Ophthalmologists Opposing Legislation in at Least Five States Seeking to Expand Optometrists’ Scope of Practice

April 13, 2009

According to the American Academy of Ophthalmology, American Medical Association and Federation of State Medical Boards, legislation is pending in Maine, Massachusetts, Nebraska, South Carolina and Texas, to authorize optometrists to perform surgical procedures, administer injections around the eyes and/or prescribe more medications, including some controlled substances. The AAO and local ophthalmology groups are opposing the bills.

Doctors opposing similar legislation in Florida and West Virginia recently won victories in their battles.

The proposed West Virginia bill was illustrative: it sought to authorize optometrists to perform surgical procedures, inject drugs and Botox, and prescribe medications, including some controlled substances and new contact lenses that dispense medicine.

Of course, optometrists beg to differ and allege physicians are using improper “scare” tactics.

Read the full article here in American Medical News.




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14 Responses to “Ophthalmologists Opposing Legislation in at Least Five States Seeking to Expand Optometrists’ Scope of Practice”

  • chris

    One last thing, dr w, unless your a retinal specialist, you won’t be treating neuroretinitis or retinal macroaneurysm. Your going to send that out to a sub specialist. That is not and OD/MD issue. I work with many general OMDs and I dont know one who would treat either of those conditions. Let’s call a spade a spade.

    I agree with the other doc, the initials dont make the man or woman, rather the man or woman make the initials.

  • chris

    ODs receive extensive training and manage not only routine type eye care but also diagnosis and treat eye disease. This is not an issue of training or a concern of an impending wave of lawsuits (as dr weitzer suggests). Look my friend, ODs have been treating eye disease dating back the the 1970s. That’s 45 years so where are all the lawsuits? This come down to one thing, money. The ophthalmologists want to hold the monopoly on eye care so they have no competition and can collect the cash. Plain and simple. As an aside, the “EyeMD” term is a slap in the face to your DO counterparts.

  • ari weitzner

    i mostly agree. but i dispute the idea that optometrists can manage glaucoma. glaucoma requires enormous experience. even many ophthalmologists over-treat low risk patients and under-treat high risk patients. conjunctivitis, simple iritis, episcleritis and most low-risk conditions- sure, optometrists can handle that, as long as they have low threshold to refer to ophthalmologist when the case is not typical.

  • samanthaOD

    Let’s keep things simple. Optometrists are more than capable of performing thorough eye examinations, may I dare say, even better than an ophthalmologist. I object to any ophthalmologist saying that we are only good for refractions. In fact, where I work (with ophthalmologists), I have caught things that they overlooked/missed. But when it comes to surgery, leave it to the MD. They are trained to be surgeons, and we should stick to the things that we are strong in… being primary eye care doctors. I didn’t go into optometry to perform surgery… if I had, I would have gone to medical school. I went into optometry because I wanted to be in a health profession where I could help people see better. Yes, I believe there are a lot of mediocre ophthalmologists out there that I would not entrust my eyes too, but I would still go to a board certified ophthalmologist over an optometrist for surgery. Why can’t we just have a good working relationship where there is a level of mutual respect for one another?

  • Karine Shagoyan

    I have high respect for MDs. However, I have to disagree that optometrist are not capable of doing injections and prescribing medication. Have any of you (who are saying ODs are not properly trained) seen curriculum of OD students? I am a OD student at NOVA Southeastern College of Optometry. We share a lot of professors with DO students. When it comes to eyes we do get an excellent training. I would not say OD should treat lung cancer (for obvious reason: that we do not have that training!!!!!!!!!!) , but eyes we KNOW!!!!!! What do you think we are learning for four years???????? just to prescribe glasses?
    I do agree though that only residency trained ODs should be able to do injections,etc.

  • Dr. Weitzner

    agreed- there are very good optom’s out there. but for disease, the vast majority of optom’s can’t possibly measure up to even a mediocre ophthalmologist, and it’s not because they are less smart, but simply because their experience is limited. it’s not an insult. would an optom want to deal with neuroretinitis? should he treat a retinal macroaneurysm? is he aware that treating it can worsen the vision, and probably should be left alone? double vision that may or may not be a brain tumor?
    optom’s, ideally, should be engaged in refraction and very basic eyecare on their own, or may engage in more clinical care in an ophthal’s office where he can be supervised.
    in answer to sandra- theoretically, one can train anybody to do any procedure. so sure, an optom can be trained to perfrom any part of an eye operation. but it’s irrelevant, as it’s not practical- stilll need the ophthal there to supervise and take care of the unexpected.

  • Lonn Gary Schwartz, OD

    The medical community suggested that there would be legions of blind optometric patients roaming the streets if we were granted diagnostic agents in the 60’s and 70’s, and the same if we were granted therapeutic agents in the 80 and 90’s. Now we hear the same hollow warnings about surgical procedures.

    I have worked with some really well trained ophthalmologists, but I have also worked with some that I wouldn’t let go near my pet rabbit. Training is very, very important, no question, but the degree does not make the eye doctor.

    I know many optometrists that I would hold up to any ophthalmologist. A really good optometrist is a wonderful thing. Try one out and find out for yourselves :).

  • Sandra Krichbaum

    One more question. Robotics. Is there a case for saying the OD might simply act as a technician to the robotics aspects of “minor” eye surgeries? Although I don’t think any surgery of the eye is minor but I’m wondering if that issue has been discussed? But you’re right Irving, there will be court cases if this passes.

  • Irv Arons

    Sandra, interesting comment about Dr. Fyodorov’s RK “factory”. I used to have a copy of the 60 Minutes tape of this procedure, but donated it to the AAO’s library.

    As for the OD/MD controversy, it’s been going on for years. I recall that, as noted above, ODs were attempting to get involved in PRK/LASIK several years ago. I wrote about it in the November 1990 issue of Vision Monday.

    Here are a few quotes:

    Laser Turf War — Part II

    “The second shoe has now dropped. First Pennsylvania School of Optometry (PCO) tried to get an excimer laser to train optometrists in the intricacies of human corneal sculpting, albeit, under the guidance of ophthalmologists at nearby Hahnemann University Medical School. The PCO purchase was to be funded by a grant of $300,000 from the American Optometric Association. But Summit Technology (and its local distributor LaserMedix of Canastota, NY) backed out of the deal after accepting a deposit, on the alleged grounds that no clinical testing IDEs were still available for human testing protocols.”

    And, the ending:

    “But, as noted above, the second shoe has now dropped. The Academy of Ophthalmology has come out with a strong policy statement about laser surgery, claiming that it ought to remain in the realm of a licensed doctor of medicine (or osteopathy), strongly supporting federal and state regulatory agencies historic position that laser surgeries should (only) be performed by an M.D,

    The Academy bases its statement on its concerns, “that the quality of care of patients undergoing laser surgery (must) be safeguarded in the same tradition as patients undergoing other types of surgery”. The policy statement goes on to state, “Because of the potentially harmful medical consequences of laser surgery, strict guidelines have been established for their use in patient care. The U.S. FDA regulates all medical devices, including ophthalmic lasers. Because of the potential for harm in connection with the use of lasers, as well as the method of use, the FDA regulates medical lasers as ‘prescription devices’. Peer review organizations across the country are subjecting laser surgery that is being performed in hospital outpatient departments to the same quality review screens as other types of outpatient surgery.”

    “The excimer laser is currently undergoing clinical trials in order to test its safety and effectiveness when used to modify refractive errors. These trials are conducted by principal investigators who are distinguished ophthalmologists from academic medical centers across the country. The use of excimer lasers for refractive conditions is currently limited to FDA-approved and monitored clinical trials. However, the use of excimer lasers for refractive surgery has also provoked scientific concerns over its safety and long term effects. Significant side effects… including corneal haze which can limit visual acuity, thickening of the epithelium and regression of the induced changes in the cornea which can lead to recurrence of the myopia.”

    So, here we are. It is the beginning of the last decade of the twentieth century, a new era, and ophthalmology is claiming its turf before optometry can get a foothold. Optometry claims that state laws give it the right to use its skills “to treat refractive conditions with light”. Does that definition include the “light” of lasers? Only time (and more court cases?) will tell.”

    I’m not sure if there was a Part I, I can’t seem to find it.

    Anyone who wishes to see the whole writeup — send an email: iarons(at)erols.com

    Irv Arons

  • Sandra Krichbaum

    As a patient I don’t understand why someone would go to an Optometrist for surgery. I’d want to seek out the best surgeon I could find to do anything to my eyes. It is one thing to seek out an Optometrist for a prescription for my “winter blepharitis” but other than that, what is the need to increase the scope of practice? Are these in areas that are devoid of Ophthalmologists?

    This seems to boil down in part to who’s driving the “money train” so to speak. People generally go where their insurance will pay. In my case I declined vision insurance because I can get a better deal on glasses with coupons from the internet. I also have to trust, to some degree, that ODs as professionals would not put themselves in a position to perform surgery or dispense medication knowing they were not trained or simply not capable. I trust the same of my MD to tell me his limitations. It would be interesting to see some long term data from the former USSR countries. I know Russia used to “wagon wheel” patients for RK surgeries back in the 80s and technicians did all or most of the work. I wonder if this legislation could also allow ODs to perform other minor plastics work past botox such as lid or eye lifts, etc.?

  • Dr. Weitzner

    i think once od’s start getting sued for poor medical care ( which is inevitable, as their training simply is insufficient), they will back off

  • Oscar Cuzzani

    I believe the political pressure is more to benefit optometrists interests than filling a spot of an underserved population. The problem is old and can be summarized as this: Is a “medical” licensing/trainining necessary to perform surgery? If the answer is yes, then optometrists cannot do surgery. However in the last decade lots of optometrists (ODs) lobbyied to do more. Some have gone to China to learn how to do refractive surgery, and recently some are taking courses at the American Academy of Ophthalmology (AAO) to take surgical courses! AAO recently banned optometrists to participate in the meeting.
    I have always had the believe that in order to avoid disputes, a well defined boundary on roles and responsibilities is needed. This has not been the case for the profession of optometry, which is viewed as an “evolving” career that initially was supposed to be ancilliary to ophthalmology. Medical carrers on the other side have been always covering the area of patient care under strict guidelines and regulatory control. IN the last few decades professional liability increased the role of regulation and government influence in the practice, as well as the management of costs and procedures by insurance companies, influencing the way doctors perform their practice. Lately in a crusade for cost containing some have advocated the use of less trained professionals, like ODs to perform medical tasks. This, no doubt increased the hope of PDs that “one day” they will become ophthalmologists without the “burden” of medical training.

    Besides the obvious differences come the not-so obvious names of the professions: “Eye docs” have been used indiscriminately for both ODs and Eye MDs . A few years ago the AAO coined the name of “Eye MD” to differentiate the professions to the public, but if you see around, there is a lot of propaganda claiming optometrists as the best profession for your eye health.
    Then comes politics where some states in US have been bland on restraining medical practices by ODs. The public seems to be reluctant to learn the differences probably due to a poor advertising by ophthalmologists or a confusing image of how each profession limits its work and ethics.
    The last move to grant ODs more roles probably was because of cost constraints. If an OD can do it cheaper….then someone (politician) gets a credit and lots get a poorly trained practitioner for a few dollars less. The cost of this? I do not know, but it does not take much to see problems around it.
    Last year the AAO tried to move towards a reconciliation between the two professions. I agree 100% with this, IF it comes with a defined map of where each profesion can and cannot do and proper legal and professional liabilities for breaching the boundaries.
    I hope this help to start a good discussion.
    Being in Canada, I do not know all the details that are ongoing in US, although I tend to read most of it. In Canada optometrists worked together with ophthalmologists and we did not have major issues. I wonder what happpens in UK. Other countries do not recognize optometrists as a profession, and this is another topic in itself.
    Taking a leadership in opening a country-wide discussion, involving ODs, Eye MDs, members in the media and in the congress/senate, could start a move in the right direction: clearing the difficulties, finding areas of mutual help, and areas of clear delegation to allow the best trained to performed the job with higher risks to harm people and the least to help in covering a large area underserved, decreasing costs etc..
    Hippocrates dictum: “primun non nocere” (First: do not harm), is probably a good slogan for the launch of a campaign.


  • ari weitzner

    agreed. vast majority have no clue re difference between od and md. if legislation passes, we’ll just have to wait for the malpractice lawsuits to come pouring in, and then you’ll see vast majority of od’s dropping this and going back to their expertise- glasses, contact lenses and routine eye care.

  • Michael Dayton

    This is a bad idea. A solution looking for a problem to solve. Never in a million years would I trust my eyes to a non-surgeon if surgery was indicated. Sadly, many older folks are unaware of the difference between someone trained to do refractions (who calls himself doctor) and a medical doctor trained in ophthalmic surgery. This legislation could be a disaster for the elderly in States contemplating such folly.