Eye surgery should be left to the experts

Guest column by Dr. Michael Keverline:

In recent years, Virginia lawmakers have considered numerous proposals that would expand the “scope of practice” of certain health care providers. This term refers to the level of care a health care provider can provide, depending on education, training, experience, and state law.

The scoping rules forbid your attending physician, for example, from performing brain surgery (and he probably wouldn’t want to anyway).

These bills have been spurred due to the healthcare workforce shortage – the need for more professionals to fill roles commonly performed by physicians or peer providers. This is why, for example, you are often seen by a nurse practitioner or physician assistant in a primary care practice or orthopedic clinic for basic needs or pain.

But clinical boundaries exist for a reason.

The latest scope issue coming to Virginia: primary care eye care physicians looking to perform laser eye surgery. Yes Senate Bill 375 and House Bill 213 pass, they would lower professional standards of care without improving access, and harm Virginians along the way.

Laser surgery is surgery, according to medical definitions and long-established Virginia laws. The Commonwealth Code is in line with the overwhelming majority of states: 43, to be exact, that do not allow optometrists to perform eye surgery.

And for good reason. Ophthalmologists – optometrists – are practitioners who diagnose eye conditions and treat vision problems. If you need prescriptions for glasses or if you have problems with your eyes or your sight, you consult an optometrist. They play an important role in eye care.

Ophthalmologists are ophthalmologists and surgeons. These are doctors who can treat the whole body, but specialize in the eyes – no different from doctors who specialize in gastrointestinal, orthopedics or neurology. In most cases, an optometrist diagnoses conditions such as glaucoma, cataracts, or retinal detachment, then refers the patient to an eye surgeon for treatment.

Similar and confusing names, with one big difference: Training and education. Ophthalmologists need at least 12 years of graduate school, five of which are intensive surgical training. They accumulate nearly 20,000 hours of training before being certified to perform surgery.

Optometrists, on the other hand, can practice for eight or nine years after graduating from high school. They do not attend medical school and receive no surgical training.

If two bills in the General Assembly pass, optometrists, if certified by the State Board of Optometry, would be allowed to perform laser eye surgery. This would place Virginia in a small group of states that allow optometrists to perform laser eye surgery (the Department of Veterans Affairs prohibits optometrists from doing these procedures).

Lasers are a powerful surgical tool that cuts or burns human tissue. They are no different from a scalpel and, in the wrong hands, can cause significant and lasting damage.

During laser surgery, patients place their head against a forehead rest. With one hand, the surgeon holds a surgical lens over the patient’s eye. With the other, the surgeon maneuvers, focuses, and fires the laser for each individual laser shot.

The procedures are performed using a tool called a YAG laser, which works by firing a beam into the eye and vaporizing the tissues. Essentially, we’re creating microscopic explosions in the eye. And like any explosion, good and bad impacts happen within the radius of the explosion.

Complications arise even when done incorrectly. When done incorrectly, damage to the lens can occur that cannot be repaired. A skilled surgeon can predict complications, recognize them when they occur, and have the skills to surgically repair the complication.

Providing safe surgical care to patients requires rigorous instruction and years of supervised residency training. It is still unclear how optometrists would get trained before claiming they are qualified to perform laser eye surgery.

Virginians do not want this bill. An independent poll commissioned by the Virginia Society of Eye Physicians & Surgeons found that only 10% of Virginia voters would be comfortable with an optometrist performing laser eye treatment.

And Virginians don’t need this bill. Optometrists claim the switch will increase access to these procedures. But even in states where laser surgery is licensed for optometrists, few offer it, and usually not in underserved areas. Eye surgeons are widely available throughout Virginia.

In fact, expanding scope of practice may lead to overuse of laser eye surgeries and drive up costs and the need for corrective medical care.

Here’s what we know for sure: If this legislation is passed, poorly trained practitioners will perform surgeries on people’s eyes.

Dr. Michael Keverline is president of the Virginia Society of Eye Physicians and Surgeons. He lives in Norfolk and practices in Portsmouth and Chesapeake.


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