Safe eye surgery requires more than a Golden Ticket

The classic movie “Willy Wonka and the chocolate factory“has Gene Wilder as the main character nonchalantly warning,”Stop. Don’tas various children try unfamiliar sweets and experience unforeseen “complications.” Of course, every instance ends with predictable unfortunate results.

Craig H. Kliger, MD

In what seems like a move worthy of Wonka’s warning, the Colorado General Assembly authorized optometrists perform eye surgery with lasers and scalpels despite the fact The legislation has no clear requirement for training on living human patients, and realistically no significant amount of such training will occur.

I will give optometrists and bill sponsors points for political savvy. They succeeded in countering the ophthalmologists (ophthalmologists) suggest that seven years of additional training were required to perform a small subset of eye surgeries calling these procedures “non-hazardous”. They did this by using terms such as “non-thermal” for lasers and “lumps and bumps” for eyelid lesions instead of “tumors.”

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In short, the General Assembly – which for the most part is made up of people without expertise in surgery – did not buy into the need for such extensive training. Yet the ability to provide potentially sight-threatening surgical care without at least reasonable training should not be a political “prize.”

In effect, the bill requires new graduates from schools where the procedures are “taught” to simply pass a standardized exam that the Colorado State Board of Optometry deems “tests the applicant’s qualifications to practice optometry…” Note that only one such examination testing surgical skills currently exists and is performed entirely on plastic or rubber models.

However, this test could simply be abandoned by the jury instead of the “multiple choice” ones already passed. Moreover, since only about 90 of the 1,650 annual optometry graduates in the United States attend a school where actual human training is currently legal (two out of 23), it seems naive to think that the vast majority could have meaningful human experience. .

Those currently practicing would apparently be no better qualified. They would follow an “approved” course (existing ones are usually 16 hours each for laser eyelid and eye surgery and include approximately 4 hours of lab experience which may not allow for meaningful human experience), plus a “monitored clinical session” – which may not not require such experience either.

Interestingly, before the bill was finalized, the term “non-thermal” applied to laser processing was removed. Proponents have probably realized that eye surgery lasers use heat to alter or even destroy tissue to achieve the desired effect. However, given this change, it then seems legitimate to ask what other security problems could have been minimized and will only be discovered when the law is implemented?

You might wonder why anyone would want to perform untrained surgery on living humans? Having done all of these procedures myself, I have no answer other than a lack of understanding of what is involved due to inexperience.

Live eyes – unlike plastic models – blink and move, as do related tissues, making treatment much more difficult (and increasing the chance of causing unpredictable damage). Moreover, living human tissue actually responds to treatment, and this response can vary greatly from patient to patient.

For example, when treating glaucoma, the intention is to reduce eye pressure by stimulating the drainage of fluid out of the eye. Overtreatment, however, can – for lack of a better word – “cook” the delicate eye structures involved, rendering them non-functional and actually increasing eye pressure, making glaucoma worse. Meanwhile, undertreatment may have no effect, wasting both a patient’s time and scarce healthcare dollars performing a worthless procedure.

There are also complications – in some cases potentially sight-threatening – that optometrists also tend to downplay. Yes, it can happen to anyone, including well-trained people. It’s just that well-trained people are actually better prepared to avoid and deal with them when they (and will) happen.

I recognize now that you might be asking why Coloradans should care what someone from California thinks. Although it has been said that all policies are local, the skills required to perform surgeries are not different in our two states.

I further recognize that proponents of the bill will characterize me – an ophthalmologist – as inherently biased. But, would you or a loved one want to have eye surgery by optometrists “trained” in this way, especially when it’s very possible that the first “real” surgery they will perform will be in their own home? office where no one will be available to come to the rescue in the event of a problem?

Mark Twain said, “It is better to deserve honors and not have them, than to have them and not deserve them. Surgical privileges are no different. If I had been allowed to perform surgery with the “training” provided for in this bill, not only would I have been incompetent, but I would have been terrified.

Patients in Colorado should be similarly scared.

So before the Governor approves of this less than fully baked idea, he might consider Wonka’s advice. warning to young Violet Beauregarde as she began chewing gum that ended up having the unforeseen “complication” of turning her into a giant blueberry: “Oh! I wouldn’t do that. I really wouldn’t.


Craig H. Kliger, MD, of San Francisco, is executive vice president of the California Academy of Eye Physicians and Surgeons.


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