A new eye care bill will allow optometrists to fully prescribe topical or oral medications and independently manage most forms of glaucoma. CSSB 993, which North Texas Senator Kelly Hancock sponsored, sits on Governor Greg Abbott’s desk and will become law later this month as long as he doesn’t veto.
The original legislation submitted by Texas House Rep. Stephanie Klick of Fort Worth would have allowed optometrists to perform minor eye surgery. Optometrists can do so in several neighboring states, but that effort was met with resistance and was edited out of the unifying House and Senate bill.
Proponents of the bill are excited about the development. “We are pleased with the outcome because patients are now able to get the care they need at the time that they need it directly from their doctor of optometry,” says Dr. Jenny Terrell, president of advocacy group Focus Texas and co-director of Community Eye Clinic in Fort Worth. “That’s important when it comes to certain eye problems that can be significant over the long term if they’re not treated in a timely way.”
Currently, optometrists are limited to prescribing ten days worth of medicine, even if the diagnosis required 14 days of medication. The patient would have to return to the optometrist for a second prescription. “That’s that’s not necessarily the best in terms of burden for the patient to have to make a second trip and take another day off work and pay another copay,” Terrell says. Now, an eye ointment or similar medication can be prescribed for the full required period.
Additionally, glaucoma management used to have to be supervised by an ophthalmologist, but now optometrists can manage most glaucoma patients independently. Because most patients with an optometrist do yearly vision checks, symptoms of glaucoma are likely to be recognized by the optometrist, who will be able to manage the condition.
But opponents of the bill see this as a uniquely American problem that could lead to problems down the line. Rather than get the training required to manage glaucoma, advocacy groups have found that changing legislation can be a more effective way to expand their scope.
“In other parts of the world, this is not an issue because licensing is different and qualifications are taken more seriously,” says Dr. Robert Gross, a pediatric ophthalmologist and Clinical Professor of Ophthalmology at UT Southwestern and past chair of the Section on Ophthalmology of the American Academy of Pediatrics. “Folks have realized that there are different ways to get what they want. In a way, it’s a little bit disappointing because the emphasis should be on education and training rather than what can we do to change the law.”
Another issue for Gross and others is the difference between the Texas Optometry Board and the Texas Medical Board, which have different levels of transparency and standards of care. When the state of Texas renewed the Texas Optometry Board during its Sunset Commission review in 2017, the commission said the board was overall well-run but wrote, “In the area of enforcement, the agency has a light touch on practitioners compared to other agencies. The optometry board issues few tough sanctions, places a limited amount of information about a licensee’s disciplinary history on the website, and does not report certain formal board actions to the National Practitioner Data Bank as would appear necessary. This pattern raises questions as to whether the board’s regulation tilts more toward the profession than the public.”
Gross was pleased to see surgery removed from the bill. While the surgeries that would have been allowed are minor and permitted in other states, the extensive surgery training that ophthalmologists go through helps them understand which cases should be selected for surgery, what to do if something goes wrong, and how these surgeries will impact the rest of the bodies symptoms. “Everything looks simple on its surface,” Gross says. “If a case goes well, it might seem simple, and that is largely because of case selection, knowledge of all of the other intervening possibilities, and differential diagnoses, which is based on years of training and the skill of the surgeon.”
Glaucoma can be complex, and even a practiced ophthalmologist like Gross refers his patients to Glaucoma specialists. “Many of these cases are challenging, even on the non-surgical side. In most circumstances, I’ll get a second opinion from a fellowship-trained glaucoma specialist,” Gross says. “I’ve been in practice for 35 years, and I’m trained in glaucoma, but I think it’s a very challenging field. People go blind from glaucoma.”
Ophthalmologists and optometrists work in harmony in most situations and have expertise where others don’t, and just because optometrists are permitted to manage glaucoma doesn’t mean they will. “Of the optometrists that I know and talk to week in and week out, I don’t know any of them that are advocates for this,” Gross says. “I think it’s a smaller group that wants this.”
Still, proponents are bullish on the bill and its impact on patients. “This is a win for Texas patients and access because patients would have to seek out other providers for having their eye conditions treated, and in some parts of some parts of the state, that’s not easy,” Terrell says. “Being able to have their local trusted doctor of optometry to fully care for the things we’re trained to care for is a win overall.”