Glaucoma Through a Legislative Lens

The word “optometry” was first used in 1865 by J.W. Verschoor in a dissertation on refraction,¹ and in 1901, optometry was established as a licensed profession in Minnesota before other state laws recognized and regulated the practice of optometry.² For the next 70 years, optometric scope of practice remained unchanged, but since 1971, there have been significant advances in scope for optometrists in every state across the country. Specifically, there have been 17 optometric scope expansions in the past 5 years and three in the past year alone, with 10 states now having laser privileges.

MATCHING ABILITY WITH CAPABILITY

The earliest legislative efforts focused on gaining the use of diagnostic and therapeutic pharmaceutical agents, which assisted in the diagnosis of glaucoma, although many states still prohibited optometrists from treating glaucoma. Then came the allowance to manage specific eye conditions, including glaucoma, with some states initially requiring comanagement with an ophthalmologist. The most recent efforts to expand scope of practice have revolved around the use of lasers, injections, and the performance of additional in-office procedures, such as eyelid lesion removal and corneal cross-linking. Being able to offer all first-line treatments for glaucoma, along with other advances, has enabled optometrists to become true primary eye care providers.

Just as medical education has evolved over time, optometric education has also changed significantly since the inception of the profession. Optometrists have been suboptimally utilized in the health care system for decades, and we hope to see that continue to change. In most states, the education optometrists receive exceeds what they are legally allowed to do in practice. Current legislative efforts are simply meant to allow optometrists to fully use their education and training. These efforts have been particularly impactful in glaucoma care. Given the lack of symptoms in the early stages of glaucoma, it is the primary eye care provider who typically identifies and initiates treatment for patients with the disease. Most modern optometrists could not fathom practicing without the ability to treat glaucoma, let alone without the ability to perform tonometry or dilate pupils. Allowing optometrists to provide the full array of first-line glaucoma treatments just makes sense. In addition to using drops and oral medications, laser treatments and slow-release implantable medications should be part of every optometrist’s treatment toolbox.

Virginia optometrist and American Optometric Association 2022 Optometrist of the Year Jeffrey Michaels, OD, FAAO, confirms this. “Optometrists are educated, trained, and certified to perform laser glaucoma care. Many states are using 1970s thought processes when it comes to optometry and are behind in adopting change,” he commented.

MILES WE HAVE TRAVELED, AND MILES WE HAVE LEFT TO GO

Optometric scope expansion is not only important for glaucoma, but also for the future of general eye care in our health system. Numerous articles speak to the looming shortage of ophthalmologists and to the growing population of individuals over 65 years of age.^3,4 Ophthalmologists are best utilized performing cataract surgeries and offering complex, high-level surgical care. There is a need for other eye care providers to offer a broader scope of in-office care, and optometrists are a perfect fit for this role, with their existing training.

Optometry has come a long way, and with every step and each new privilege gained, we have exhibited nothing but competence. The relationship between optometry and ophthalmology is well-established and could be described fairly as codependent. There are times, especially during the management of patients with glaucoma, when a patient needs more advanced surgical care and a referral to an ophthalmologist. Optometrists provide preoperative and postoperative care for many, if not the majority, of procedures performed by ophthalmologists, and ophthalmologists have trusted optometrists to care for their surgical patients, confident in the OD’s ability to identify and treat complications that arise. Accordingly, as optometrists have gained additional privileges, results predictably demonstrate that the patient safety issues suggested by political ophthalmology are just not there,⁵ opening the door for more states to confidently expand optometric scope and improve access to eye care in local communities, especially for glaucoma.

During our recent legislative effort in Colorado, political ophthalmology, as they have done in other states, not only argued that they had a concern for patient safety (without adequate evidence to back it up), but also that they believe there is not an issue with access to care, but we know that to be untrue.

According to Coby Ramsey, OD, “In Wyoming, there are no full-time glaucoma specialists and very few full-time ophthalmologists. Being able to offer all treatment options has been great for our patients.” Residents of rural Colorado have similar access issues. A rural Colorado patient told his optometrist unequivocally that he would rather go blind from glaucoma than travel to Denver for care.

According to the Colorado State Office of Rural Health, “Rural areas have insufficient access to primary care and other health care services, which results in poorer health outcomes, higher costs, and higher acuity conditions at time of treatment.”⁶ They also published that rural patients traveling to non-local (urban) hospitals have a cost burden upwards of $600 for a single visit, which creates a major barrier to care. Access issues are not unique to rural areas; patients in urban areas can be affected by long waits and duplicative visits.

Dr. Jeff Michaels explained, “Any time a patient has to be referred for care because an out-of-date law won’t allow an optometrist to fully use their education and training, there is an access issue. No person wants to be forced to go to a different doctor for additional tests and exams when their OD is capable of providing the treatment in-office.”

STAY CURRENT

Glaucoma technology is evolving, and as primary eye care providers, optometrists must stay up to speed. Optometric laser and surgical courses are routinely offered at Northeastern State University Oklahoma College of Optometry and the University of Pikeville Kentucky College of Optometry, and periodically at other locations around the country, providing the opportunity for practitioners to stay up to date and refresh their training. Remember, it’s up to each optometrist to stay apprised of current procedures and protocols.

Optometrists are the first to diagnose, manage, and treat glaucoma for the majority of patients in the United States. It is important that optometrists have a full set of tools available to manage their patients. As stated earlier, recent scope expansions only allow optometrists to practice to the level of their education and training. The various “advanced” procedure courses most states require to ensure competency are an extension of current education and training rather than the introduction of new knowledge. The techniques, safety protocols, and management of complications for all these procedures are built into current optometric education and have been for decades. The basic components of the instruments used for the laser procedures are identical to the equipment we use daily.

Although a compromise to patient safety continues to be the primary argument political ophthalmology raises, nationwide data show the opposite to be true. There have been more than 100,000 laser procedures safely performed by optometrists in Oklahoma, Kentucky, and Louisiana alone. Tens of thousands more have been performed in the six other states that followed. Arkansas optometrists performed 1,000 procedures in the first 9 months after they received scope expansion. There has been no increase in malpractice rates or claims in states that have expanded scope to high levels, according to Lockton Affinity, the largest provider of optometrist malpractice insurance in the United States (Table). The National Provider Database has shown no increase in judgments or actions against optometrists, and there has never been a repeal of optometric scope expansion in the country by any state legislature.

ADVANCING FORWARD

The future of glaucoma management depends on a robust team of well-trained eye care providers who offer a diverse array of treatment options. A growing number of states are moving forward to improve access and care to their communities by allowing optometrists to practice at the top of their education. You can help keep progress moving by staying up to date with the latest news, taking courses to keep your skills sharp, or even getting involved with your local state optometric associations.