Opinion: Ophthalmologists on Scope of Practice

AI. Howard Fine, MD

Eugene, Oregon
I do not believe optometrists should perform any surgery under any circumstances. Optometrists receive book training on pathology, but they do not really understand pathologic physiology from first-hand experience gained from dealing with patients on an ongoing basis. Therefore, their ability to deliver postoperative care and manage intraoperative complications would be suboptimal. More importantly, ophthalmologists undergo a lengthy training process under the supervision of highly trained experts in order to develop adequate skills to consistently provide optimal care. I think optometrists who want to operate should attend medical school and complete a residency in ophthalmology.

Lee T. Nordan, MD

Carlsbad, California
My comments on the attempts of optometrists to perform ophthalmic surgery will not be particularly lengthy, but they should leave no doubt as to my position on the subject.

As stated by the National President of Vietnam Veterans of America,1 “The [Veterans Administration] encourages [optometrists] to attend medical school and become ophthalmologists.” Anyone who believes that optometric training is a legitimate replacement for a medical school education and a 3-year ophthalmic residency in which medical school graduates are intensively trained in the techniques, complications, and difficult judgments associated with ocular surgery is, in my opinion, ignorant, delusional, or paid off.

All of the excellent optometrists with whom I have worked during the past 25 years quickly became impressed with the difficult treatment options posed by various situations that developed during surgery when a patient's vision depended upon a surgeon's skill and judgment. These practitioners readily admitted that they had neither the necessary training nor the capacity in the surgical arena and looked to me to treat the complications that had arisen. Is a 3-month training course going to provide an optometrist with sufficient surgical knowledge? By the same token, can ophthalmology legitimately defend a technician who places sutures during cataract extraction surgery (in the old days) at the conclusion of surgery or one who operates a laser that creates a LASIK flap? Eye surgery should be performed by eye surgeons, without exception.

For many years, California's organized optometric group has been lobbying and conducting legal proceedings against an ophthalmologist's right to perform refractions, claiming that ophthalmologists are not qualified to conduct such examinations. Optometry continues a campaign of turf warfare for political and financial reasons. These attempted forays into surgery by optometry have nothing to do with patient welfare. It makes me wonder what oath or altruistic goal is mumbled at the conclusion of optometric training. In fairness to most optometrists, I believe that these attempts to perform surgery are mainly a political gambit directed by a runaway leadership.

In recent years, the AAO and the ASCRS, as well as many of the state ophthalmic societies, have greatly improved their capacity to communicate with legislators. The battle against parasurgical professionals' desires to perform surgery in all of medicine will be very successful if the American public realizes the catastrophic consequences of lowering the standards for surgeons. However, any process involving the lay public at the grassroots level is very inefficient in the short term. This struggle must be waged at the political level, where money and power are the key ingredients.

The optometrists are very well organized politically and financially. Ophthalmology needs to continue improving its political and financial organization. Then, all ophthalmologists should join the fight big-time and thoroughly convince the legislators and the American public that the optometrists' desire to perform surgery is not in a patient's best interest and would represent a restructuring of the ideals that all patients deserve the best possible medical care.

Daniel S. Durrie, MD

Kansas City, Missouri
I think that optometrists' and ophthalmologists' sharing in patient care has been very beneficial to patients. The optometrists generally know the patients very well because they have been treating them for years with glasses, contact lenses, and bifocals, and this information is quite helpful to the ophthalmologists with respect to surgical planning. Also, after the surgical process has been completed and the patient is discharged from the care of the surgeon, it is frequently more convenient for the patient to return to the optometrist for routine care.

Recently, there have been changes in the scope of optometric practice law in Oklahoma and questions about optometrists' ability to perform surgery in the Veterans Administration system. I think that, if a patient needs ocular surgery, his surgeon must be someone who has gone to medical school and completed an ophthalmology residency (7 years of training) to ensure that the patient receives the best possible care.

I am very disappointed that many of the leaders in optometry have not expressed publicly that they are not in favor of increasing the scope of practice for optometrists to include surgery, although they have said so to me personally. If this scope-of-practice expansion trend continues, ophthalmologists will have to look seriously at their participation in optometric education, perhaps including, at least for me, dropping the residency program for optometrists that I have run for 10 years. I think that many optometrists who are employees of ophthalmology clinics may be looking for jobs.

The line has been drawn, not by the doctors, but by what patients expect. Optometrists and ophthalmologists have had a relationship that has been built on what is best for patient care, and it does not include nonsurgeons' performing surgery. Patient care should continue to be the number-one priority.

Samuel Masket, MD

Los Angeles, California
On the surface, the question of whether Optometrists should have an expanded scope of practice to include surgery would appear to have a simple answer. Given that Optometrists are not medical doctors and have not attended medical school or a residency program that includes surgical training, it would seem obvious that they should not conduct surgery. However, there has been a trend in recent years that has allowed nonmedical practitioners to gain broader privileges through legislation; this has occurred in Ophthalmology as well as other areas of medical care. To me, the most interesting aspect of these scope-of-practice expansions is that, in certain states (Oklahoma is a prime example), optometrists have had the opportunity to determine their own scope of practice, which now permits them to practice eye surgery. Optometrists in that state have self-governance and are not overseen by the state medical or surgical boards, but rather by state optometric boards. On the other hand, I sense that all providers of surgery should be under the jurisdiction of the state boards for medicine and surgery.

Optometrists have gained a broader scope of practice through strong lobbying activity at the state level. State ophthalmological societies, by contrast, are hindered by an average membership rate of 50% and are typically underfunded. Ophthalmology has historically organized strongly at the national level for other areas of advocacy such as reimbursement and regulation, but has not been as effective in working with state legislatures. This so-called battle over optometric scope of practice is being fought in the state legislatures, where optometrists outnumber ophthalmologists by roughly 2:1 and tend to be more aggressive in their efforts. Furthermore, optometrists have, perhaps, partly achieved these scope-of-practice gains by participating in medical education programs—a fact that they use in conversations with state legislators. They argue that this knowledge base, in combination with comanagement experience, should enable them to provide the same level of care as ophthalmologists. The essential question is whether or not there are negative public health effects of optometric scope-of-practice expansion. Unless organized ophthalmology is successful with lobbying at the state level, which is very costly, I foresee that the optometric scope-of-practice expansion trend will continue, particularly in rural states where geography plays a role in the delivery of care.

Additionally, there is the question of the lay public's understanding of the current differences between the specialties. Although the AAO has made concerted efforts to distinguish ophthalmologists from optometrists by creating the Eye M.D. logo, it is remarkable that the lay public still has a poor understanding of the distinction between the two professions. Many people do not understand that the ophthalmologist has gone through medical school and is specifically trained to provide general medical care as well as medical and surgical care of the eye.

For the far-reaching future, I sense that we will probably see a merger of the disciplines, perhaps beginning in the form of a common basic education. Those interested in providing primary eye will then do so, and those interested in providing surgical care may follow that pursuit with additional training. The ultimate merger of the specialties, with attention to work force needs, would benefit the quality of patient care, because individuals would be able to pursue their primary interest.

I. Howard Fine, MD, is Clinical Professor of Ophthalmology at the Casey Eye Institute at Oregon Health & Science University in Portland and is in clinical practice with Drs. Fine, Hoffman & Packer, LLC in Eugene, Oregon. Dr. Fine may be reached at (541) 687-2110; hfine@finemd.com.
Lee T. Nordan, MD, is a technology consultant for Vision Membrane Technologies, Inc. Dr. Nordan may be reached at (760) 431-1846; laserltn@aol.com.
Daniel S. Durrie, MD, is Director of Durrie Vision in Overland Park, Kansas, and is Clinical Assistant Professor of Ophthalmology at the Kansas University Medical Center in Kansas City, Kansas. Dr. Durrie may be reached at (913) 497-3737; ddurrie@durrievision.com.
Samuel Masket, MD, is in private practice in Los Angeles and is Clinical Professor of Ophthalmology at UCLA. Dr. Masket may be reached at (310) 229-1220; avcmasket@aol.com.
1. Academy Express. American Academy of Ophthalmology. 2004;3:31.