When the legislative session opened in Tallahassee earlier this month, lawmakers and lobbyists were surprised by an epic battle over eye surgery.
A series of bills authorizing optometrists, who are not medical doctors, to perform such surgery have ignited the latest round of what critics call “the eyeball war” in Florida. On one side are optometrists who claim they are capable of performing many common procedures. On the other side are ophthalmologists, who insist that such surgery should be done only by trained and licensed medical doctors. Billions of dollars in fees are at stake in this battle, which echoes similar disputes across the country. There is also a political dimension because one of the top lobbyists for the legislation, Michael Corcoran, is the brother of Florida’s Speaker of the House Richard Corcoran, R-Land O’Lakes.
State Senator Jack Latvala, R-Clearwater, introduced the bill in the Senate on February 23. In the House, Rep. Manny Diaz, Jr., R- Hialeah Gardens, introduced a companion bill to allow non-doctors to perform eye surgery on February 24.
State law currently bars non-doctors from performing such eye surgery. Sweeping away such barriers, the new legislation would also allow optometrists to prescribe the same drugs that doctors can and act like surgeons in caring for patients across Florida, one of the largest markets for eye surgery in the world. The optometrists, if the law passes, would be required to complete some additional but undefined specialized medical training. That additional training will not involve becoming a licensed medical doctor.
The proposed state law could affect almost all of the Sunshine State’s 20 million residents.
“If you live long enough, you will get cataracts and eventually need corrective surgery,” said Jaime Membreno, a veteran and ophthalmologist from Kissimmee. “Allowing optometrists to do this kind of surgical procedure is like allowing the mechanic to fly a fighter jet.”
Optometrists see it differently. “The fact is we are the primary care for the optics of the eye,” said Salvatore DeCanio, an optometrist in South Florida. “We know far more about optics and prisms in the eye than ophthalmologists. They have a different specialty.”
DeCanio, who is a fellow of the American Academy of Optometry and has 32 years of experience in optometry, said he and his colleagues already do far more than ask patients to read eye charts.
“I removed something from the cornea today on a patient who was in need of immediate care,” he said. “I am part of a group that is comfortable with some mildly invasive procedures. As an optometrist, the cornea and lens of the eye is not a strange animal for us.”
Both the American Optometric Association and the Florida Optometric Association did not return calls from the American Media Institute. Instead, the American Optometric Association provided a written statement that read in part: Patients trust optometrists “to deliver the highest quality, most advanced and most personalized care as well as the best outcomes.
Ophthalmologists, who are licensed medical doctors and trained surgeons, are outraged over what they say is heightened risk to patients. Even a small mistake in eye surgery can lead to irreversible blindness, said Dr. William Mallon of Vero Beach, a leading opponent of the legislation.
“It takes a minimum twelve years of schooling and training to perform eye surgery,” said Dr. Mallon. “Medical school. Supervised residency. The night before my surgeries, I go for a run and get a full night’s sleep. I know that if I lose focus for even a single second of surgery, my patient’s life could be permanently changed. Recently I operated successfully on a one-eyed patient, who was terrified to have a cataract removed from her one remaining good eye. I understood her fear. I think about the stakes every time I walk into the operating room.”
Dr. Mallon cast the bill as part of a larger push by optometrists, who often make referrals to ophthalmologists, to use political leverage to make money. He gave up his practice in Jacksonville in 1999, in part, because he was told that his patients’ post-surgical care would have to be overseen by optometrists or they wouldn’t refer any patients to him. He believes post-surgical care, as well as eye surgeries themselves, should be directed by doctors.
“Those optometrists totally controlled the market up there,” he said. “They were risking the patients’ well-being for a 20% fee-sharing arrangement.”
Such fee-sharing arrangements, known as “co-management,” are an increasingly common practice in Florida and are legal if done correctly. Critics say the practice is unethical. Usually these arrangements are not disclosed to patients. Mallon and other critics say this arrangement puts money ahead of the best care for patients.
Behind the political battle are patients’ lives and careers. Cases of vision loss and other complications have grown in the handful of states that allow optometrists to prescribe medicine and perform laser eye surgery, studies show. Additionally, trained doctors can spot a range of maladies — everything from lymphoma and heart arrhythmias to sleep apnea and diabetes — that non-medical doctors are not as extensively trained to look for. What everyone can see is the mountain of money at stake, though both sides insist that patient outcomes are the real issue.
Optometrists, who are now legally allowed to call themselves “optometric physicians” in Florida, have long sought to put themselves on an equal footing with traditionally trained doctors. Ambition plays a role, too. Many optometrists have opened small chains—dozens of storefronts selling eye glasses and eye care—that would further prosper with the added business. Ophthalmologists tend to have small practices and directly supervise all patient procedures; their boutique enterprises would suffer from big-chain competition.
The push to give optometrists new powers is driven by a complex web of dark money — contributions filtered through shadowy political organizations to hide their source — that has funded massive lobbying efforts. In the last election cycle, optometrists spent $2.1 million on candidates, according to FloridaPolitics.com. For the 2018 election cycle, optometrists have raised more money for Sunshine State lawmakers than any other health-care lobby.
Optometrists greatly outnumber ophthalmologists in Florida, as they do in most states, and usually outraise their doctor rivals by a large margin. Most of the optometrists’ donations to politicians flow through a non-profit organization called the Florida Optometry Eye Health Fund. Checks written to it are tax-deductible and the lobbying organization is exempt from federal income taxes and state sales taxes.
“The Florida Optometry Eye Health Fund had the highest revenues during the previous tax year among all 501(c)4 nonprofit organizations based in Florida,” said Laura Curlin, the data director at MapLight, a non-profit focused on political transparency.
By contrast, ophthalmologists raised less than $200,000 — less than one-tenth of the amount raised by their rivals, public filings show.
Florida is in the forefront since the state has one of the nation’s highest concentrations of retired people, who typically need more eye care than working-age people do. Similar legislative battles, however, are breaking out all over the country.
“Every year when state legislatures open around the country,” said Dan Briceland, a spokesman for American Academy of Ophthalmology, “there are efforts by non-physician practitioners to lobby for expanded scope of practice.”
The long-running lobbying war between optometrists and ophthalmologists – what politicos derisively call the “Eyeball Wars” – is intensifying.
The conflict pits two different sets of eye professionals, with very different educational backgrounds, against one another.
Ophthalmologists must attend four years of college and four years of medical school, followed by internships lasting at least one year, three years of residency and usually at least an additional year fellowship, which includes hundreds of hours of practice supervised by experienced medical doctors.
Optometrists usually complete four years of college and graduate school, but are not required to graduate from medical school. A few optometry schools allow applications from students who didn’t complete an undergraduate degree. In virtually all cases, optometrists do not work in internships at hospitals or supervised residencies at medical facilities.
The proposed Florida legislation would create a new type of medical professional – a “certified optometrist” – who would complete a specialized post-graduate degree, which is not a medical school degree.
States including Oklahoma, Louisiana, and Kentucky that have experimented with surgical powers for optometrists have had mixed results. Oklahoma was the first state to allow optometrists to perform surgical procedures, in 1998.
Patients there who had eye surgeries performed by optometrists were, after accounting for confounding variables, 189 percent more likely to need a follow-up procedure than when the same operation was performed by an ophthalmologist, according to a University of Michigan study published in the Journal of American Medical Association of Ophthalmology.
Veterans hospitals have also experimented with using optometrists to perform surgeries and subsequently backed away from the practice.
“After what happened here, we made a change in policy to ensure that anyone receiving surgical care for cataracts saw an ophthalmologist as part of their treatment for the condition” says Michael Hill-Jackson, a public affairs officer with the Veterans Affairs Hospital in Palo Alto, CA.
When a veteran unexpectedly lost his eyesight after treatment for glaucoma by an optometrist in 2009, the veterans hospital launched a full-scale investigation. It found 381 patients who had been treated by optometrists and were at risk of progressive vision loss. A further review of these cases revealed that 87 patients were “high risk for further vision loss and 23 were suffering from progressive vision loss.” Seven veterans had been blinded in one or both eyes or had their vision reduced.
Each side sees these two studies differently. For the ophthalmologists, they offer proof that allowing non-doctors to perform surgery is risky and dangerous. For optometrists, these studies are just snapshots of bad luck. They do not point to other studies that make a positive case for optometrists cutting out cataracts or cancer; instead, they say, the record is still open. Indeed, the record is sparse because so few jurisdictions have allowed optometrists to operate on eyes.
One Indian River country optometrist spoke off-the-record with the American Media Institute because she fears her colleagues at the Florida Optometric Association would harm her business if she publicly questioned their agenda. While she favors permitting optometrists to carry out laser eye surgeries, she opposes opening all eye surgeries to her fellow optometrists. “I think there is a whole subset of very good optometrists who are wannabe ophthalmologists,” she said. “That’s fine but those people should go to medical school before they perform operations.”