Over the past several decades, optometry’s scope of practice has evolved significantly on a national level. The spectrum of clinical responsibility for today’s optometrist has expanded greatly and continues to shift to more medically-based patient care.
Since optometry is a legislated profession, every state varies in regard to scope of practice. Restrictive laws, often based on misunderstanding and confusion around optometric education and capability, can create unnecessary barriers to care for patients. Despite significant advances in today’s optometric education, examination, and licensure requirements, many optometrists remain unable to practice to the fullest scope of their education and expertise. This ultimately has a negative impact on patients’ access to care while also increasing overall healthcare costs.
In this article, we’ll discuss the importance of continued optometric scope of practice expansion (including laser privileges) nationwide and how it’s ultimately a net benefit to patients, optometrists, and ophthalmologists alike. We’ll also review ways all optometrists can take actionable steps to have scope of practice expansion passed in their state.
We’ll close with comments and perspectives from ophthalmologist Dr. Richard Castillo, and discuss how optometric scope expansion is inevitably the way we’re going to meet our nation’s evergrowing eye care needs.
Minor Surgical Procedures & Laser Privileges in Optometry?
There has been significant debate as to whether optometrists are qualified to safely perform minor surgical procedures (eg. chalazion removal) and use lasers (eg. LPI/YAG) in practice. We are referring to minor surgical procedures that can be performed in-office, not more invasive eye surgeries that require anesthesia and an operating room (eg. cataract/cornea, PRK, LASIK, or retinal detachment).
Today’s rigorous 4-year optometry school curricula focus exclusively on the study of ocular health and vision care – including education and training in performing laser procedures on the eye. The National Board of Examiners in Optometry (NBEO) now also requires a “Laser and Surgical Procedures Examination” as part of the national board exam series.
While every state varies as to the specific scope of practice, in general, those with laser privileges allow optometrists to perform YAG capsulotomies, Selective Laser Trabeculoplasty (SLT), and Laser Peripheral Iridotomy (LPI). YAG laser is performed to treat posterior capsular opacification after cataract surgery. SLT laser procedures are performed to treat ocular hypertension and open-angle glaucoma. LPI laser is typically used to treat acute angle closure and/or narrow-angle glaucoma. In most states, these relatively noninvasive procedures are all exclusively performed by ophthalmologists.
When optometrists are able to perform the aforementioned noninvasive laser eye procedures, patients have greater access to care and improved continuity of care. Patients are not required to travel far distances, take additional time off from work, and pay additional surgical center/examination fees for procedures that their primary care optometrist can safely perform in-office. This is especially true for patients in rural communities across the country.
Trends Among Eye Care Providers
According to the US Bureau of Labor Statistics, there were approximately 39,000 practicing optometrists in the United States in 2021, down 4% from 2014 according to the American Optometric Association (AOA). In 2021, the number of US ophthalmologists was roughly 18,500, also down 4% from 2015 according to the American Academy of Ophthalmology. According to the Health Resources and Services Administration, by 2025, there will be a shortage of about 6,000 ophthalmologists.
Over 90% of Americans support laws that allow optometrists to provide eye care to the fullest scope of their education. It was also shown that 62% of Americans trusted their optometrist to provide their eye health and vision care – statistically equivalent to the 64% who felt the same about ophthalmologists.
Despite many advances in health care, access to eye care remains a logistical challenge for many Americans living in rural settings. According to the AOA, 39% of US counties have access to an optometrist but not an ophthalmologist, to meet their eye care needs. This equates to roughly 8% of the population (25 million individuals) not having access to an ophthalmologist.
An additional 12% of US counties do not have access to ANY eye care provider. In rural parts of the country, it is not uncommon for patients to drive 4 to 5 hours round trip to see an ophthalmologist for ocular disease management. Some patients may even be required to drive to a different state for an eye procedure that could be safely performed by their optometrist (eg. SLT laser for glaucoma).
Even when ophthalmologists and optometrists coexist in the same geographical area, there are numerous other barriers to patient care, most notably insurance coverage and transportation. In some cases, the nearest ophthalmologist may not offer or perform a specific procedure.
Scope of practice expansion for optometry has myriad benefits and is starting to occur at increasing rates around the country. Optometric scope expansion affords ophthalmologists more time in the operating room in lieu of providing routine office-based medical eye care (which ODs are trained and qualified to provide).
Are Optometrists Putting Patients at Risk?
Since the late 1990s, states nationwide have been slowly passing legislation for scope of practice expansion to include laser privileges for optometrists – ten to be exact. They are Alaska, Arkansas, Indiana, Kentucky, Louisiana, Mississippi, Oklahoma, Wyoming, and most recently, Virginia and Colorado.
Since Oklahoma became the first state to grant ODs laser privileges (1998), there have been no malpractice judgments related to doctors of optometry performing laser procedures per the AOA. Over 50,000 laser procedures have been performed by optometrists in Oklahoma over the past 30 years. Between Louisiana and Kentucky, there have been over 50,000 additional laser procedures performed by optometrists, all without any complaints to the state board or reported malpractice cases.
Optometrists also take a professional oath to put patient safety first and do not want to increase their risk of medical lawsuits or increased malpractice coverage. Optometrists are licensed doctors, held to the same legal standards as other physicians – including ophthalmologists. If an optometrist does not feel comfortable performing a certain laser procedure, patients can always be referred to the nearest ophthalmologist.
Also, in states that allow ODs to perform laser and other minor surgical procedures, patients always have the freedom to choose where they go to receive their eye health and vision care – including any specialty procedures. They are not required to see an optometrist if they prefer not to.
States who’ve passed legislation granting optometrists laser privilege require ODs to complete additional training and continuing education specific to these laser procedures. These are typically done through accredited schools and colleges of optometry in the state. The Optometric Procedures Institute also holds in-person workshops for optometrists to gain additional training in laser and minor surgical procedures.
In 2022 retrospective study in the UK looked at the safety and efficacy of advanced nurse practitioners to perform YAG laser procedures when compared to trained ophthalmologists. The study looked at over 6,000 eyes and concluded that nurse practitioners are able to deliver safe and effective YAG laser procedures. Treatment outcomes were similar to those of ophthalmologists.
In 2016, a JAMA study found that patients receiving laser trabeculoplasty by an optometrist required additional treatment and follow-up as compared to those who received the same procedure by an ophthalmologist.
Optometric scope expansion in each state, whether broad or limited, may not be adopted by every optometrist, nor may be appropriate for every OD or practice setting to engage in. Not every optometrist will begin offering new clinical services for their patients overnight (or ever). There are certainly added costs of equipment, training, and possibly additional staff that may render certain clinical privileges impractical or unfeasible. It will likely be ODs in larger institutions with more resources that initially implement new privileges if/when expanded scope of practice legislation is passed (eg. VA/IHS hospitals, academic settings, and community health centers).
Also, some optometrists may simply have no interest in expanding their services to patients as they’re fully engaged in other niches within the profession. While recent optometry new grads undergo testing and certification for laser privileges as part of their education and national board examination, older graduates may require more than simply a weekend training workshop to obtain the necessary skills and competency.
Some ophthalmologists argue that their more extensive medical training can potentially save patients from losing their vision as some ocular diseases can be difficult to diagnose and may need extra scrutiny to formulate the proper diagnosis and treatment plan. Others firmly believe that since optometrists don’t go to medical school and have no residency requirements with specific training to perform eye surgery, they’re simply putting patients at risk for further complications. It is argued that any surgical training for optometrists that consists of a 32-hour weekend crash course is not comparable to the extensive surgical training ophthalmologists receive.
Baby Boomers & Ocular Disease
The baby boomer population (born between 1946 and 1964) is estimated at 73 million, the 2nd largest age group after their children (millennials, born between 1982 and 2000). Since 2010, approximately 10,000 people per day turn 65 years ago, and by 2030, all baby boomers will be at least 65 years of age. As this age demographic increases, so does the incidence and prevalence of ocular diseases including cataracts, diabetic retinopathy, macular degeneration, and glaucoma.
By 2030, the number of people in the US with cataracts is expected to rise significantly, nearly doubling from 20 million to almost 40 million. The same holds true for people affected by open-angle glaucoma, from 2.7 million (2010) to 4 million in 2030.
Patients who’ve had cataract surgery will likely require laser treatment at some point. It has been shown that 1 in 5 patients will typically need YAG capsulotomy treatment within 5 years after having cataract surgery. Laser treatment options are also crucial in the management of open-angle glaucoma. Given recent results of the LiGHT trial, SLT laser treatment has been shown to be an effective first-line therapy for individuals with ocular hypertension and open-angle glaucoma.
How to Expand Scope of Practice in Your State
In April 2021, the state of Wyoming passed a bill for scope-of-practice expansion, allowing optometrists to perform minor surgical procedures, which included laser privileges. They were the 7th state to allow ODs to perform noninvasive laser procedures.
We interviewed the president of the Wyoming Optometric Association, Jeremy Nett, OD, and Past-President of the Arkansas Optometric Association, Joe Sugg, OD to find out why optometric scope expansion is crucial for optometry, ophthalmology, and most importantly, patients. We’ll also discuss actionable steps all ODs can take in their respective states to push for updated legislation and scope-of-practice expansion.
1) What are some of the main benefits for patients, optometrists, and ophthalmologists respectively in regard to having OD laser privileges in your state?
Dr. Nett: Optometric scope expansion (including laser privileges) has had an enormous benefit for the people of Wyoming. Patients now have more choices and access to care. They can receive care more quickly, are able to maintain continuity of care with an eye care provider they know and trust, and benefit from cost savings by reducing the need for additional office visits. Reduced time off work for a specialty provider/ophthalmology consult that may operate a considerable distance away, even out of state is both a cost savings and added convenience to the patient.
Optometrists have benefited from continuity of care by being able to diagnose, treat and manage procedures post operatively. Additionally, optometrists are able to practice to the full extent of their education and training. The financial benefit of performing laser procedures is minimal at this point due to the cost of equipment but providing the convenience to patients will have longer-term impacts. Another benefit of expanded scope is that practices can now recruit new graduates looking to practice at the highest level of their education.
Ophthalmologists in Wyoming, which number less than 15 in-state providers, can benefit from optometrists performing minor laser procedures by allowing them to focus on other, more complex surgical endeavors. There are approximately 170 practicing Doctors of Optometry in the state of Wyoming, over 100 of which are members of the Wyoming Optometric Association.
Dr. Sugg: The main benefit is for patients, and that is access to care. They can see the doctor they know and trust to receive this care, and they don’t have to deal with the burdens of travel, delayed care, and additional cost in order to receive it. The benefit for optometrists is the same as for patients – it allows optometrists to provide care they are trained to provide right there in the office. For the ophthalmologist, this can create better efficiency within the eye care delivery system and help get them in the operating room where they need (and want) to be.
2) What are some specific actionable steps all optometrists can take to help facilitate the expansion of their state’s scope of practice to include laser privileges?
Dr. Nett: There are several steps optometrists can take to help facilitate scope expansion.
Education is key. That means optometrists need to invest in continuing education in advanced optometric and laser procedures to demonstrate a commitment to performing the additional privileges safely and effectively. It means optometrists need to educate their patients about their ability to safely perform these additional procedures. It means optometrists need to educate their legislators by explaining and demonstrating their training and the required equipment to legislators. Educating other members or the health care team can help to reduce the potential “fear-mongering” that is often used to try and defeat scope expansion bills.
Another step is establishing connections with legislators by creating a grassroots network. When working on any legislation, it is important to get involved, work together and create a system of communication. It is imperative for the optometrists in the state to develop a leadership team and to communicate with their legislators and each other.
We learned in Wyoming that it paid to take the high road; meaning no negative portrayal of our opponents, highlighting the positives of scope expansion including better access to care and patient choice, and stating our training and qualifications to safely perform the procedures in question. We learned that persistence paid off, and that transparency and honesty really are good policies. We learned to expect the unexpected, to hope for the best, and prepare like crazy for the worst.
Dr. Sugg: Most important is to get involved with the American Optometric Association (AOA) and your state AOA affiliate. Let the leadership of your state affiliate know you are interested in advocacy. That is the first, and most important, step for any optometrist who is interested in scope expansion.
Perspectives from Ophthalmology
Dr. Castillo: The quality and breadth of optometric education in the year 2022 encompasses the full spectrum of eye care. Optometrists have been co-managing laser and surgical care hand-in-hand with their ophthalmology colleagues in all 50 states for decades. With regards to office procedures such as lasers and office surgery, today’s optometric physicians are specifically trained in the technical aspects of these procedures and evaluated with respect to entry-level competency by objective regulatory boards before being credentialed to provide these services to the public.
The word “surgery” is a big umbrella. Opponents of optometric scope expansion have politicized the term. There is much that the political opposition will attempt to hide behind the mystique of the word. Fact: all optometric physicians that have graduated over the last several decades have been trained in, and engaged in rendering both the preoperative and post-operative care of all the office-based procedures under consideration.
It is important for legislators to realize that the potential complications associated with these procedures are not necessarily unique to either lasers or office surgery. These are the exact same conditions that present from a myriad of other pathologies and traumas which are already treated by optometrists in all 50 states and have been for decades.
In the year 2022, our nation’s Optometric Physicians are clinicians, educators, and accomplished researchers. They are our caring neighbors, friends, family, and prominent members of what constitute the fabric of our society. They are ethical, mature, knowledgeable, and skilled professionals who approach their purpose with all the sincerity, devotion, and compassion of any other healthcare provider who has received and accepted this life’s calling.
Authors: Kevin Cornwell, OD, Richard E. Castillo, OD, DO, Jeremy Nett, OD, Joe Sugg, OD
Dr. Richard E. Castillo, OD, DO, is a graduate of the NSU College of Optometry (OD) as well as the OSU College of Osteopathic Medicine & Surgery (DO), where he completed a Residency in Ophthalmology. He has been NSU’s Chief of Surgical Services and clinical professor since 1999, serving his community as an Optometric Physician and Ophthalmologist. He also serves as Assistant Dean overseeing the surgical training program, as well as optometrists and students in the University’s Ophthalmic Surgery Service. Dr. Castillo established the NSU-OCO Optometric Surgical Procedures Clinic in 1999, training scores of optometric faculty, students and residents as well as DO and MD colleagues in optometric surgical and laser procedures, for over two decades.
Dr. Castillo has served on multiple committees for the National Board of Examiners in Optometry including the Laser & Surgical Examination (NBEO:LSPE) task force/development committee and has been contributing to optometric education nationwide since 1995. He maintains a very active national CME lecture schedule and continues to serve as an educational and practice consultant as well as an unwavering advocate for the advancement and modernization of state optometry laws.
Dr. Castillo is also co-chair of the AOA’s Contemporary Practice Task Force, current President of the American Society of Optometric Surgeons, past chair of the National Commission for Vision and Health. He is a member of the Oklahoma Medical Reserve Service Corps. Dr. Castillo is a recipient of the 2021 Arkansas Optometric Association’s Special Service Award, the Oklahoma Association of Optometric Physician’s 2017 Distinguished Service Award and has been acknowledged by the Oklahoma State Board of Examiners in Optometry for outstanding contributions to the advancement of optometric surgical care.
Dr. Nett received his Doctor of Optometry from Pacific University College of Optometry. He is a member of the American Optometric Association, the AOA’s Contact Lens and Cornea section, the AOA’s Sport Vision Section, Beta Sigma Kappa International Optometric Honor Society and currently serves on the board of the Wyoming Optometric Association. His hobbies include cycling, hiking, fishing, archery and supporting the University of Wyoming’s athletic teams with his wife and son.
Dr. Joe Sugg is a native of Jonesboro, Arkansas and has lived and practiced in Heber Springs since 2009. He graduated from the Southern College of Optometry in Memphis, Tennessee with honors in 2009 with his Doctorate of Optometry. Dr. Sugg earned multiple awards recognizing outstanding clinical performance while in optometry school. He is a Diplomate of the American Board of Optometry. He started his career at Heber Springs Eye Care Center in 2009. In 2013, Dr. Sugg received the “Young O.D. of the Year Award” presented by the Arkansas Optometric Association. In 2015, Dr. Sugg and the staff at Heber Springs Eye Care Center received a “Practice of Excellence Award” presented by the Hayes Center for Practice Excellence at Southern College of Optometry. He currently serves as the Immediate Past President of the Arkansas Optometric Association as well as on various committees within the Association. He has previously served on the Exhibits Committee for SECO International, and he currently serves on the Industry Relations Committee for the American Optometric Association. He participates in the Brandon Burlsworth Eyes of a Champion program and also helps provide eye exams at the Arkansas Special Olympics.