As an aging population, growing patient-to-ophthalmologist ratios, demand for new treatments and an increasingly stretched healthcare dollar put eye care under more and more pressure internationally, the scope of optometry is changing.
In several parts of the western world optometrists are taking on more of the ophthalmological load, prescribing drugs, managing new treatments and, most controversially, some laser procedures. With New Zealand not immune to these pressures, the debate over optometry’s changing scope of practice and its resulting effects is heading this way too.
The international picture
Take YAG laser capsulotomy for example: a simple, regularly performed procedure used to treat capsule thickening, most commonly several months or more after cataract surgery, to improve vision. Oklahoma was the first state in the US to pass legislation allowing optometrists to perform YAG laser capsulotomies about 20 years ago. Kentucky followed in 2011, with other states then beginning their own lobbying for similar changes.
“Three or four decades ago it was ‘pushing the boat out’ to have optometrists even dilate the eyes and now that is routine across the world. Optometrists performing YAG capsulotomies is starting to undergo that same evolution in my opinion,” says Associate Professor Nate Lighthizer, who teaches the procedure at the Oklahoma College of Optometry.
In the UK, optometrist Tim Hunter, who heads optometry services at the Leeds Teaching Hospital NHS Trust, has been providing support for the YAG clinic since 2014, undertaking peripheral iridotomies and anterior and posterior capsulotomies alongside his ophthalmology colleagues. “It is a better use of resources to use non-medical staff,” he says. Plus, he adds, you have the added bonus that all the training and extra skills you equip these non-medical staff with to undertake these procedures then stays in your service. “Additionally, it frees up ophthalmologists to provide services that only a medically-qualified individual can.”
Leeds is not the only NHS hospital moving in this direction. Moorfields Eye Hospital has also just published a final policy and procedure document on ND YAG laser capsulotomy by nurses and optometrists.
Closer to home
Last year, MiVision reported that Australian optometrists were “watching with interest” what was happening in the US in this area. But Andrew Hogan, the former president of Optometry Australia, stressed it was premature to suggest the move would be replicated in Australia any time soon. While the then president of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO), Associate Professor Mark Daniell, took a stronger line, saying: “RANZCO believes that only properly trained medical professionals should perform complicated medical procedures such as eye surgery. While it is still a rare practice, we believe that the move in certain states in the US to allow optometrists to perform eye surgeries is incredibly dangerous.”
Just a few months ago, however, Optometry Australia released its 20-year vision for optometry in Australia, Optometry 2040 - taking control of your future. In it, the association noted, “Looking to the future, there is an opportunity for optometry to play an increased role in both eye care and broader health care... with a concrete role as part of a primary health care team. In some international contexts scope of practice for optometrists has broadened to support them in playing a greater role in treating a broader scope of ocular disease.”
In some quarters, New Zealand is having a similar debate and there have been some big changes to optometrists’ and others (such as nurses’) scopes of practice to broaden their ability to help both ophthalmologists and patients. For example, in July 2014 changes to the Medicines Act enabled nurse practitioners and optometrists to prescribe all medicines appropriate to their scope of practice, rather than limiting them to a list of medicines specified in regulation. But here again, there are all sorts of disparities across the international eye health world when it comes to which drugs can be prescribed by whom and who can give injections of these drugs. For example, in New Zealand ophthalmic nurses, but not optometrists can give intravitreal anti-VEGF injections, which is something only ophthalmologists can do in Australia, though this is changing.
A problem of definition?
As new medical technologies emerge, there is also an increasing grey area surrounding the procedures themselves, with at least some of the debate simply boiling down to whether a procedure, such as a YAG laser capsulotomy, is defined as surgery or not. Some practitioners claim that as it’s not breaching the epithelial boundary, it is not a surgical procedure and thus is a “safe” procedure to hand over to trained non-medical specialists. However, in a recent statement, the Optometrists and Dispensing Opticians Board (ODOB), New Zealand’s government-appointed regulator for optometry and dispensing opticians, said undertaking YAG laser capsulotomy is outside the current scope of practice for optometry in New Zealand and asked the New Zealand Association of Optometrists (NZAO) to remind its members of this, which the NZAO duly did.
Optometrists working outside their scope of practice could face action by the Board, the ODOB went on to state, which could include, amongst other things, referral of the matter to a professional conduct committee (PCC) for investigation, possible interim suspension of a practitioner’s practising certificate or the imposition of interim conditions on their scope of practice. A PCC has the authority to lay charges against a practitioner before the Health Practitioners Disciplinary Tribunal, which can result in very serious ramifications for a practitioner’s livelihood, it stressed.
Less scarily, however, the ODOB recommends that optometrists contemplating any tasks that they would not ordinarily perform contact the Board in the first instance to determine whether the task is within the scope of practice. “The practice of optometry in other jurisdictions, and the views of others, may not always reflect the current scope of practice in New Zealand. When in doubt, contact the Board.”
The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) has also recently reiterated its stance in this area, but in a somewhat softer, more open-to-change manner. “RANZCO only supports the use of lasers by those eye health practitioners who are appropriately trained and qualified to use them. At this time that does not include optometrists and we do not expect that this will change in the near future,” said RANZCO chief executive Dr David Andrews, when contacted by NZ Optics.
NZAO representative, optometrist Wilson Sue, is even more optimistic change is on the agenda for Kiwi optometrists in the future. “Expanding or changing scopes of practice for health practitioners contributes to the removal of barriers to public health care access and improvement of health equity in New Zealand,” he says, adding that under the Health Practitioners Competence Assurance Act 2003 the pathway for this to happen is already there.
Wellington ophthalmologist Dr Helen Long, who is interested in establishing nurse training for YAG capsulotomies, says mastering the technique is not difficult. “I would expect anyone proficient in the use of a slit-lamp could be trained to perform YAG laser capsulotomies safely given the low risk of the procedure. If the question is 'how long would it take?' that would depend on the individual and how much training time was available, etc.”
In principle, however, she says, “The major advantage in nurse- or optometrist-led YAG capsulotomies is the paucity of ophthalmologists. I would have thought the relatively low numbers makes it of little benefit to have scattered machines in the community, but having more staff able to perform capsulotomies in hospital departments would free doctors to do more diabetic argon laser, laser peripheral iridotomies, etc.”
A widespread debate
Speaking to a number of ophthalmologists, it is obvious that not all procedures over which debate rages both here and internationally fall into the same category. Definitions, scopes of practice and the regulatory framework vary from country to country and state to state. Even locally, opinions about changing the scope of practice for optometrists to include YAG laser procedures range from highly-supportive to dead against it.
Similarly, overseas the debate has been heated and drawn out and politically-charged on both sides. Although Oklahoma, Louisiana and Kentucky all allow optometrists scope with regard to some surgical procedures, at least two dozen other states have been or are currently embroiled in similar discussions.
“Legislature after legislature has turned this down, after they pulled down the curtain, after they look at the real facts,” Arizona ophthalmologist and American Academy of Ophthalmology (AAO) board member Dr Daniel Briceland told The News & Observer as North Carolina currently considers a bill expanding its optometrists’ scope.
Certainly the outcomes don’t always appear to be positive, at least according to one contentious study which followed 891 Oklahoma Medicare patients who had undergone laser trabeculoplasty (LTP). This study found the proportion of eyes which had undergone LTP by an optometrist and which then required repeat treatment was more than double the proportion of eyes that received this procedure by an ophthalmologist1. “Considerable differences exist among the proportions of patients requiring additional LTPs comparing those who were initially treated by ophthalmologists with those initially treated by optometrists,” it concluded, urging caution when approving laser privileges for optometrists practising in other states “until the reasons for these differences are better understood.” However, the study was based on Medicare billing codes and it turned out the optometrist-treated patients were having their procedure split over two sessions, while the ophthalmologist-treated patients had the same treatment in a single session, so the study was swiftly labelled “flawed”2 by the American Optometric Association (AOA), which suggested it was little more than “a thinly veiled attempt to suppress increased optometric medical care in a treatment area where ophthalmologists presently enjoy no competition.”
So, is the argument about improving access to eye care for all patients versus protecting surgical safety for patients? Or is it about optometrists wanting to expand their offerings and ophthalmologists protecting their turf?
Oklahoma College A/Prof Lighthizer says it should be about what is best for the patient. “The quality of eye care in the United States is high because optometry and ophthalmology have recognised that optometrists being able to treat eye disease with drops, orals and now certain laser procedures, works well for patient care. Ophthalmologists are busier and busier with cataract surgery, glaucoma surgeries and many other surgeries, and it works well for many OD/MD (optometrist/ophthalmologist) practices in numerous states to have ODs shoulder the load of YAG laser procedures.”
For any of this to happen in New Zealand, we would require not just an abundance of nonpartisan goodwill between the ophthalmic and optometric communities, but also for the ODOB to develop a policy, in consultation with RANZCO and other relevant parties, allowing optometrists to practice certain laser procedures, coupled with approved and detailed training options. Appropriate choice of patients, education and training and an effective relationship between optometry and ophthalmology, allowing co-management and supervision of cases, are all critical factors upon which all proponents agree, and have all agreed in the past as optometry’s scope has changed.
“Nearly all of the 23 optometry schools in the United States include lasers, injections and certain surgical training in their curriculum,” says A/Prof Lighthizer. “Many optometrists, including myself, have done residencies after four years of optometry school. This extensive training has prepared optometrists to treat many aspects of medical eye care, including YAG laser capsulotomies for posterior capsular opacification.” Malpractice rates are actually lower in Oklahoma than in other states, he adds, saying this is one of many indicators that procedures are going very well.
Oklahoma ophthalmologist Dr Chad Chamberlain agrees. “There has been a significant change in attitude regarding the co-management model for cataract surgeries, including which providers perform YAG laser capsulotomies. Initially there was significant resistance, however, since almost all of the optometrists in Oklahoma manage their scope of care with diligence, it has become more accepted as a safe practice.” But he stressed the need for an established relationship with an ophthalmologist to consult with and to refer more complex cases back to, pointing out that it’s not only the patient and the optometrist who stand to win. “Surgical ophthalmologists can also benefit by gaining more time to address high-level-of-care issues that they might otherwise have to forgo. Most ophthalmologists do not feel that optometrists performing YAG’s creates a threat and, for busy practices, it helps balance the burden of care.”
Could we see optometrists performing even more procedures in the future?
“Certainly, that is a possibility,” says A/Prof Lighthizer. “And with the ever-increasing breadth of optometric training, it is one that will only provide more access to quality patient care for patients. Only time will tell what will happen, but it is up to optometry and ophthalmology to work together in the best interest of patient care.”
- Comparison of outcomes of laser trabeculoplasty performed by optometrists vs ophthalmologists in Oklahoma, Joshua Stein, Peter Zhao, Chris Andrews, Gregory Skuta et al, JAMA Ophthalmol. 2016;134(10):1095-1101