Non-physicians doing laser surgery on eyes? Idaho doctors call proposal ‘dangerous’
The Idaho Legislature is considering a proposal to allow optometrists to do surgical procedures that only doctors are now allowed to perform. Supporters say the bill would bring health care to rural areas, but eye doctors warn that the change could put Idahoans’ eyes in danger.
The bill, Senate Bill 1052, is part of a nationwide effort by the optometry industry to expand the eye treatments that optometrists can do.
The industry has spent tens of thousands of dollars on campaign contributions to Idaho legislators and Gov. Brad Little. And on March 8, optometrists won a victory when the Idaho Senate approved the bill 23-11. After getting a first reading in the House, it was sent to the Ways and Means Committee on Monday.
Between 1996 and 2017, only three states allowed optometrists to operate with lasers. In the last six years, however, seven more states have been added to that list. Forty-plus bills across 20 states failed — including a 2020 attempt in Idaho.
The 2020 bill was an expansive proposal to clarify and expand the role of optometrists in Idaho. This year’s bill is more focused: It would allow optometrists to do three specific laser surgery procedures that are used to treat conditions that affect glaucoma and cataract patients. LASIK, the most well-known form of laser eye surgery that is used to correct vision, would still be performed only by medical doctors.
Still, the American Medical Association said the three proposed surgeries are three too many.
Optometrists vs. ophthalmologists
Ophthalmologists and optometrists have confusingly similar names but different training requirements.
Ophthalmologists are medical doctors with 12 to 14 years of education and training, including a bachelor’s degree, medical school, internships and residency. Those training to be ophthalmologists average 17,000 hours of clinical training with live patients, according to the American Academy of Ophthalmology.
Optometrists are health care professionals with about eight years of education and training, including a bachelor’s degree and a four-year optometrist degree. Those training to be optometrists average 2,500 hours of clinical training with live patients, according to Eye M.D.s of Idaho. That is consistent with listed hours on optometry program websites, including University of California, Berkeley and the University of Alabama at Birmingham.
(A third group of eye specialists, opticians, receive one- or two-year certificates or diplomas, WebMD says. Opticians can fill prescriptions for glasses or contacts.)
In most states, including Idaho, only ophthalmologists are allowed to perform laser eye surgeries. Optometrists say they’re trained and willing to do them too.
“These therapeutic laser procedures have been a part of our training and education for several decades now,” optometrist Lauren Huber, owner of Six One Six Vision Center in Eagle, told the Idaho Statesman by phone. “...These procedures are becoming mainstay care for procedures that I treat every day, helping patients after their cataract surgeries and treating patients with glaucoma. I would love the opportunity to be able to perform these procedures on my own patients.”
Do optometrists have enough training?
Opponents, which include the Idaho Medical Association and the Idaho Society of Ophthalmology, say patient safety is their biggest concern.
“Optometrists do not have the education, training, or experience to perform any type of surgery, including laser surgery involving the eye or tissues surrounding the eye,” the American Medical Association wrote in a letter to the Senate Health and Welfare Committee. “Allowing optometrists to perform laser surgery would pose a serious threat to the safety of patients in Idaho.”
The association said most optometrist training focuses on “examining the eye for vision prescription, dispensing corrective lenses, and performing some eye screening functions.”
Training on live patients is a major point of contention. Brent Betts, an ophthalmologist at Intermountain Eye Center in Boise and the chief ophthalmologist for St. Luke’s Health System in Ada and Canyon counties, said he performed hundreds of surgeries on live patients under the supervision of other doctors before he became an ophthalmologist.
Under the bill, optometrists would not be required to have operated on a live patient before performing surgeries. Most optometry students do not practice on live patients, and people can pass the optometry board examination by demonstrating on a model eye.
Even for optometrists who want to train in lasers with live patients, it can be difficult to get that opportunity. Of the 25 optometry schools that teach these procedures, 23 are in states where optometrists are not allowed to perform laser surgeries on patients, according to a letter from the Kentucky Academy of Eye Physicians and Surgeons to legislators.
“No one wants to be someone’s first surgical patient,” Betts told the Statesman by phone.
In 2019, the Vermont Legislature directed the state’s Office of Professional Regulation to conduct a study evaluating the benefits, costs and risks of a similar bill. The concluding 2020 study said one of the biggest concerns was the lack of transparency in optometrists’ training. The Vermont office contacted 21 optometry schools requesting details about how their students were educated on advanced procedures. None of them responded.
“Despite multiple efforts through various sources, OPR was unable to gather specific or detailed information about the curricula and courses offered by the U.S. schools of optometry in these advanced procedures,” the office’s report said. “Other states attempting to gather such information have met with similar refusal to disclose detailed curricula.”
Debates over safety
Debate on this issue has been fueled by a lack of conclusive data on patient outcomes.
Supporters of the bill say there haven’t been safety issues in states where optometrists have been doing these practices for decades.
“Combined between (Oklahoma and Kentucky), we have about 110,000 of these laser surgeries that have been done by optometrists without any, any complaints, any exceptions, any negative problems,” Sen. C. Scott Grow, R-Eagle, said in the Senate on Wednesday.Grow introduced the bill.
Access Eyedaho, a website created by the Idaho Optometric Physicians Association, asserts that only one negative outcome has been reported to state boards of optometry in Oklahoma, Kentucky and Louisiana since 1998.
Ophthalmologists say those numbers indicate only that no patient has complained to the state boards of optometry. The Kentucky surgeons’ letter detailed five unnamed patients whom Kentucky ophthalmologists said they had treated after mistakes were made by optometrists.
The Vermont Office of Professional Regulation said it was given “inaccurate reports” from other states during its study.
“The states that have expanded the scope of practice report that there have been no complaints, complications or malpractice cases against any optometrists,” the office’s report said. “However, the data from the National Practitioner DataBank contradicts these reports. (Vermont Optometric Association) references low malpractice insurance rates as an indicator of safety, but the insurance industry itself disputes this characterization.”
The National Practitioner DataBank said 59 malpractice payments and adverse events were reported to the NPDB for Oklahoma optometrists between 1992 and 2019. The Oklahoma Board of Examiners executive director told Vermont that no complaints were made by optometry patients, but he did know of three cases that were not reported by patients, according to the Office of Professional Regulation.
The office recommended against optometric expansion.
Could Idaho’s bill expand health care coverage?
The biggest potential benefit brought up by supporters of the bill is increased access. Of Idaho’s 44 counties, 39 have resident optometrists, but just 12 have resident ophthalmologists, according to the Idaho Optometric Physicians Association.
Daniel Gealy, an ophthalmologist at Retina Specialists of Idaho in Boise, is skeptical about how likely the law is to actually increase access. The medical equipment needed to perform laser surgeries is expensive, costing tens to hundreds of thousands of dollars depending on the quality of the equipment.
Rural areas may not have enough patients to make equipment purchases cost-effective, he said.
“You have to do a lot of them to justify purchasing a very big expensive piece of equipment,” Gealy told the Statesman by phone. “It doesn’t make any sense to buy a $60,000 machine and do five of these lasers a year.”
Huber, of Six One Six Vision Center in Eagle, said profit is “not the sole reason why people purchase equipment” and believes some optometrists would buy it to improve patients’ well-being.
“I find it very interesting that ophthalmologists have any idea of how much an optometrist makes or is willing to fit into better the care of their patients,” Huber said.
Some states have an issue with wait times. Gealy said the average wait time is one month in the Treasure Valley, which he believes is normal for a non-emergency procedure. Huber said wait times can be one to two months, which can feel long to patients.
Optometrists donate to lawmakers
Optometrists have been spending on Idaho legislative and other candidates.
Since 2020, donors listed as the Idaho Optometric Physicians, the Idaho Optometric Physicians Association and the Idaho Optometric Physicians PAC have given $36,400 to Idaho political candidates and groups, according to the Idaho Secretary of State’s website. Ninety percent of those donations were made in the last year. The three groups donated to 17 of the 23 senators who voted, 13 of whom voted in favor of the bill.
The largest donations went to Gov. Brad Little, who received $4,250, and Grow, who received $2,500.
Procedures
The new bill would allow optometrists to perform three new surgeries:
Laser capsulotomy: This procedure involves removes a film from the back of the eye by lasering a hole through the scar tissue membrane after cataract surgery. In rare cases, if done incorrectly, the surgery can lead to lens damage, increased eye pressure, decline in vision and retinal swelling.
Laser trabeculoplasty: This procedure lowers eye pressure in glaucoma patients by using a laser to create tiny holes in the eye’s draining system to allow for easier draining of fluid out of the eye. Risks include bleeding in the eye, increased eye pressure and inflammation.
Peripheral iridotomy: When the drainage system of the eye becomes narrow or closed in glaucoma patients, pressure in the eye that can lead to vision loss. This procedure uses a laser to widen that drainage system, according to The Dean McGee Eye Institute.
This procedure is the riskiest of the three, because a blood vessel can be hit and cause the eye to fill with blood and need immediate more intensive surgery.
Betts said this is a relatively uncommon procedure, best done by someone who is practiced in performing them regularly. His colleague, a glaucoma specialist who performs the majority of these procedures in the Boise area, gets less than 100 of these per year, according to Betts.
“Those cases are extremely difficult to perform,” Betts said. “So much so that, as a sub-specialist, I don’t even do them anymore. I send them to the glaucoma specialist.”
If something goes wrong during a peripheral iridotomy, a patient may need to be rushed to a hospital for more invasive eye surgery. Betts said he is concerned at the idea of the procedure being performed in places where that type of secondary care is not easily accessible.
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