Keep Eye Surgery In The Hands Of Ophthalmologists

By Kurt F. Heitman, MD 

The strength of our armed forces depends on the different levels of training, skill, and experience of the ranks. There's good reason why an artillery mechanic has a different skill set than a cyber operations officer or why a fighter pilot has unique training from a counterintelligence officer. Our healthcare system is no different: it depends on a highly specialized workforce equipped with the education and training necessary to deliver safe, effective care.

Unfortunately, the Department of Veterans Affairs (VA) is taking steps to allow optometrists to perform surgery on the eyes of veterans. The VA recently changed its Community Care "Standardized Episode of Care: Eye Care Comprehensiveopens in a new tab or window" guidelines by removing language that allows only ophthalmologists to perform surgery. Optometrists are an essential part of a veteran's eye care team, but they are trained only to provide primary eye care -- they don't have the medical education or surgical training necessary to perform surgery.

Allowing optometrists to perform eye surgery at VA facilities or through the VA's Community Care Program means that the first human subject an optometrist performs surgery on could be a veteran. As a concerned veteran and physician, I won't let those who fought for our country be subjected to a lower standard of care at the VA.

There are no shortcuts to safely performing surgery. After 4 years of medical school and 4 years of residency, an ophthalmologist will have performed hundreds of surgeries of varying complexity. These procedures are mastered over 8 to 10 years through countless hours of closely monitored, one-on-one mentored surgical cases taught by board-certified ophthalmologists.

In contrast, optometry school is a 4-year degree program focusing on primary eye care. They are trained to provide routine eye exams and vision tests, prescribe and fit eyeglasses and contact lenses, monitor eye conditions related to diseases such as diabetes, and provide low-vision aids. Clinical surgical training is not part of the education of the vast majority of optometry students.

Contrary to some claims made by the optometric community, there are no shortages of ophthalmologists in the community who can provide timely laser and scalpel surgery on veterans.

So, it is baffling why a handful of states -- collectively representing approximately 10% of the U.S. population according to the U.S. Census Bureauopens in a new tab or window -- allow optometrists to perform laser eye surgery. Researchers have found that most Medicare beneficiaries (more than 90%) live within a 30-minute driveopens in a new tab or window of an ophthalmologist. The overwhelming majority of states authorize only ophthalmologists to perform surgery because most policymakers understand that a comprehensive medical and surgical education is the best way to ensure patient safety.

Moreover, studies have shown that loosening standards can lead to patient harm. Having laser surgery performed by an optometrist made it twice as likelyopens in a new tab or window for patients to need additional treatment than if the procedure was performed by an ophthalmologist. The same research found that there was a 189% increased risk of needing additional laser surgery in the same eye after an optometrist, rather than an ophthalmologist, performed the procedure. Furthermore, troubling complications may be understated because optometrists are regulated by state boards of optometry, which for most states do not requireopens in a new tab or window optometrists to report adverse outcomes on the patients they treat.

For all these reasons, stateopens in a new tab or window publicopens in a new tab or window opinion pollsopens in a new tab or window highlight widespread opposition to the loosening of surgical standards. Additionally, there has been media scrutiny, which has exposed how the push to loosen standards is more about politicsopens in a new tab or window than it is about patient health.

Just recently, the risks to patient safety weighed heavily on Gov. Gavin Newsom (D.-Ca.) when he vetoed a billopens in a new tab or window that would have allowed optometrists to perform eye surgery. Newsom wrote, "I am not convinced that the education and training required is sufficient to prepare optometrists to perform the surgical procedures identified. This bill would allow optometrists to perform advanced surgical procedures with less than 1 year of training. In comparison, physicians who perform these procedures must complete at least a 3-year residency program. For this reason, I cannot sign this bill."

Veterans have benefitted from established, consistent, high-quality surgical eye care for decades. Why change this now? The VA says the changes are meant to improve efficiency and consistency in the delivery of comprehensive eye care across the VA. But allowing optometrists to perform eye surgery in the VA would not solve access issues. While there are regional variations, most Medicare beneficiaries live within a 30-minute driveopens in a new tab or window of an ophthalmologist. Allowing optometrists with variable education and training to perform these procedures is not the answer. Instead, this change will lower the standard of surgical eye care that veterans now rely upon. Eye surgery is delicate and requires the skill and judgement only a highly trained and experienced surgeon can provide.

The VA should immediately reinstate the guidelines that have protected our veterans so they can continue to receive the highest level of surgical eye care from trained ophthalmologists.

Kurt F. Heitman, MD,opens in a new tab or window is an ophthalmologist in Greenville, South Carolina. He served as a flight surgeon and an ophthalmologist in the U.S. Air Force from 1987 to 1991, and is past president of the South Carolina Society of Ophthalmology.

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