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Eyeball wars - patients, politics and profit

05/09/2017By Richard Chiu • Staff Journalist
A battle for control has once again erupted over scope of practice in the billion-dollar US eyecare industry. With vested interests and misinformation on both sides, RICHARD CHIU and MATTHEW WOODLEY cut through the politics to reveal the potential impact on the most important casualties from the ‘eyeball wars'.

Optometry’s fight for more autonomy and fewer restrictions within the US is not new. Ever since 1988, when Oklahoma became the first state to allow optometrists to perform certain minor surgeries with scalpels and lasers, debate has raged sporadically over whether such legislation is in the best interests of the patients, or those performing the procedures.

Optometrists argue that it expands the availability of specialist eyecare to people who would otherwise been unable to access it, while ophthalmologists have labelled any steps to broaden scope of practice for optometrists as ‘dangerous’.

Earlier this year debate exploded dramatically again, after powerful lobbyists working on behalf of optometrists in the country’s largest eyecare market began pressuring lawmakers to revisit the controversial topic.

Florida

Despite being the site of one of the most acrimonious chapters in the saga, the Sunshine State had been relatively peaceful since the negotiation of a ‘truce’ four years earlier. However, the ‘eyeball wars’ returned in earnest when lobbyists, backed by millions of dollars from various powerful optometric bodies within the state, made a concerted push for legislative change.

According to state tax filings, optometrists are among the largest donors to political causes in Florida. The result has been a series of bills proposing to entrust the Florida Board of Optometry (FBO) with the sole authority to determine what constitutes the practice of optometry, opening the door to lucrative procedures such as anti-VEGF eye injections and Lasik surgery. All that would be needed to perform such procedures is the completion of specialised board-certified training courses – a change that ophthalmologists vehemently oppose, but optometrists believe is long overdue.

Jaime Membreno
“If you live long enough, you will get cataracts and eventually need corrective surgery. Allowing optometrists to do this kind of surgical procedure is like allowing the mechanic to fly a fighter jet,”
Jaime Membreno, Veteran Ophthalmologist

“The fact is we are the primary care for the optics of the eye. We know far more about optics and prisms in the eye than ophthalmologists. They have a different specialty,” South Floridian American Academy of Optometry fellow Dr Salvatore DeCanio told investigative news service The American Media Institute. 

As Florida is home to millions of aging retirees, its expected the demand for invasive age-related procedures, such as cataract removal, will increase greatly in the coming years and optometrists see themselves as part of the solution. Indeed, DeCanio, who has been practicing optometry for more than three decades, said optometrists have been doing more than just prescribe eyewear or ask patients to read eye charts for years.

“I removed something from the cornea (today) on a patient who was in need of immediate care and I am part of a group that is comfortable with some mildly invasive procedures. As an optometrist, the cornea and lens of the eye is not a strange animal for us,” he said.

However, despite the confidence displayed by many of the state’s optometric bodies, and a campaign that saw more than US$2.1 million (AU$2.67 m) poured into lobbying efforts to support the legislation, a vote on Senate Bill 1168 – the aforementioned legislation that would have allowed optometrists to determine their own scope of practice – was postponed and then withdrawn from consideration just two months after it was filed.

Meanwhile, a similar House bill that would allow optometrists to perform surgery on the anterior eye and expand prescribing power to include all narcotics also never made it out of the chamber. A decision on whether to continue with the campaign will be made later in the year, but early indications are that another effort will be made again in 2018.

“My vote is to do it,” Dr Ken Lawson, the former president of the Florida Optometric Association, told local newspaper The Orlando Sentinel. “I’d rather go up there and fail repeatedly. You have a passion for sticking up for your patients, and as long as you maintain that, there’s no reason to get upset.”

However, others are getting upset at optometry’s continued forays into politics, most notably ophthalmologists.

“If you live long enough, you will get cataracts and eventually need corrective surgery. Allowing optometrists to do this kind of surgical procedure is like allowing the mechanic to fly a fighter jet,” Dr Jaime Membreno, a veteran ophthalmologist practicing out of Kissimmee, Florida said.

Another leading critic of the proposed laws, Vero Beach ophthalmologist Dr William Mallon, echoed the sentiment and pointed out that the delicate nature of eye surgery meant the law would increase the risk of patients suffering irreversible damage.

“It takes a minimum 12 years of schooling and training to perform eye surgery, including medical school, supervised residency, etc. The night before my surgeries, I go for a run and get a full night’s sleep. I know that if I lose focus for even a single second of surgery, my patient’s life could be permanently changed,” Mallon said.

“Recently I operated successfully on a one-eyed patient, who was terrified to have a cataract removed from her one remaining good eye. I understood her fear. I think about the stakes every time I walk into the operating room.”

However, with the amount of money being spent by optometry dwarfing whatever ophthalmologists have been able to raise in the past – plus the fact that one of the primary lobbyists for the proposed law, Mr Michael Corcoran, is the brother of Florida State Speaker of the House Richard Corcoran – many pundits believe the changes are only a matter of time.

In fact, some states have already forged ahead with legislation to expand the scope of practice for optometry within their jurisdiction.

Current state of play

On May 9, Georgia Governor Nathan Deal signed SB 153 into law, allowing optometrists to perform eye injections once they had completed a specialised 30-hour injectables training program, supervised by a licensed and board-certified ophthalmologist. The move made Georgia the 14th US state to allow optometrists to perform eye injections, and was hailed as a great victory by the Georgia Optometric Association (GOA).

"Optometrists argue that it expands the availability of specialist eyecare to people who would otherwise been unable to access it, while ophthalmologists have labelled any steps to broaden scope of practice for optometrists as ‘dangerous’"

“This measure being signed into law supports our position that Georgia’s doctors of optometry are highly skilled, well-trained and experienced medical professionals who are working to give their patients access to much-needed eyecare services,” GOA president and optometrist Dr Ben Casella said.

“As the training for doctors of optometry continues to increase to keep up with advancing technology, it is essential for state law to keep up as well and this new law makes that possible. The process of treatment via injection has been taught, both didactically and clinically, in colleges of optometry for many years.”

Meanwhile, Alaska has also recently expanded scope of practice, granting the state’s optometry board sweeping powers to self regulate and determine what procedures an optometrist can and cannot perform. Governor Bill Walker signed HB 103 and its senate companion into law on July 26, in spite of opposition from the Alaska State Medical Association, Alaska State Medical Board, Alaska Society of Eye Physicians and Surgeons, and the American Academy of Ophthalmology.

In fact, opposition from similar groups has been so strong that a 2010 American Medical Association review revealed that since 1997, there had been 46 attempts in 21 states by optometry organisations to legislate surgery privileges, with all but one of these attempts blocked.

However, since the release of the report, Oklahoma, Kentucky and New Mexico have all passed legislation expanding the scope of practice for optometry, despite confronting the same opposition from ophthalmologists on each occasion. With similar bills currently in front of multiple statehouses, it appears expanded scope of practice for optometry is inevitable.

Better access to eyecare

The rationale behind optometrists expanding their scope of practice is simple – access. According to the US Bureau of Labor Statistics, there are around 37,000 practicing optometrists in the country, nearly double the estimated number of 20,000 ophthalmologists. Optometry’s distribution is also more widespread, with most US eye doctors based in major cities.

“There are 550 doctors of optometry in 106 of Kentucky’s 120 counties. In contrast, two-thirds of the state’s counties do not have an ophthalmologist and at the same time, patient need is increasing,” Kentucky Optometric Association president Dr Ian Ben Gaddie said in support of the 2011 legislation that expanded optometry’s power within the state.

Ian Ben Gaddie
"Patients benefit by having greater and easier access to a wide range of eyecare performed by the eye doctor they know and trust,”
Dr Ian Ben Gaddie, Kentucky Optometric Association President

“This law will enable patients to visit their local eye doctor to undergo these procedures, instead of having to travel to an ophthalmologist – often in another city or county – for the same level of care. Patients benefit by having greater and easier access to a wide range of eyecare performed by the eye doctor they know and trust,” Gaddie added.

Aside from the benefits associated with greater access, optometrists also argue they have been teaching many of the procedures, such as eye injections, in their schools for years and that current legislation is cumbersome and cannot keep pace with medical advances.

However, ophthalmologists do not share the same confidence in the level, nor the amount of training optometrists receive in order to perform such delicate procedures.

Australian scope of practice

Back home, optometric scope of practice has not generated the same level of debate. According to Optometry Australia national president Mr Andrew Hogan attempts to expand invasive procedures that optometrists are able to perform appear unlikely in the short to medium term.

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“Optometry Australia (OA) is not undertaking any specific advocacy in relation to the use of injectable agents or to laser surgery as a current goal. That said, optometry practice has, like all health professions, evolved over time, to meet the changing needs of the community and reflect skills and capacities in entry-level training, and it would be remiss of us not to be mindful of this,” he said.

“Any change to any health profession’s scope of practice requires an evidence-based case and a considered approach, which is as it should be.”

Mark Daniell
"By working collaboratively, ophthalmologists and optometrists can ensure that eye diseases are diagnosed and treated, by the appropriate eyecare professional, as early and effectively as possible,”
Mark Daniell, College’s President Associate Professor

Meanwhile, RANZCO has adopted a similar position to its peers in the US. In response to questions from Insight, the College’s president Associate Professor Mark Daniell said it was essential that healthcare professionals provided the care that was suitable to their training and scope of practice.

“Ophthalmologists are medically trained doctors and surgeons, able to diagnose and treat a range of medical conditions. Optometrists are clinically trained, not medically trained, and it is therefore not appropriate for them to perform complex or dangerous medical procedures, such as injections into the eyeball or laser surgery,” he said.

“Optometrists play an essential role in identifying risk of eye disease and diagnosing certain eye conditions, providing prescriptions for eye drops and, importantly, referring patients on for further diagnosis and medical treatment as necessary. By working collaboratively, ophthalmologists and optometrists can ensure that eye diseases are diagnosed and treated, by the appropriate eyecare professional, as early and effectively as possible,” Daniell added.

However, while it currently appears as though the cooperation and mutual respect of the two organisations will prevent an outbreak of hostilities like that seen in the US, 82% of respondents to OA’s biennial member survey said they would like to see the profession’s scope of practice extended. Whether that includes injections or laser surgery remains to be seen, but it may be worth using the situation in the US as a guide for what the potential consequences may be.

KEYNOTE SPEAKERS

Jaime Membreno

Woodford Van Meter

Ian Ben Gaddie

Ken Lawson

Salvatore DeCanio

Michael Corcoran

Nathan Deal

Richard Corcoran

Andrew Hogan

Mark Daniell

 

Too much risk

Ophthalmologists have been united in their opposition of optometrists performing surgery from the beginning. The main basis for their reluctance to expanding optometry’s scope of practice stems from a belief that their training is not adequate to support that type of work.


An example of the dangers that ophthalmologists often point to when discussing this issue is a University of Michigan study that focused on 1,384 laser trabeculoplasty (LT) procedures performed in Oklahoma following legislative change to expand optometry’s scope of practice.

It found that patients treated by optometrists for LT had a 189% increased risk of needing another LT procedure, compared to those handled by ophthalmologists. It also found that the proportion of eyes treated by optometrists needing additional LT in the same eye (35.9%) was more than twice the proportion of those treated by ophthalmologists.

These results were somewhat predicted by the AMA when the law was passed: “Without education or training in surgical skills or incisions and subsequent tissue reactions, the scope of practice expansion put patients at serious risk. Moreover, ophthalmologists’ understanding of the patient as a whole might allow them to recognise an eye condition optometrists may consider routine as an indication of something serious.”

The American Optometric Association (AOA) disputed the veracity of the study by claiming that the optometrists’ follow-up sessions were a result of them following protocal, rather than error on behalf of the practitioner. The AOA also suggested that opposition to allowing optometrists to perform such procedures was due to ophthalmologists not wanting extra competition, rather than safety concerns.

However, another example, this time originating from California, also raised safety concerns associated with expanding optometry’s scope of practice. Veterans Affairs Hospital in Palo Alto used to allow optometrists to perform some surgical eye procedures until a patient lost his sight after being treated for glaucoma by an optometrist.

Woodford Van Meter
"The people pushing the bill to me looked like your dog when you come into the kitchen and he’s taken a piece of meat off your plate"
Dr Woodford Van Meter, ex-president Kentucky Academy of Eye Physicians and Surgeons

The fallout resulted in a full-scale inquiry and the project being shelved. The investigation subsequently revealed that 381 patients from the hospital that had been treated by optometrists risked progressive vision loss, 87 of which were found to be at high risk of further vision loss, and 23 who had already been impacted by progressive vision loss. Seven of the patients were also found to have already had their vision reduced, or completely lost vision in one or both eyes.

Aside from safety concerns, ophthalmologists have also accused some proponents of expanding scope of practice of engaging in political games in order to pass legislation. In a 2011 article featured in The Atlantic, it was revealed ophthalmologists knew about the successful Kentucky bill just 12 hours before it entered a Senate committee, rather than the customary 72.

The entire process, from the bill’s first public posting to the Governor signing it into law, took only 17 days. Dr Woodford Van Meter, then president of the Kentucky Academy of Eye Physicians and Surgeons, said he and his colleagues were given just 10 minutes to make their case at an informal hearing put together at the last minute in the state’s Senate.

“The people pushing the bill to me looked like your dog when you come into the kitchen and he’s taken a piece of meat off your plate,” Van Meter said. “He just looks guilty as sin, but he’s sitting there smiling with big eyes like nothing in the world ever happened.”

In the rush to get the bill passed, an error unwittingly slipped through that gave optometrists the ability to inject into the posterior segment of the eye. It also banned common laser procedures LASIK and PRK, but inexplicably left out LASEK. At the time, Gaddie acknowledged the loophole but said he expected the Kentucky Optometry Board would not allow excimer laser procedures at all. However, at the time he was not on the optometry board.

 

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