Vermont legislators considering bill to expand scope of practice for optometrists

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Legislators in Vermont are considering a bill that would allow optometrists to perform certain surgeries that are currently the exclusive purview of ophthalmologists.

In 2022, the Vermont Senate Committee on Government Operations requested that the Secretary of State’s Office of Professional Regulation (OPR) to find ways to expand optometrists’ scope of practice.¹

In the fall of 2023, the OPR issued a report recommending the creation of a new specialty endorsement license for Vermont optometrists that would allow them to perform a specific list of operations.

Senate Bill 233 received a first reading on January 9, 2024. It is sponsored by Alison Clarkson, D-Woodstock, and Brian Collamore, R-Rutland.

The proposal in Vermont would revise and further define the scope of practice for optometrists. It would also create a specialty endorsement license that would allow qualified optometrists to perform certain advanced therapeutic procedures.

Traditionally, optometrists have referred patients to ophthalmologists for procedures including surgeries, injections and lasers, but that line is being muddied by legislation like that now being considered in Vermont. Recently, South Dakota became the latest state to expand the scope of practice for optometrists, making it the 12th state in the nation to authorize doctors of optometry for ophthalmic lasers, bolstering patients’ access to this level of care.²

South Dakota Gov. Kristi Noem signed House Bill 1099 into law on March 5. The South Dakota law allows doctors of optometry to administer injections around the eye, use local anesthetic for office-based surgical procedures, and perform laser procedures, including selective laser trabeculoplasty (SLT) and posterior capsulotomy with a yttrium aluminum garnet laser (YAG), in accordance with new education and certification requirements. Optometrists will be required to complete a three-part process to perform the additional procedures.

The South Dakota State Medical Association and the South Dakota Academy of Ophthalmology both expressed opposition to the measure, pointing out that optometrists receive far less training in these areas than ophthalmologists, and this could lead to potential issues.

In Vermont, under the proposal the level of service would include surgeries that previously only ophthalmologists could perform. The argument made by optometrists is that it expands on the in-office procedures they already do, increasing access and lowering costs for patients. The counter-argument made by ophthalmologists is that it's dangerous, because optometrists don't have the training or experience required.²

Jessica McNally, MD, president of the Vermont Ophthalmological Society, told the Burlington Free Press that ophthalmologists have the training necessary to perform the procedures, including completion of a 4-year undergraduate degree program followed by 4 years of medical school. After medical school, ophthalmologists spend 4 to 6 years of residency and fellowship training that can include specialties such as general surgery, emergency medicine and internal medicine, but focuses primarily on advanced medical and surgical treatment of the eye.

Dean Barcelow, OD, president of the Vermont Optometric Association, told the publication that the legislation would allow optometrists to perform injections into the "superficial eye," or the eyelid, not into the eye. Optometrists also want to be able to inject dye into a patient's veins to look for leaky blood vessels in the eye. They also would be able to remove small, benign lesions, such as skin tags on the eyelid or close to the eyelid.

They also would be able to perform some well-designed laser procedures, including one related to cataract surgery, another procedure that involves using a laser to add an "emergency drain" to the eye when the natural drain closes up and fluid begins to build up, and a third that has to do with improving draining by stimulating the tissue that drains the eye to become more efficient, which is particularly useful for glaucoma patients in early stages of the disease, or who can't take drops.³

The OPR detailed in its report that “only optometrists with a "specialty endorsement license" should be permitted to perform these advanced procedures.”

Moreover, according to the report, in order to obtain the specialty endorsement license, optometrists would be required to complete a post-degree “preceptorship” − essentially instruction − in performing the advanced procedures on “live, human patients.” Optometrists would also have to pass examinations showing they know how to do the laser and non-laser surgeries and injections.³

Optometrists performing these advanced procedures would be required to report the outcomes to OPR biennially and to report "adverse events" to OPR immediately.

In its report, the OPR could not determine whether expanding the scope of practice for optometrists would improve access or lower costs.³ That would seemingly negate one of the arguments being made in favor of the proposal.

SB 233 was referred to the Committee on Health and Welfare.

References:

1. Robinson PD Sarah Mearhoff, Shaun. Final Reading: Two Vermont eye-care professions are at odds. VTDigger. Published February 22, 2024. Accessed March 11, 2024. https://vtdigger.org/2024/02/22/final-reading-two-vermont-eye-care-professions-are-at-odds/

2. South Dakota secures scope expansion for injections, optometric laser procedures. www.aoa.org. Accessed March 11, 2024. https://www.aoa.org/news/advocacy/state-advocacy/south-dakota-secures-scope-expansion-for-injections-optometric-laser-procedures?sso=y

3. Vermont Legislature is deciding who should be allowed to do surgery on your eyes. Burlington Free Press. Accessed March 11, 2024. https://www.burlingtonfreepress.com/story/news/2024/03/11/vermont-optometrists-push-for-expanded-scope-of-work/72866932007/