Optometrists doing eye surgery? California AB 2236 vetoed for patient safety with David Aizuss, MD


AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, monkeypox, medical education, advocacy issues, burnout, vaccines and more.



In today’s AMA Update, David Aizuss, MD, an ophthalmologist in Calabasas, California, and a member of the AMA Board of Trustees discusses the California Assembly Bill 2236—which would have allowed optometrists to perform advanced eye procedures, including surgery—and how AMA and state advocacy helped defeat it. AMA Chief Experience Officer Todd Unger hosts.

Learn how the AMA is #FightingForDocs and access resources from the AMA Recovery Plan for America’s Physicians.


  • David Aizuss, MD, ophthalmologist; member, AMA Board of Trustees

AMA Recovery Plan for America’s Physicians

After fighting for physicians during the pandemic, the AMA is taking on the next extraordinary challenge: Renewing the nation’s commitment to physicians.

Unger: Hello and welcome to the AMA Update, our video and podcast series. Today, we're talking about a bill in California that would have allowed optometrists to perform advanced eye procedures including surgery and how AMA and state advocacy helped defeat it.

Fighting this kind of scope creep is an important pillar of the AMA's recovery plan for America's physicians. And I'm joined today by Dr. David Aizuss, an ophthalmologist in Calabasas, California, and a member of the AMA Board of Trustees. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Aizuss, thanks for being here today.

Dr. Aizuss: Thanks for having me.

Unger: Well, let's talk about this bill. At the end of September, California Governor Newsom vetoed it. And that bill would have increased the scope of practice for some optometrists. Why don't you just start by telling us more about the bill itself?

Dr. Aizuss: So California Assembly Bill AB 2236 would have allowed optometrists to perform advanced eye procedures, including surgery after completing minimal additional training. The bill would have allowed optometrists to perform eye surgeries that required the use of a scalpel, as well as an injection, as well as anterior segment laser.

So this included removing growths from the eyelids, which an optometrist judged as, quote, "non-cancerous" by appearance only, lasers for control of chronic glaucoma, lasers for treating acute glaucoma and lasers for what is known as a secondary cataract that occurs after primary cataract surgery. And ophthalmologists undergo a four-year residency after medical school with large numbers of patients that are supervised by clinical and full-time faculty during this experience, as well as by senior residents and even fellows who've already completed their residency training.

During that extended period of supervised education, ophthalmologists learn the indications for surgery. They perform procedures. They have extensive supervised post-operative care. And they understand when procedures should or should not be performed. Optometrists, in contrast, would have completed a 32-hour weekend training course for these procedures compared to physicians who completed at least a four-year residency program.

Unger: So let's talk a little bit more about that because, for those of the folks out there that are patients, it might not exactly be clear that difference between optometrist and ophthalmologist. You just covered an important part in terms of the training and education. Anything else you want to point out that separates those two?

Dr. Aizuss: Sure. First of all, it's important to really make clear that ophthalmology training has to include not only the technical skills to perform a procedure but also the medical knowledge that's needed to analyze when surgery is clinically indicated. Surgery on or around the human eye is not something to be taken lightly.

Overall, ophthalmologist training, as I mentioned, includes four years of medical education, an additional four to six years of postgraduate residency and fellowship. Physicians learn the most effective, safe and appropriate treatments, including surgical, pharmacologic and other interventions based on each patient's unique medical needs.

Optometric education and training rarely goes beyond the postgraduate level. And it's focused almost entirely on examining the eye for vision prescriptions like corrective eye lenses, glasses, contact lenses and performing some eye screening functions. Optometric training recently has included medication treatment for glaucoma and use of topical antibiotics for conjunctivitis. But that is the full extent of their medical therapeutic training.

In contrast, ophthalmologists undergo the full exposure of four years of medical education, learning how systemic therapy impacts all parts of the human body and the interactions of such treatments followed by a comprehensive first-year postgraduate training year after medical school followed by an additional three years of ophthalmology residency training.

So as we all know, there's certainly a place for optometrists on the eye care team. I have six that work for me in my practice. But students of optometry are not exposed to standard surgical treatment, to standard surgical procedure training, to aseptic surgical technique or to the medical response to adverse surgical events in their education.

Unger: Well, thank you for that. That's obviously a huge set of very important differences. And I think it underscores really the implications of what could have happened had that California bill been passed. Talk a little bit more about what that would have meant for physicians and patients had it happened.

Dr. Aizuss: So you mentioned at your introduction about the creeping scope of practice. This legislation crystallizes how scope creep can result in threats to patient safety. Surgery in the eye is neither risk free, nor uncomplicated. It is one of the most intensive things that a patient can undergo because one false movement inside the eye can result in loss of vision or even total blindness.

Underqualified and uneducated persons performing medical procedures can lead to mistakes or errors occurring at the patient's expense, not at the optometrist expense. The training in AB 2236 was a far cry from the rigor that exists for training eye physicians and eye surgeons. And the reduction in surgical licensing requirements that would have occurred would have been tremendously detrimental to patient safety.

So during the battle to prevent passage of this legislation, we explain how the development of clinical judgment and competency comes from continued practice on patients, exposures to patients and procedures that ensures, if something goes wrong, the physician is trained to address the issue immediately and efficiently to minimize damage to the patient's eyes and eyesight, which an optometrist is incapable of doing, not because they don't want to but they just don't have the training or experience.

The bill was amended to create a certification program with extra training requirements for optometrists wanting to perform these advanced surgical procedures. However, as we talked about, it was not a substitute to the extensive level of training that ophthalmologists take and also fail to account for the unique and complex medical needs of certain patient populations, particularly the geriatric population and the pediatric population.

Had this bill passed, it would have exposed patients to really serious risks, loss of vision or even life-threatening consequences. And as I noted, the delicate nature of these procedures can result in damage to the eye if done incorrectly, which is irreversible for the patient.

Unger: So this is clearly a really, really important issue and couldn't be a better demonstration of how important an advocacy is. So let's talk a little bit about how the AMA worked with other stakeholders to help defeat this bill in line with a lot of work that the AMA is doing with others at the state level and what is just this continuous fight against scope creep. Let's talk specifically about the advocacy efforts out in California.

Dr. Aizuss: So Todd, as you know, we at the AMA believe that patients need and deserve physician-led health care teams. And the AMA is fighting legislation like this all over the country and at the federal level to ensure that physicians remain the leaders of the health care team, which is what patients want and patients need. And this has been proven in polling of patients. They prefer physician-led care.

So in this case, the AMA stood along the California Medical Association, the California Academy of Eye Physicians and Surgeons, the American Academy of Ophthalmology, the American College of Surgeons and other national and state specialty societies in opposing the legislation. And defeating this type of legislation is always a team effort. In this case, it was no different. And it demonstrates the strength of organized medicine nationwide.

The California Academy of Eye Physicians and Surgeons have been dealing with optometric scope expansion attempts via legislation for many years. Indeed, this bill when first introduced was non-substantive. It had no language indicating that it was an effort to expand surgical privileges. And it passed out of the California Assembly as a result with no opposition.

It was not until the end of June that it was amended to include some level of surgical procedures. And thankfully, CAEPS mobilized its member physicians, obtained the attention of the California Medical Association about the threat to patient safety that this legislation entailed. Organized medicine was mobilized. Grassroots activism was spurred. Meetings with legislators were increased. And the AMA provided a national perspective, hammering home the differences in education and training and patient safety and the national implication of this type of legislation.

Unger: Because that could clearly set a dangerous precedent. And again, you point out what a great example of the power of organized medicine, speaking with a unified voice and about that teamwork that comes from the AMA Scope of Practice Partnership. Let's talk a little bit about that partnership and what role you see it playing as we head into 2023.

Dr. Aizuss: So every year and with increasing frequency, states are seeing bills similar to this one in California. That's why the AMA founded the Scope of Practice Partnership a number of years ago. It's currently chaired by Dr. Scott Ferguson, who's a radiologist and a member of the AMA Board of Trustees. Previously, it was chaired by Dr. Jack Resneck, the current president of the AMA. I am personally on the SOPP Steering Committee as well.

The SOPP played a major role this year because, as soon as they were contacted, the AMA immediately, on the request of the California Medical Association, pointed out the differences in education and training of ophthalmologists and optometrists through letters to the legislature and directly to Governor Newsom, which was spurred by the activities of the SOPP.

And this was an episode where medicine's unified opposition clearly made a difference. The SOPP is 105 medical societies whose goal is focusing on our fight to prevent inappropriate scope of practice expansion through legislative, regulatory and judicial activities by providing the resources needed to battle these pieces of legislation.

So looking ahead to 2023, we'll continue to support SOPP member's efforts to fight legislation like California's Optometry Bill. We anticipate opposing legislation that will remove physicians from the care team, such as bills that would allow nurse practitioners, physician assistants and others to practice medicine without any physician involvement.

So we do this by creating advocacy tools that are available to physicians and state medical associations to help meet the challenges and also by providing grants to SOPP member organizations, which have helped fund robust, state-level, public relations campaigns and helps educate lawmakers and patients on the importance of physician-led care.

Unger: Dr. Aizuss, thank you so much for taking us through all of the details of this important advocacy work. I just want to say thank you to you and all of our partners for helping stop what could have been a very dangerous bill for patients. We do hear from all of you out there about how important this issue of scope of practice expansion is. That's why it's one of the pillars of our Recovery Plan for America's Physicians.

And I want you to go to the AMA site and take a look at the details of what AMA is doing, especially with our Scope of Practice Partnership to stop that. You can find that on our website at ama-assn.org/recovery. You can also find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.