Optometrists, ophthalmologists fight over eye care rights

"Even though I love my optometrist, I would never, ever let him do surgery," says Denishia Martin Hostetler, an Angie's List member in Bowling Green, Ky., where lawmakers this year gave optometrists the right to perform some surgical procedures and expand scope of practice in other ways. "I would want a full-fledged MD, with lots of experience and credentials."

But Tom Wiesle, a member in Plano, Texas, expresses a less popular opinion in saying he'd feel comfortable going to his optometrist for laser surgery - if only his state allowed it. "I totally trust him," Wiesle says. "He's just so knowledgeable."

From California to Maine and 16 states in between, optometrists have been pushing to broaden services, exacerbating a turf war with ophthalmologists who provide the full spectrum of eye care. By being allowed to do more, optometrists insist they can help patients save money and benefit through improved continuity of care and fewer referrals to ophthalmologists, who are more expensive. "We're not holding ourselves up to be ophthalmologists," says Bill Reynolds, an optometrist in Richmond, Ky., and legislative chair for the Kentucky Optometric Association. But training and expertise have evolved, he argues, and practice needs to catch up.

Ophthalmologists fire back that optometrists - who attend a four-year post-graduate optometry program but lack their eight years of medical school, internship and residency training - are sidestepping critical experience and education. "They want to practice medicine without going to medical school," says Dr. Daniel Briceland, a highly rated ophthalmologist in Sun City, Ariz., and secretary for state affairs with the American Academy of Ophthalmology. "This is how people get hurt."

Intense optometrist lobbying over the last three years has produced mixed results. In eight states, they won approval to prescribe more drugs, administer additional types of injections like local anesthesia and - in the case of Kentucky - perform laser surgery. They failed to prevail in seven others, with lawmakers withdrawing proposals, killing bills on adjournment or stripping scope-of-practice provisions. Texas, South Carolina and Nebraska were still considering legislation at press time.

In West Virginia, the debate grew especially contentious as eye doctors on both sides of the issue testified at the state capitol in Charleston, with ophthalmologists sporting "Surgery by Surgeons" stickers and optometrists wearing "I Support Optometric Physicians" badges. West Virginia legislator Don Perdue thinks optometrists and ophthalmologists are sincerely concerned about what's best for patients, but add that both have professional clout and financial interests at stake as well - "money being of primary interest." Where scope of practice overlap, Perdue contends, they're vying for the same patients.

As chair for the state's House of Delegates Health and Human Resources Committee, Perdue became intimately acquainted with the two groups during a marathon negotiating session last year. "We spent those 16 hours locked in my office literally trying to keep people from clawing each others' eyeballs out," says Perdue, who ultimately voted with the majority to allow optometrists to prescribe more medications and administer some injections after laser surgery was taken off the table.

California legislators also rejected laser surgery but agreed to reduce training requirements for treating glaucoma, saying optometrists graduating after 2008 receive sufficient preparation in school. However, medical groups have sued to prohibit the new regulations from taking effect, saying optometrist education doesn't go far enough. "[The regulations] don't protect patients," says Dr. Craig H. Kliger, an ophthalmologist and executive vice president of the California Academy of Eye Physicians & Surgeons.

Optometrists' move to deliver more of the care traditionally provided by ophthalmologists has helped to blur the line between the two professions. According to a recent online poll of Angie's List members, 93 percent claim to know the difference between optometrists and ophthalmologists, but 25 percent went on to incorrectly describe an optometrist as a medical doctor. "I thought they had to go to medical school," Hostetler says. "But they're referred to as doctors nonetheless. That's kind of a misnomer." Chuckling, she adds: "I have three master's degrees and I don't get to be a 'doctor.'"

Like Hostetler, most poll respondents have reservations about seeing an optometrist for anything but basic eye care. Just 8 percent would turn to one for help with glaucoma - which optometrists are permitted to treat in every state but Massachusetts. When it comes to injections and laser surgery, only 2 and 4 percent, respectively, say they would trust an optometrist.

Oklahoma became the first state to allow optometrists to perform some laser surgeries in 1998. That's also when lawmakers explicitly upheld their right to administer injections, remove eyelid lesions and prescribe an expanded list of medications. "The procedures we're doing are not technically involved," says David Cockrell, an optometrist in Stillwater and spokesman for the American Optometric Association. "We've never had a single case of a patient being harmed reported to the [state optometry] board. That's a pretty startling statistic."

It's also a misleading one, says ophthalmologist Dr. David Parke II, former head of the highly rated Dean McGee Eye Institute, based in Oklahoma City. "We had several patients come in with horrible complications from totally unnecessary surgical procedures," says Parke, now the executive vice president and CEO of the American Academy of Ophthalmology.

Pam Odum of Owasso, Okla., outside Tulsa, says she never would have gone to an optometrist for laser surgery had she known he was not a medical doctor. "I was almost blinded," says Odum, who sued Jan Jay Rigney for negligence and says his incompetence in performing a procedure to correct astigmatism and the homemade eye solution he gave her caused temporary blindness and permanent blind spots. "To this day, I have limited vision," Odum says. Rigney, who settled the case with Odum for an undisclosed sum, declined to comment.

Cockrell says if malpractice were a big issue, insurance rates for optometrists would have shot up in Oklahoma. Parke argues the reason they haven't is because optometrists are mostly still prescribing just glasses and contacts, which carry little risk. The potential danger to patients is very real, he adds.

Out of some 25 highly rated Oklahoma optometrists surveyed by Angie's List Magazine, only three say they perform PRK or another type of laser surgery. Although it's been more than a decade since the new law went into effect, most continue to refer patients to ophthalmologists at surgery centers who perform a high volume of procedures, including Lasik, which optometrists aren't permitted to handle.

Tami Ross, a highly rated optometrist in Oklahoma City, says she's certified to perform laser surgery but the investment in equipment isn't practical. "The lasers are pretty expensive," she says, estimating that PRK equipment costs as much as $500,000. "Unless you can pay for them doing [procedures on] a lot of folks, it's not worth having them."

However, Ross adds that many more optometrists in rural areas are performing surgery and she expects to see an increase in cities, too, because laser training's become the norm in optometry schools. "It's part of their curriculum now, so you're going to see more and more of that done than in the past," she says. "The new [optometrists] are taught it from day one."

Optometrists in neighboring Texas are among those seeking approval to perform laser surgery. If successful, optometrist Jeff Thomas says he might expand his services to include corrective surgery for certain cataract patients. The highly rated Dallas area optometrist - and Wiesle's provider - agrees with his peers that broadening care can reduce the need for referrals, save money and better serve patients. "That's the bottom line," he adds.

A household survey conducted by the Agency for Healthcare Research and Quality says patients spend about $50 on an eye exam out of pocket, whether they see an optometrist or ophthalmologist. But the total spent by all parties, including insurance, Medicare or Medicaid, is $132 for ophthalmologists compared to $94 for optometrists, says Jeff Rice, CEO and founder of Healthcare Blue Book, which analyzed more than 15,000 patient records. Similarly, he says, opening a blocked tear duct costs the system $169 for an optometrist versus $232 for an ophthalmologist.

"On average, it looks like ophthalmology gets paid about 40 percent more than optometry for the exact same services," Rice says. "I think it costs more because of the higher level of training and some of the additional overhead of a medical practice." Ophthalmologists also earn more than twice what optometrists make - $305,724 compared to $126,319, according to CareerBuilder.com.

In Texas, Thomas says he was taught how to use lasers and treat glaucoma when he went to the University of Houston College of Optometry in the 1990s, years before the state allowed optometrists to prescribe glaucoma medications. "They definitely train beyond the current scope of practice," he says.

Due to legal restrictions, students at the school gain experience by performing laser surgery on animals, primarily rabbits, says Earl Smith, the school's current dean. "About a quarter of our class rotate through Oklahoma and get experience on humans," Smith says, adding that others only operate on people after they graduate.

All 19 accredited optometry schools nationwide teach courses on lasers, according to Smith, also the president of the Association of Schools and Colleges of Optometry, a nonprofit representing the interests of optometric education. However, Smith didn't have precise details about hands-on training. "Every school strives to make sure their graduates are eligible for licensure in every state," he says, meaning they learn skills to match scope of practice and beyond.

However, Briceland says post-optometry school education can amount to weekend courses at the Holiday Inn to learn surgery. "There's no standard of education," he says. While ophthalmologists may also learn new laser techniques at short seminars, Briceland says ophthalmologists already have a broad base of experience. For example, they perform many different surgeries, from Lasik to cataract surgery, on human patients during medical school, internships, residencies and up to two years of optional fellowship training. "How can you claim four years of post-college education is the same as 8 to 10?" Briceland asks. "You can't."

Educational differences didn't stop Kentucky optometrists, who successfully pushed to become the second state nationwide to allow them to perform some laser surgeries. A strong bipartisan majority passed the bill in February and Gov. Steve Beshear signed it into law the same month. "This new law will mean more Kentuckians can get the eye care they need," Beshear said, pledging that optometrists who expand scope of practice will undergo extensive training. In addition to surgery, the Kentucky law gives optometrists the ability to administer injections like local anesthesia, prescribe more drugs and grants the state optometry board broad authority to further expand scope of practice, save for prohibited procedures like PRK and Lasik.

Critics say nearly $400,000 in campaign contributions was responsible for the legislation's swift approval. "The optometrists had an excellent lobby," says state Rep. Susan Westrom, one of only a few legislators who voted against the law. She contends it was rushed through: "I don't think we can trust the outcome because we didn't have all the information."

Though Westrom goes to an optometrist and considers their role integral to eye care, she sees no reason for the broad expansion of practice. Woodford Van Meter, a highly rated ophthalmologist in Lexington, Ky., and president of the Kentucky Academy of Eye Physicians and Surgeons, agrees with her. "There's never been a consumer group, an advocacy group or a patient group that's said this is a good idea," he says.

But Reynolds believes expanded services are a logical step in the evolution of primary eye care. "I think that if consumer groups were properly educated on it, if they could look at the educational background of optometry [and] at the history of safety of optometrists, they would be in favor of these procedures," he says.


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Comments

I thought this article was well written and informative. I don't consider this biased reporting at all, as I felt both sides were represented. Personally, I don't trust anyone but an MD to perform surgery, especially on my eyes. Just like I wouldn't want my chiropractor - as much as I trust him - doing surgery on my back!

Blatently biased article - or worse - incomplete research. Either way, I'll be discontinuing my association with Angie's List. Poorly done, Angie. I hope the repercussions aren't too detrimental.

I object strongly to making Angie's list a forum for complex health-related issues. There are more factors involved than your superficial article describes, and the opinions of the casually interested or the parties to the contention do not make for informed debate. I have some knowledge of the issues, but this is not the place to discuss them.

As someone who has maternal and paternal history of glaucoma, I trust a doctor (read opthamologist NOT optometrist) for all my eye care.

Your leader asks about trust, but your article is about force (legal "right"). I might not trust my optometrist to perform some surgeries, but this does not mean that she shouldn't have the legal right to offer that surgery. I wouldn't trust my internist (with whom I am quite pleased) to conduct surgery even though he has the legal right do so.

As reported in the Courier-Journal this morning, the General Assembly's Administrative Regulation Review Subcommittee declined to dismiss reject the regulations. That is equal to an approval, moving it closer to law. This regulation calls for only 32 hours of additional training for an optometrist to perform certain laser surgeries. As quoted in the article, cosmetologists are required to complete 1,700 hours before licensure. Because of the way optometrists paid for this regulation to be pushed through the legislature, I now go to an opthamologist for even routine eye exams. In protest? you bet. Does it cost me more? Yes, it does. Quality is worth it.

I have Glaucoma and am being treated very nicely by an Opthamologist. I cannot see the issue in which Optometrists are seeking to expand their servies. I'll stay with a properly certified MD. It's also difficult for me to understand why Angie's List is taking up the cross for Optometrists.

Wow, first don't ever let anyone cut your eyes unless you're blind, you'll continue to have to wear glasses and possibly get other complications worse than you could ever dream of. Now allowing monkeys to do it! That takes the cake!

It says a lot that all the negative comments on the article come from optometrists. Patients seem to consider MDs better qualified and that's whom they trust with something as critical as their eyesight. Next subject: how do you feel about having nurses provide your anesthesia, without physician supervision? It may be hard to know who is who since nurse anesthetists have been awarding themselves 6-month degrees to become "Doctors of Nursing" and many of these then introduce themselves to surgical patients/families as "Dr.Anesthetist."

Personally I am not comfrtable with an optometrist doing anything with my eyes other than the simple vision tests & examinations including dialation and prescription for glasses or contacts. I have been to both and actually had a metal sliver embeded in my cornea that had been ther for several years but had never bothered me. I didn't even know it was there and had been to my optometrist for an exam after the fact. He didn't notice anything and as I stated, it didn't bother me until one very bright sunny day after a snow storm I was driving home from work and all of a sudden my eye felt like someone stuck a pin in it, I teared up and I couldn't see. I actually had to park the car and have my wife pick me up. She took me to an ophthalmologist that day and within seconds of examining my eye he found the sliver of metal, removed it and I was fine within a few days. I was amazed that the optometrist who was well known and considerd to be one of the best in our area never saw this issue after a complete eye examination with dialation never noticed this and the ophthalmologist saw it within seconds. He is also associated with Wills Eye Hospital which is one of the top if not the top institute for eyes. So in my opinion, optometrists should just stick with what they do now.

Did it occur to you that if you had metal in your eye for years it would not be so superficial and so easily removed in office? Don't you realize that the previous doctor did not miss metal in your eye,but that it had just recently happened when it started bothering you?

I never see an optometrist for eye care; our vision is too important to entrust it to any but the most qualified ophthalmologist.

The Kentucky legislation causes me some concern. I live there and my husband wore contacts in both eyes for years before going to an opthamologist for Lasik. The opthamologist listened to my husband explain his vision trouble, especially in the contacts prescribed for his left eye (most recently a toric lens). After examining him, the opthamologist found that my husband had nearly 20/20 vision in the left eye. After Lasik on the right eye, my husband now sees nearly perfectly. In retrospect there may be a lot of explanations for why two different optometrists made two different and unnecessary prescriptions for lenses in a well-seeing eye, but the outcome is the same.

Okay, how do we know all these Doctor [Letter]s commenting here aren't the same person? If you're not using your name, well... It's an interesting topic. If passing a law allows folks who were a residency short of performing surgery before to start cutting, well, there's a reason to be pretty danged careful. The Good Dr [Letter]s need to argue why optometrists should be allowed to perform surgery rather than simply bash Angie's List, or I've got another reason not to trust them with the tissue in my eyes.

As a medical professional I am well aware of the risks of surgery. Far too often "little procedures" turn into major events that require serious medical intervention. Yes, it would be cheaper to have someone with less training do surgery but how far do we go when trying to decrease the cost of health care. Especially when discussing elective procedures.

I have also heard of opthamologists performing plastic surgery--that was not part of their training. When you see "board certified" in an ad, ask "board certified by whom and in what branch of medicine." Did they take a weekend seminar, or did they go to med school to learn that specialty?

Miki, oculoplastics is a subspecialty of ophthalmology. One needs to study 2-3 years to be an oculoplastic surgeon. Face is a very complex area with many different expertises needed.

I have had some very bad experences with eye doctors meaning optometrist , I would never let one operate on me. I have been to three optometrist in the last five years. as my sight ages, they just shrug it off. and my glasses here in the usa are no less than $380. I have had to buy from zenni several time. got a not so quite unedstanding on that. My last eye doctor was from eyeear opitical, saw their doctor and he saaid he did not like to stir the pot so to speak, I my mother and me had not said yes our vision had change he was willing to rewrite the glasses strenth we already had! avoid the exame all togeather. last pair of glasses I buy for them, They did not even adjust the glasses to my face. I can do this with a pair fo 50 dollar glasses from Zenni on the internet. so I would never let these Drs. operate on me. ever. The MD goes to school and can handle complications I would hope. It is kind of like the ENT drs now attending a coulple of hours and are doing plactic surgery. Bad Idea.

I wish I could understand most of what you are saying! But I do understand what you are saying about the high price of a pair of glasses. OUTRAGEOUS!

The optometrists who read this well done report are obviously not very happy with it. That may tell us more about them than the report. The truth is that there are good reasons why licensure has to mean something, and just because someone may want to improve their status and income, that doesn't necessarily make it a good idea.

I'm just curious why you say this is a "well-done" report? What is your background? Have you done extensive research yourself in this area? There is, in fact, a heated debate about optometry and ophthalmology education and ability to perform procedures. Both professions are trained rather well, and require extensive board certification to practice in any state in the country. the real question here, and it is not adequately explained, is whether the surgeries the ODs are performing are within the scope of practice for an OD. The story at the head of the article talks about a "bad" OD - in the US, ODs are not licensed to perform LASIK or intra-ocular surgeries in any state (it sounds like what this patient's surgery was). Who's to say that this patient happened to fall into the category of the small percentage of patient's who suffer from adverse events following surgery (ALL surgeries have adverse events that COULD happen, regardless of which type of doctor). Also, ODs are not performing surgeries that OMDs perform - we cannot do LASIK, retinal surgery, cataract surgery, or extra-ocular muscle surgery. The real issue here (with most of the comments, as well), is that the population is not educated as to what the surgeries truly are. Yes, the procedures are called surgeries because of the devices we use, but the term "surgery" carries with it a fear of complication by all patients. Realistically, ODs perform procedures not involving cutting into the eye, where as OMDs perform surgery, resulting in cutting into the eye in most cases. ODs are merely trying to lessen the load of OMDs so that OMDs have the freedom to specialize even more. As far as training goes, YES ODs do have board certification the occurs ONLY after 4 years of specialized schooling (not a weekend class), residency options are offered to further knowledge (which I am currently taking part in), and we are specifically trained in ocular disease. ODs do not want to treat the rest of the body, but schooling is specifically aimed at detection of systemic disease through evaluation of the eyes. OMDs get the system ic training (including 1-2 weeks spent on the eye) in a four year medical school, THEN study eye-specific disease and procedures in Ophthalmology-specific training (sound like the OD program - wow, what a surprise). OMDs are better equipped, and are certified, to treat the systemic disease of a patient, but don't necessarily have a better ability to recognize ocular or systemic disease upon graduation versus an OD. Again, OMDs are eye-specialists that can treat systemic roots of disease and perform surgery. ODs are like PCPs for the eyes - we refer to specialists when needed (like you have a heart problem and your PCP refers you to a cardiologist - you wouldn't have your PCP WHO WENT TO MEDICAL SCHOOL perform your heart surgery, would you), but ODs can and do treat ocular disease as physicians.

I agree with the commenter Christine. Each has their own scope of practice and should work together. I completely trust my optometrist to provide general eye care for healthy eyes and to screen my vision for any potential problems since that is what they are well-trained to do, but if there is anything wrong, I am going to an MD. A lot of people don't know that the eye is sort of a window in the body's state of health; sometimes symptoms of a more systemic condition show up in the eyes first. An optometrist, having not gone through medical school, internship, residency, and fellowship, is simply not trained to address these issues adequately. A good optometrist is concerned for their patients' health and knows when to refer to an MD. A bad one is one that tries to push unnecessary out-of-pocket expenses (like having a picture of my retina taken. If there is something wrong, my insurance will pay for the MD to look at it and take a picture if necessary) or strange herbal eye drops. The problem is that there are great optometrists and then there are really bad ones. MDs have to go through multiple phases of training and pass several intense board exams, a process which weeds out the competent from the incompetent. If optometrists want to expand their scope of practice, they ought to go through more (regulated) training programs as well. My brother is an ophthalmology resident, and he's told me that he often sees patients with complications due to misdiagnosis or incorrect medications prescribed by optometrists. The reason you don't hear much about malpractice claims is because the patients don't know their issue was caused by the optometrist! The ophthalmologist will rarely point the finger at the optometrist because optometrists are ophthalmologists' source of referrals. Ratting out the optometrists would be like biting the hand that feeds you...

OD's also have multiple phases of training via 3 national board, practical competency, and licensure examinations on top of the endless number of examinations through Optometry school. I just wanted to throw that out there a lot of people know what it takes to graduate medical school but virtually no one knows what it takes to graduate through optometry school (MD's included). Further, like you said, there are great OD's and bad ones. The same applies to Ophthalmologists as well. The great ones are the absolute authority on eye diseases, but who is to say a bad Ophthalmologist did not cause the issue (I'm not insulting your brother, just giving a hypothetical)? Optometry students spend literally 2 years devoted to ocular disease alone. Diabetic retinopathy, Age-Related Macular Degeneration, and Glaucoma can be treated for years without requiring an Ophthalmologist (aka surgical intervention). Granted, our education does not equate 3+ years of Ophthalmology residency, but to imply that we do not know how to detect and, if warranted, treat ocular disease is inane. Finally, you are fortunate to have a brother who is an Ophthalmology resident, but if the average patient goes straight to an Ophthalmologist for an eye condition (even a painful one like anterior uveitis) that can be easily treated by an Optometrist, that patient will really irritate the OMD. They have a large patient load, and you would literally be wasting their time if you did this. I've worked with several OMD's and they have very limited time with the patients and as a result come off as having poor bedside manner. In reality, they are trying to give the proper attention to every patient they have.

It is a shame that this article was not taken as I would hope, intended. And that is to educate the public. Not everyone even knows there is a difference between optometry and ophthalmology, though both are called doctors. An ophthalmologist can spend an additional 4 years of training to be able to perform eye surgery and treatment (fellowship) in a particular sub-specialty in the field of ophthalmology. Optometry, as nursing, as physical therapy, as pharmacists, all provide patient care but only physicians go to medical school. Jut because you go by Dr. doesn't mean that you have the training to perform surgery. When it comes to my eyes or my family, only an ophthalmologist will perform surgery. I have no problem going to an optician for my prescription for glasses. As with the information on other services provided through Angie's List, this is educational.

I bet everyone would be happy to know that the eye exams they get from an md are done by technicians with only on the job training! How about the ophthalmologist learned how to do a procedure the weekend before at a hotel. Do you think your dentist is not a doctor? How about a podiatrist that does foot surgeries! Optometrist are doctors with much more education on eyes than an md. Do you know that they spend one week on eyes in traditional medical school! Ask your general pcp what they know about eyes... Nothing. I had ophthalmology resident second year that couldn't find a retinal tear. Btw, just wait and see what the physicians assistants are allowed to do in the future. With no medical school or surgery training. I know some that are essentially doing knee replacements.

I had both....optometrist for the glasses.....opthamologist for the retinal surgery. So from a consumer point of view I have an educated opinion about all this discussion. I would not want a "technician" opening my innards up to take out my appendix.....ergo.....why would I want a non-doctor poking instruments in my eye, including a laser, to do a delicate operation that will prevent me from going blind? I want the guy with the most education about ALL aspects of the human body if he is going to stick something in some part of it. This turf war is all about money in the end, but I have to defer to the real doctors when it comes to surgery. I only have two eyes that are not so good anyway...why not get the best for them? Just saying:)

I felt the article to be unbiased. It is clear that OD on the list were not happy. But, none made any arguments of their own as to why their scope of practice could or should be expanded. Telling, isn't it! Of course, this is Texas so they will allow it. Just like they allow anything anybody else wants to do in contrast to patient's wellbeing.

I have worked in the eye health care business for 20 years and have seen and read about the lobby efforts and money the optometrists have paid to get their scope of practice expanded. It's simple, you cannot buy a education you earn it. If you wanted to be a physician and surgeon GO TO MEDICAL School, get the training, knowledge, peoples EYEs are risk. God only gave us two.

I'm sorry, do you tech for a specialist or something? Working "in the eye health care business" from the standpoint of a technician, receptionist, or administrator does not give you any special insights about what happens in an exam room, even if you're in there with the "real doctors". But, nice try.

You only have one set of eyes. Why mess with the most precious sense your body has? Why would anyone allow an non-M.D. (optometrist) to do surgery on their eyes? In fact, when you see your ophthalmologist, make sure they wash their hands (and equipment) BEFORE they touch you. I went in for a checkup and an assistant to my eye doctor (ophthalmologist) said a woman came in with an eye infection she got at another office because they didn't do this.

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