Scope of Practice

Optometrists doing eye surgery? Radical bill vetoed on safety grounds

Kevin B. O'Reilly , Senior News Editor

California Gov. Gavin Newsom this week vetoed a radical measure that would have allowed optometrists without the necessary training and education to perform complex procedures such as laser eye surgery and administering needle injections to the eye.

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“I am not convinced that the education and training required is sufficient to prepare optometrists to perform the surgical procedures identified,” Newsom wrote in his veto message (PDF). “This bill would allow optometrists to perform advanced surgical procedures with less than one year of training. In comparison, physicians who perform these procedures must complete at least a three-year residency program. For this reason, I cannot sign this bill.”

The AMA, California Medical Association and other physician organizations urged Newsom to veto Assembly Bill 2236, which was passed by a one-vote margin in the state Assembly. This legislation crystallizes how the creeping expansion of scope of practice can result in threats to patient safety. The AMA is fighting legislation like this across the country and at the federal level to ensure that physicians remain the leaders of health care teams, which is what patients want—and need.

“Surgery on the human eye is not risk-free nor ‘uncomplicated,’” AMA Executive Vice President and CEO James L. Madara, MD, noted in a letter this month asking Newsom to veto the bill. “Complex surgical procedures, such as laser eye surgery and needle injections administered to the eye, as AB 2236 would allow optometrists to perform, require specialized education and training, as well as medical supervision during surgical preparation, performance of the procedure, and postoperative patient care.

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“Such training must include not only the technical skills needed to perform the procedure itself, but also the medical knowledge needed to analyze when surgery may or may not be clinically indicated. Surgery on or around the human eye is not something to be taken lightly. Patient safety and the highest quality of care demand that individuals who perform invasive procedures have the appropriate medical education and training,” added Dr. Madara, who had earlier written (PDF) to a key California Senate committee chair urging opposition.

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As part of its wide-ranging fight against scope creep, the AMA has helped defeat multiple bills that would have expanded the scope of optometrists, including a similar bill in Alabama, as well as legislation in Utah and Washington that would have allowed optometrists to perform eye surgery and increase their prescriptive authority.

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The AMA’s letter clearly outlined the differences in training relevant to AB 2236.

“Ophthalmologists’ training includes four years of medical education and an additional four to six years in postgraduate residencies and fellowships,” Dr. Madara wrote. “During that advanced training, physicians learn the most effective, safe and appropriate treatments, including surgical, pharmacologic and other interventions based on each patient’s unique medical needs.

“In sharp contrast, optometric education and training rarely go beyond the postgraduate level and are focused almost entirely on examining the eye for vision prescription, dispensing corrective lenses and performing some eye screening functions,” the AMA’s letter says. “Optometrists do not possess the comprehensive medical knowledge necessary to safely perform surgical procedures on patients. Students of optometry are not exposed to standard surgical procedure training, aseptic surgical technique or medical response to adverse surgical events as a part of their education.”

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While ophthalmologists must pursue four years of residency training—three years in a surgical residency program following a one-year internship, with many going on to complete subspecialty training in a fellowship program—Dr. Madara noted that optometrists aren’t required to take part in any postgraduate advanced training. “This distinction is critical,” he wrote to the governor. “In short, there is no substitute for the level of experience and education attained by a fully trained ophthalmologist.”

The bill was amended to create a certification program with extra training requirements for optometrists wanting to perform these advanced surgical procedures.

But that modest change “is not a substitute for the level of training of ophthalmologists,” Dr. Madara pointed out, calling the bill a “dangerous proposition” that failed to “account for the unique and often more complex medical needs of certain patient populations such as the elderly and children. Simply put, AB 2236 falls short in preserving the health and safety of patients in California.”

The California Medical Association mobilized its grassroots network of doctors “to make sure that Gov. Newsom understood that this bill would leave patients vulnerable to serious risk of life-long consequences that could be devastating to their vision and their lives,” the association said in a news release.

"CMA is grateful that Gov. Newsom has recognized that the inadequate training stipulated by AB 2236 would expose patients to serious health risks, loss of vision or even life-threatening consequences,” said CMA President Robert E. Wailes, MD.