complaints, and both were on procedures not authorized by House Bill 36.”
Bryan’s statement continued, “Clearly, the record on patient safety for optometrists is sterling. That’s why this bill is really about who controls access to care. Our view is that patients should have a greater choice of providers. Clearly the data has shown that giving patients choice has led to great outcomes, whether they choose an optometrist or an ophthalmologist.”
However, there is a difference of opinion regarding the outcomes in states like Oklahoma, Kentucky and Louisiana that have previously passed measures similar to HB 36. While optometrists point to “great outcomes,” ophthalmologists point to a study in the Journal of the American Medical Association (JAMA). The 2016 study was conducted in Oklahoma, and focused on a procedure called a laser trabeculoplasty (LTP). This is a procedure where doctors use lasers to treat certain types of glaucoma by burning areas of the trabecular meshwork, located near the base of the iris, to increase fluid flow.
In its findings, the study states, “Among the 1,384 eyes receiving laser trabeculoplasty, the proportion of eyes treated by optometrists requiring additional laser trabeculoplasty in the same eye (35.9%) was more than double the proportion of those treated by ophthalmologists (15.1%). Optometrist-treated eyes had a 189% increased risk of requiring additional laser trabeculoplasty.”
Under the heading, “Conclusions and Relevance” the JAMA study stated, “Considerable differences exist among the proportions of patients requiring additional LTPs comparing those who were initially treated by ophthalmologists with those initially treated by optometrists. Health policy makers should be cautious about approving laser privileges for optometrists practicing in other states until the reasons for these differences are better understood.”
Depending on who is making their case, the outcomes are viewed differently. differently. In an article posted at www.wral.com on March 21, Adrianne Drollette, executive director of the North Carolina Optometric Society is quoted as having said that the JAMA study is “biased and flawed.”
The story also quotes her as having said, “That study was actually funded by the American Academy of Ophthalmology for the purpose of fighting back on optometry scope-of-practice expansion. Again, there have been no quality-of-care issues on any of these procedures that we’re looking to do.”
Stoneburner responded to that statement during the podcast. She said, “As far as no complications, that’s just simply not true. We know that there are many complications, and have reports on that.”
The debate is being framed around “patient safety”, but some argue the real heart of the matter is expanding consumer choices versus restricting competition.
And the idea of a free market is one that may prevail, saying that customers should be allowed to make informed decisions about who performs these advanced procedures on their eyes, and the market will weed out the incompetent.
The focus on eye care has been somewhat contentious and the lines of which side is right can become blurry.
The bill has had a hearing with no vote in the House Health Committee. It is not known if it will be heard again and move to the full House for a vote.