The Battle of the Eye Doctors

Photo credit: American Optometric Association

by Dick Hall-Sizemore

One of the constants over the many years that I have been around or following the Virginia General Assembly has been the fight between optometrists and ophthalmologists.

The legislative battles between these two groups provide a good lesson in two aspects of the legislative process: the politics of regulation of professions and the role of campaign money. This article will discuss the first aspect and a subsequent article will examine the role of campaign donations.

The ongoing battle of the optometrists and the ophthalmologists has been over treatment of conditions of the eye beyond vision defects. Ophthalmologists have been to medical school and specialize in diseases of the eye. Although they have the title of “doctor,” optometrists have not been to medical school, but have undergone training that enables them to examine patients for vision problems and prescribe corrective lenses. During their vision examinations, if they detect any medical problems, they are supposed to refer the patient to an ophthalmologist.

It started off with the “drops in the eye” bill. Administering “drops” in the eyes would enable optometrists to expand, beyond vision testing, the types of procedures they could perform. They argued that they were sufficiently trained to undertake such activities and their being able to do so would improve access to eye care for the public. The ophthalmologists countered that only medically trained personnel should be allowed to perform such procedures.

It took a few years, but, eventually, the optometrists won out. Since then, they have systematically and gradually expanded the scope of what they are allowed to do. In 2018, for example, the General Assembly enacted SB 511, authorizing optometrists to administer limited injections of Schedule IV steroids to treat a chalazion, a type of cyst in the eyelid, usually due to a blocked gland. The legislation included language expanding the scope of the practice of optometry to include the “evaluation, examination, diagnosis, and treatment of abnormal or diseased conditions of the human eye and its adnexa by the use of medically recognized and appropriate devices, procedures, or technologies.” However, the language specifically prohibited optometrists from providing “treatment through surgery, including laser surgery”.

The front this year in this ongoing battle is an attempt to breach the prohibition on surgery. SB 375 (Petersen, D-Fairfax) would authorize optometrists to perform three specific laser eye surgeries used to treat glaucoma and the effects of cataract surgery. Based on the coverage of the debate over the bill in a Senate subcommittee by the Richmond Times Dispatch, the basic arguments have not changed. The optometrists pointed out that members of their profession have been allowed to perform these procedures in eight states. The success rate in those states demonstrates that optometrists are qualified to perform. Allowing optometrists to perform these procedures, argued the lobbyist for the Virginia Optometric Association, would provide patients with a continuity of care.

The ophthalmologists appearing before the subcommittee contended that the bill is not needed because there is no shortage of eye physicians in the Commonwealth and there would be no cost savings for patients. Furthermore, because laser surgery is “intensely precise,” allowing practitioners other than trained physicians to perform the procedures would be “putting peoples’ eyes at risk.”

The subcommittee voted 5-3 to recommend to the full committee that the bill be reported.

This legislation can be viewed from two perspectives:

  • One group, which has barriers to entry into its membership, is attempting to maintain its control over a lucrative area in the face of an attempted incursion by another group, with both groups claiming their positions are in the best interests of the public.
  • A continuation of the recent movement to allow non-physicians, trained in specific medical areas, to perform some of the procedures formerly reserved for doctors.

I don’t consider myself sufficiently qualified to weigh in on this question of whether optometrists should be allowed to perform certain types of eye surgery. Furthermore, I am not entirely comfortable with legislators making these types of judgments. However, as Senator Saslaw, D-Fairfax, pointed out, ophthalmologists have for years been protesting the expansion of the scope of optometry, predicting “the end of civilization. And that just hasn’t happened.” Lastly, I note that, during my last eye exam, an optometric technician did most of the work that an optometrist had done in the past.

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16 responses to “The Battle of the Eye Doctors”

  1. energyNOW_Fan Avatar

    I see, said the blind man.
    My eyes are pretty bad so this is interesting topic.

    1. Nancy Naive Avatar
      Nancy Naive

      I see, said the blind carpenter as he picked up his hammer and saw.

      I view optometrists performing surgery like I would medical device salesmen performing surgery, and I knew one of those who did.

      1. …or mechanical engineers performing orthopedic surgery.

        1. Nancy Naive Avatar
          Nancy Naive

          My deviated septum was corrected by a mechie. And in an operating room, not a bar. My ENT got his BSME before becoming an MD.

          1. I have long thought that a mechanical engineering undergraduate degree (with a lot of Biology technical electives) would provide the perfect precursor to medical school for those who wish to be orthopedic surgeons.

            I once discussed the issue with the orthho who has done the most surgeries on me and he agreed – even though he had not followed that path.

          2. energyNOW_Fan Avatar

            Chem Engr more likely path

          3. Nancy Naive Avatar
            Nancy Naive

            I think you are correct. I have known 3 doctors with undergraduate engineering degrees. One of them worked 10 years at the yard before entering EVMS in his 30s. He retired two years ago.

  2. LarrytheG Avatar

    Things like diabetes ore age-related pathologies need a board-certified ophthalmologist IMHO and without a clear understanding of who are trained and certified to do that – I fear some folks will take the less expensive, walk-in type care, and then it’s really important that the optometrist knows his/her stuff and does the right thing.

    I know some folks resent the govt “deciding” for folks – and it’s totally true some consumers are more than able to do the research and arrive at a good decision but more than ever if nothing else has demonstrated, Covid has in terms of how people vett information even stuff that is critical to their own health. Of course, it may be that folks don’t want “help” at all and are more than happy with making less than educated choices.

    Most of us have been to the dentist many times over our life and gotten x-rayed and most of us just “trust” the tech and the equipment (which BTW has a “VDH” date sticker on often and usually.

  3. Eric the half a troll Avatar
    Eric the half a troll

    ‘However, as Senator Saslaw, D-Fairfax, pointed out, ophthalmologists have for years been protesting the expansion of the scope of optometry, predicting “the end of civilization. And that just hasn’t happened.”’

    Google “risk normalization”…

  4. I love the fact that you MUST have an eye exam within 365 days of ordering contacts/glasses….even though your vision might not have changed.

  5. James McCarthy Avatar
    James McCarthy

    Only a mention of the fact that ophthalmologists attend medical school as a basis for their training. Not a word about the training of optometrists to perform surgical and other invasive procedures. Yes, legislators are not in a position to judge the individual expertise of either — but the requirement of medical school establishes one acceptable criterion creating public confidence.

    1. Dick Hall-Sizemore Avatar
      Dick Hall-Sizemore

      I did not address the adequacy of training for optometrists to perform laser surgery because I (1) don’t what training is required or provided and (2) even I had known, I am not qualified to offer an opinion as to its adequacy. For all I know, optometrists are, or can be, qualified to perform these procedures safely.

      1. Optometrists complete four years of doctor of optometry school and train for nearly 10,000 hours to learn how to diagnose and treat glaucoma, cataracts and other diseases. Those 10,000 hours include extensive education about the three procedures included in this legislation. All optometrists must be certified in laser procedures before performing them on patients. To be certified, they must have extensive clinical experience, complete hands-on training and pass a national certification exam.

  6. Stephen Haner Avatar
    Stephen Haner

    Yes I would advise new legislators decades ago that among the decisions they needed to make was whether they were pro-optometrist or pro-ophthalmologist. Once in a camp they could expect regular campaign donations from that team….but get crossed up on a vote and Katie Bar the Door. Absolutely no partisan element to this in those days.

  7. Nancy Naive Avatar
    Nancy Naive

    I just want a law forcing optometrists to provide their prescriptions, including pupil distance, without charge should the patient choose to not be ripped off by buying really, really expensive glasses in the showroom at the optometrist’s office.

    And yeah, yeah, I know, there’s already a law. But, it doesn’t include pupil distance, AND IT ISN’T INFORCED, except by the patient’s feet.

    The whole industry is a rip. I’m speaking on behalf of the spousal unit. I buy my glasses at Ace.

  8. Your definition of what an optometrist is able to due is grossly out of date. When I went to optometry school between 197401978, after obtaining an undergraduate degree from William and Mary, we had extensive training in the diagnosis and treatment of ocular diseases and treatment. I remember when Virginia ODs were trying to get the right to use diagnostic dilating drops many years ago. The ophthalmologists argued that “people were going to die in the streets” if ODs were allowed to do that. I’m still waiting for that to happen. Similar arguments were used when we got the right to use therapeutic eyedrops to create various eye infections and diseases. Just as any medical care provider knows when it is the appropriate time to refer patients to a specialist for more intensive care, ODs do the same every day and are the primary care providers of eye care to the citizens of Virginia. ODs must obtain 20 hours of continuing education every year to maintain their license. Most obtain many more hours every year. Just as every other health care profession has new technologies which have been developed to improve patient diagnostic abilities and care, the same applies to optometry. Having to get legislative approval every time we want to improve our scope of practice is ridiculous. For MDs, any time they want to learn a new procedure or technology, they attend a course, just as an OD would, and learn how to use the procedure for the benefit of their patients. Many surgical procedures end up being a “see one, do one, teach one” for MDs. There is no one monitoring the quality of care they provide after “learning” those new procedures and during the course of my career, I have seen many eyes literally butchered by many of the ophthalmologists who hold themselves forth as “experts” in their care and many are the first to protest against ODs’ efforts to expand their scope of practice.

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