Expanding the Scope of Practice

We know that timely intervention is required to preserve the vision and quality of life of patients who have glaucoma, corneal disease, age-related macular degeneration, and ocular surface disease, among other chronic conditions. A pragmatic and evidence-based strategy to improve their access to care is to expand optometrists’ scope of practice. Here, I explain why.

WORKFORCE REALITIES

An estimated 39,205 practicing ODs in the United States are supported by a pipeline of roughly 1,600 to 1,800 new OD graduates each year.¹ This large and widely distributed workforce currently provides most of the primary eye care in this country.²

In contrast, an analysis of US residency cohorts reveals that approximately 450 to 500 new ophthalmologists graduate each year.¹ Based on graduation rates and retirement projections, the ophthalmology workforce is expected to shrink in the coming decades.² Specifically, a recent observational cohort study that used data from the Department of Health and Human Services, Health Resources and Services Administration website estimates that the total ophthalmologist supply will decrease by 12% from 2020 to 2035.²

Also, surveys show annual turnover rates among ophthalmologists in the range of several percentage points, meaning losses to retirement and career changes year after year.³ Combined with an aging US population, the net result is a mismatch among the needs of patients and the supply of ophthalmologists.

Something else to keep in mind: A disproportionately greater number of optometrists than ophthalmologists practice in rural and underserved areas. Scope expansion could, therefore, improve access to advanced care in these areas for patients who might otherwise have to travel long distances for treatment.^4,5

Minnesota may be a case in point. Specifically, recent legislation authorizing optometrists to perform periorbital injections in the clinic allows patients who have related conditions, such as hemifacial spasm, to receive treatment without having to travel long distances.

RISING DEMAND FOR COMPLEX EYE CARE

As the US population ages, the need for comprehensive chronic disease management grows.² Delays in the detection and treatment of such conditions (eg, glaucoma and age-related macular degeneration, among others) increases affected patients’ risk of irreversible vision loss. Costs incurred by the health care system can rise as well.⁶

A PATIENT-CENTERED SOLUTION

Evidence from other countries and pilot programs in the United States support the ability of appropriately trained nonsurgical providers to deliver procedures, such as intravitreal injections and laser therapies, safely and effectively.^7-9 When standardized, the outcomes achieved by these providers can be as favorable as those by eye surgeons.^7-9

Specifically, research has shown that when competency-based training, supervised practice, clear referral pathways, and robust reporting systems are in place, procedures delivered by trained optometrists are safe and effective.^8-10

Something else to consider: Empowering optometrists to handle a greater volume of medical eye care would allow ophthalmologists to focus on complex surgeries, which could maximize efficiency across the ocular care continuum.

A COLLABORATIVE FUTURE

Without bold action, a shortage of fellowship-trained ophthalmologists and an aging US population could leave many patients without timely access to eye care.

A substantial cadre of residency-trained optometrists is prepared to manage medical eye diseases.^5,10,11 In fact, a recent survey reveals more than half of the US optometrists who responded had completed a postdoctoral residency (most commonly in ocular disease or primary care), and national analyses have documented nearly 300 accredited optometry residency programs that support subspecialty training and faculty development.^12-14 These data indicate that many current optometrists possess formal postgraduate training that equips them to safely expand their medical and procedural roles if outcome monitoring and continuing education are in place.

As the burden of chronic ocular disease grows, the responsibility falls on the optometrist—the most widely distributed primary eye care provider in the nation—to meet this escalating demand. To ensure patients maintain access to essential medical care, every OD must understand the importance of scope-of-practice expansion and commit to advanced clinical training. By evolving our medical capabilities, we move beyond being the entry point of the health care system to the definitive solution for the millions of Americans who will otherwise face a crisis in access to eye care.