Healthcare in the US is going through a very turbulent time. Questions abound on subjects such as the delivery of medical care, its funding, insurance options, and the cost of drugs. Approximately 1 year ago, I expressed my views about the future of the delivery of healthcare in the US by describing a system in which hospitals would compete to provide care after a patient had selected a certain level of insurance benefit associated with a chosen premium. Certainly, I do not have many specific answers with respect to the American healthcare system, but I am thinking about it and offering my best ideas. Clearly, it is difficult to design a system to care for mostly healthy individuals who often require $500,000 worth of medical care within 6 months of their deaths as a result of a debilitating injury or stroke.

As one ponders how to fix the American healthcare system, several issues seem constant. The public demands the best possible care and holds physicians accountable for the care they provide. Virtually every proposal aims to reduce the cost (or the rate of increase) of healthcare, and unfortunately a decrease in the quality of care is invariably involved. This month, I would like to focus on one aspect of this scenario: the delivery of eye care and how changes to this system relate to optometry.

PRIMARY CARE

Today, many patients' primary eye-care providers are optometrists. Twenty years ago, most states did not allow an optometrist to diagnose a disease. Nowadays, these clinicians may not only diagnose ocular disease, but they are allowed to treat many of them with antibiotics, glaucoma medications, topical steroids, and other therapeutic agents.

Numerous optometrists perform patients' initial and follow-up ocular examinations within an ophthalmologist's office, and many have become involved in the examination of ocular surgical candidates and serve as surgical technicians. These practitioners are surely learning that an increased scope of practice confers greater responsibility.

FALLACIES

Within the past year or so, I have been asked to share my opinion in legal cases concerning (1) an optometrist who was the primary caregiver for a patient with a Pseudomonas ulcer of the cornea and a poor outcome after several months of treatment, (2) an optometrist who recommended LASIK to a patient with known keratoconus, (3) an optometrist who failed to diagnose chronic retinal detachments during a LASIK screening, and (4) an optometrist who prescribed ongoing treatment with a topical steroid in a patient who developed progressive glaucomatous damage.

This list of cases is not meant to imply that ophthalmologists never make mistakes or that the aforementioned optometrists were necessarily negligent. My point is that, because society has permitted optometrists to elevate the scope of their practice and their level of skill, it is also time for the leaders of optometry to modernize their profession and to stop endorsing the fallacies (1) that ocular surgery is only about as complicated as a refraction owing to technological advancements and (2) that optometrists are qualified to perform eye surgery.

In particular, I believe that schools and teachers of optometry should cease promoting the following:
• Hand/eye coordination exercises to improve binocularity. Obviously, bouncing on a trampoline does not increase binocular function;
• Wearing undercorrected glasses to stop the progression of refractive error. Has anyone recently heard the advertisements for the See Clearly method developed by an optometrist?
• Dyslexia as primarily a problem of the eye that is best treated with ocular exercises (assuming that refractive error, ocular motility, and any ocular disease have been addressed);
• Ocular exercises as worthwhile treatments for ocular disease and/or ametropia, except in cases of mild accommodative exotropia;
• Wearing hard contact lenses to stop the progression of myopia. In reality, the axial length of the eye is increasing;
• Orthokeratology as a method of permanently correcting refractive error;
• The Bates method (and all variations thereof) as a legitimate or valuable means for improving visual acuity; and
• The perception that patients are better served by an optometrist versus a properly trained ophthalmologist who performs ocular surgery.

All of the widespread methods for treating ocular disease that I have mentioned have been discredited through the years to my satisfaction. I think that optometry should modernize its teachings and standards. During my ophthalmic career, I had the pleasure of working with many top-notch optometrists. Whenever the topic of eye exercises, hand/eye coordination exercises, or the Bates method arose, these clinicians were embarrassed and appalled that the practice of optometry still included such concepts. These same optometrists had witnessed quality ocular surgery and respected its beauty and difficulty. They recognized that, despite differences in ophthalmologists' surgical ability, they themselves had neither the training nor the experience to execute quality ocular surgery.

Although it is a separate issue, I should note that ophthalmology—in some cases along with optometry—also must conduct some major tests of the scientific method with regard to vitamin therapy for age-related macular degeneration and UV-filtering spectacle lenses to prevent cataracts or the progression of age-related macular degeneration. The body of scientific evidence that I have examined is less than convincing in these two areas—despite a hope to benefit patients and a great deal of financial pressure.

CONCLUSION

If optometrists are poised to increase their scope of practice and expertise in eye care (whether through patients' choice or an insurance company's mandate), then it is time for these practitioners and schools of optometry to hold themselves to a higher standard. As always, comments are welcome.

Lee T. Nordan, MD, is a technology consultant for Vision Membrane Technologies, Inc., in Carlsbad, California.
Dr. Nordan may be reached at (760) 431-1846; laserltn@aol.com.

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