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Will Texas Eye Surgeons No Longer Need a Medical Degree?

Twin bills would expand the practice of optometrists. Advocates say they improve access. Critics say they could put patients at risk.
Eye Doctor Surgery

Twin bills have been filed in the Texas House and Senate that would expand the scope of optometry practices, but critics say the new scope may endanger patients and allow optometrists to perform procedures for which they are not prepared. 

House Bill 2340 and Senate Bill 993 would allow optometrists to perform surgeries, manage complex glaucomas without any physician collaboration, prescribe hydrocodone-combination medications and other controlled substances, perform, prescribe, or order visual diagnostic studies, and shift medicine and surgery regulation from the Texas Medical Board to the Texas Optometry Board. 

Similar bills have been passed in other states. In Kentucky, optometrists can remove lumps on eyelids and perform surgery, and the bill gives the state’s Board of Optometric Examiners the authority to determine the practice of optometry, which would mean the board can expand its scope of practice. Arkansas has a similar law that survived an attempted reversal last fall by Safe Surgery Arkansas. Oklahoma and Louisiana also have similar legislation.

In 2018, Safe Vision Texas, “a coalition of patients and physicians dedicated to preserving quality eye care in Texas,” was formed. The group is critical of the Texas legislation and says its aim is to protect patient protection laws. 

These bills put Texas ophthalmologists in a challenging situation. They often work with optometrists to manage glaucoma patients, and they receive referrals from optometrists when their patients show up with eye problems outside their scope. Simultaneously, the bill expands optometrists’ practice into the realm of ophthalmologists, making them competitors for business. 

Advocates say the bills would expand access to communities without ophthalmologists, especially rural communities. They also claim the bills would reduce costs. In Texas, there were just 1,670 ophthalmologists and more than 4,000 optometrists in 2019—the latter figure representing more than 25 percent growth since 2014. If more practitioners of these procedures are in areas that need them most, it will help patients. But that is only if optometrists choose to practice in areas where their co-practitioners are few. Around 95 percent of Texans live within a 30-minute drive of an ophthalmologist right now. 

Recent research suggests the bills’ necessity may be limited as well. A similar bill was also proposed in Vermont. The state’s Office of Professional Regulation conducted a study to see how the bill would impact access, patient safety, costs, and the training needed to oversee the new scope. “OPR finds that there is little need for, and minimal cost savings associated with, expanding the optometric scope of practice to include advanced procedures,” the study says. “For these reasons, OPR recommends against expanding the optometric scope of practice to include the proposed advanced procedures.”

Another significant criticism of the bills is that they allow optometrists to perform procedures for which they are ill-trained. Optometrists do not attend medical school, though they spend four years in optometry school learning about the eye. “Their curriculum doesn’t allow for much in-depth knowledge about the disease process or relation of problems seen in the eye to problems that occur in the rest of the body,” says Dr. Mark Mazow, a Dallas ophthalmologist who is president of the Texas Ophthalmological Association. “And they are not trained much in the treatment of those problems—certainly not in things that require surgery.”

With four years of medical school, a three-year residency, and a one-year fellowship, Mazow feels that ophthalmologists are better trained for surgery and managing disease. “You spend countless hours in the clinic and the hospital and in the operating room, being monitored and learning to do surgery,” Mazow says. “First, by actually scrubbing in with your mentors, watching them do it, and then, little by little, we learn to do more and more.”

The bills would allow optometrists to do some surgeries after taking a class and passing a written test without the hours of hands-on training that ophthalmologists receive. “You can’t legislate knowledge and impart knowledge and skill on certain practitioners,” Mazow says. 

Mazow says he isn’t against the idea of optometrists taking on more responsibilities but says they need more and different training to do so. “It’s not a matter of taking an observational course, watching some videos, and passing a written test that that would qualify you to undertake surgery for the citizens of Texas,” he says. “If the curriculum can be reformed, I think future graduates might be able to do that. But currently, their curriculum doesn’t allow for that.”

The legislative session has been busy responding to the pandemic and the fallout after the winter storm. We will follow the legislation and its impact on the business of healthcare. We reached out to the Texas Optometric Association about the bill but did not receive a response. 

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