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Politics

Non-doctors in Florida Lobby for OK to Perform Eye Surgery

March 29, 2017 - 6:00am

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.”

 

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Comments

I have no standing in this debate. Although I am a retired Optometrist who was licensed to the full limits of my profession while I practiced, I am now fully retired. My wife is an Optometrist who returned to Medical School because SHE wished to further her education not because Optometry was not to her liking. I taught at a College of Optometry for eight years. I know of the professional education of each profession personally. The things that disturb me most are the distortion of facts. You cannot define anything or anybody by what they are not, only by what they are. Optometrists are not Medical Doctors...Correct, but neither are Dentist or Podiatrists. We don't see this problem in those professions because there is no medical specialty for teeth and most Orthopedists can't be bothered with feet, yet we allow these professions to practice without medical supervision even in our hospitals. Taking nothing away from these professions, but the same right applies to Optometrists. I won't cite the official definition of Optometrist but it doesn't begin "An optometrist is not...". As each profession increases its education and requirements for certification then so should it increase its scope of practice.

The fact that this article continuously referred to optometrists as "non-doctors" is extremely insulting. We are primary eye care physicians and have doctor in our title. Just because we are not MDs doesn't mean we aren't doctors. Optometrist go to school for 4 years to learn about eyes, that's it. Those 4 years are so that we can be trained In providing quality eye care for everyone. There are more of us than there are Ophthalmologists, that is the reason this bill is completely acceptable. It is much easier for patients to find access to Optometrists than it is for them to find Ophthalmologist. That being said, there are different kinds of eye surgeries. And some, like cataract surgery should be left to the MDs, they are trained to do such things and optometrists are not. But simple procedures, like YAGs could easily be performed by optometrists and are being done so in 3 other states.

Yes, you're an eye care professional. Yes, you won the right to call yourself doctor. So do PhDs. That's not the same as spending four years in medical school, one year in a surgical prelim year, three years in an ophthalmology residency, and then an additional one or two years in a surgical fellowship. If you had spent that time, you'd realize just what you don't know and how easy it is for something to go wrong during surgery. You are welcome partners in providing good eye health to patients--but part of that is knowing what you don't know. Realizing that your training and expertise is not the same is one of those things. Would you trust an optometrist to do strabismus surgery on your child? If you had a detachment, would you go to an optometrist or a vitreoretinal surgeon? Optometrists should refer to medical professionals who have the right training and experience to provide the right care for patients.

Let's not distort facts. General ophthalmology permits these procedures, but does not require a surgical prelim year nor the 1-2 years fellowship you mentioned. I would not trust a general ophthalmologist with strabismus surgery any more than a local optometrist. Optometrists love working with strab surgeons, retinal specialists, cataract surgeons and the like and truly appreciate the services they provide that are well beyond what an optometrist can do. The frustration comes when simple procedures that optometrists are trained to perform and are frequently already managing post-operatively are being delayed because the local ophthalmologist is booked out for three months. Multiple studies on labor statistics demonstrate a shortage of ophthalmologists that will only grow as the baby boomer generation ages. Allowing optometrists to perform the procedures they are trained to do IS pro patient care so that care is not delayed longer than it already is.

"There are many more of us then them" That's the silly logic of an optometrist That same logic means passengers should be able to fly the jet... there are more of us then pilots That same logic will be used on patients eyes Can this be any more rediculous??? Only an idiot would vote for this

"There are many more of us then them" That's the silly logic of an optometrist That same logic means passengers should be able to fly the jet... there are more of us then pilots That same logic will be used on patients eyes Can this be any more rediculous??? Only an idiot would vote for this

It's a real shame. We, as a society, continue to become more corrupt. I am ashamed of the legislators. They should be ashamed of themselves for allowing this out of committee.

What is the public need for optometrists in Florida to be able to perform surgery? If 40 miles is the longest distance to an Ophthalmologist, it isn't access to care. Unless Optometrists are offering to give patients a discount on their care for seeing an OD instead of an MD (they are not, and are paid equally to MDs to perform eye exams ) (who have invested in 4 to 7 more years of training to improve their skills), there doesn't appear to be a financial benefit for patients to see an optometrist. This is a legislative, PAC funded, power grab by optometrists who wish they had been smart enough to get into medical school and have been saving up lobbying money to try to expand their scope of practice on an unsuspecting public.

Where are you getting 4-7 more years of of experience? Your avg OMD is not doing 2-3 felllwships. Get out of here with that. I know a few MDs in the area with yes more schooling but i wouldn't send my dog to them. Schooling doesn't always directly correlate to being a better doctor there buckaroo

I am trained as both an optometrist and ophthalmologist. Optometrists can be great eye physicians and surgeons, all it takes is 4 years of medical school, 1 year of internship, and 3 years of residency, and add in another 1-2 years of fellowship while you're at it. Anyone who thinks that even a well trained and well meaning OD can gain the additional required training to adequately insure patient in a period of a few weeks is either delusional or a fool. PhD psychologists are doctors, too, but that doesn't qualify them to prescribe medication.

All that schooling and you don't know the difference between "insure" and "ensure".

I am trained as a PRK optometric eye surgeon and have performed several procedures and I am ALSO in medical school. These procedures are well within the current scope of training for Doctor's of Optometry. The only reason I went to medical school is to challenge myself to go further and farther than where I'm at in optometry. And there is no reason valid reason to hold back Doctor's of Optometry from performing the YAG, SLT, and PRK procedures. I myself am paying my way through medical school on the PRK laser eye surgeries I do in the summer time. Stop the fear mongering please. All of the procedures in this bill are executed at the touch of a button. Cataract surgery nor extensive retinal surgery is NOT a part of this bill. Dr. Mallin needs to stop scaring the sh*t out of the patients with his lies. This has turned nasty in Florida and the patients see bickering doctors that look like two divorcing parents.

Someone's upset they spent 20 years in college.

These officials who were elected into office by the people don't seem to care to do the peoples work. To even consider allowing someone who decided NOT to go to school to get a degree as a medical doctor that proves he's a trained surgeon to operate on people is about the stupidest thing I've heard of coming out of Tallahassee. (Note I said about). I think it's about time the GOP started thinking about the people who elected them and keeping their best interests at heart and not the people who can give large sums of cash. This is a problem in today's politics that's getting worse with each passing day. It seems the people vote for something and the GOP does what it can to prevent the people from getting it or do all it can to regulate it out of existence. A prime example of this is healthcare.

From the bill "(3) The following surgical procedures, except for the preoperative and postoperative care of these procedures, are excluded from the scope of practice of optometry by a certified optometrist in ophthalmic surgery: (a) Penetrating keratoplasty, corneal transplant, or lamellar keratoplasty. (b) The administration of general anesthesia. (c) Surgery done with general anesthesia. (d) Laser or non-laser injection into the vitreous chamber of the eye to treat a macular or retinal disease. (e) Surgery related to the removal of the eye from a living human being. (f) Surgery requiring full-thickness incision or excision of the cornea or sclera, other than paracentesis in an emergency situation requiring immediate reduction of the pressure inside the eye. (g) Surgery requiring incision of the iris and ciliary body, including iris diathermy or incision with cryotherapy. (h) Surgery requiring incision of the vitreous. (i) Surgery requiring incision of the retina. (j) Surgical extraction of the crystalline lens. (k) Surgical intraocular prosthetic implants. (l) Incisional or excisional surgery of extraocular muscles. (m) Surgery of the eyelid for suspect eyelid malignancies or for repair of, including plastic surgery for, blepharochalasis or mechanical ptosis. (n) Tarsorrhaphy. (o) Surgery of the boney orbit, including orbital implants. (p) Incisional or excisional surgery of the lacrimal system other than lacrimal probing or related procedures. (q) Surgery requiring full-thickness conjunctivoplasty with graft or flap. (r) Pterygium surgery."

Dougie, I say this as respectively to you as I can both as a Doctor of Optometry and a medical school student... EDUCATE yourself and think twice before you speak once. This is the procedure in question. takes about 1:44 to watch it. If you actually took the time to see what is included in this bill you would see that this procedures are taught and trained the exact same way in the optometry curriculum as it is in the ophthalmology curriculum. When you comment on things you don't know it looks as though you haven't done an iota of research on the topic. I can't post a video of an slt procedure because it's triggering this sites "spam filter" so you are just going to have to google "SLT" "YAG" or "PRK" procedure. If you do these are two to five minute PROCEDURES. Not full on retinal or cataract surgery but procedures that are taught safely and effectively in the optometric curriculum. Cmon man use your head and stop being manipulated by my colleagues.

Optometrists are doctors. There are several types of physicians that are not MD's. Optometrists are Eye Physicians and ophthalmologists are Eye Surgeons. Many states allow optometrists to perform laser procedures, injectables, and surgical procedures. Co-management of patients allow both specialties to provide the best care for the patient. Ophthalmologists are trained in surgery and want to spend their time doing surgery. Seventy percent of all eye exams are performed by optometrists. The co-management fees are not fee splitting. They are set by the government and are not kick backs.

You are not a "physician" and no matter how many times you state it, it will never make it true. You are a doctor of optometry. Stop bastardizing the word, it is offensive and misleading to the public.

Define Physician? According to Merriam-Webster - Medical Definition of physician. : "a skilled health-care professional trained and licensed to practice medicine; specifically : a doctor of medicine or osteopathy." If optometrist want to be medical doctors and can pay politicians to change the law then by the same logic opticians after paying the same politicians should be able to prescribe glasses...by taking a few courses of course. Would an optometrist want another optometrist to do their mother's surgery....and they love their mother?

Actually the first patients that sat for me under proctored ophthalmology supervision were high school classmates. Not my mother, but my best friends.

While we're at it, let's amend the bill to allow chiropractors to perform spinal surgery.

This piece of legislation is a payback money grab to those who have contributed $$$ to legislators; nothing more. Having had 3 eye surgeries to correct a torn and detached retina as well as removal of the cataract, I trusted my care to the Bascom Palmer Clinic, a teaching hospital affiliated w the U of Miami Med School. I realize that this legislation would exclude retinal surgery from being performed by ODs, nevertheless wouldn't they now be allowed to do the cataract removal? If so, this I believe would have created a much higher probability for a compromised result, as certain procedures had to be modified to accommodate changes to the eyeball due to the previous retinal injury and repair. Bottom line: Anyone who performs invasive procedures to the eye needs to be of the highest skill w extensive training. An OD w some post grad courses just doesn't "cut" it.

From the bill "(3) The following surgical procedures, except for the preoperative and postoperative care of these procedures, are excluded from the scope of practice of optometry by a certified optometrist in ophthalmic surgery: (a) Penetrating keratoplasty, corneal transplant, or lamellar keratoplasty. (b) The administration of general anesthesia. (c) Surgery done with general anesthesia. (d) Laser or non-laser injection into the vitreous chamber of the eye to treat a macular or retinal disease. (e) Surgery related to the removal of the eye from a living human being. (f) Surgery requiring full-thickness incision or excision of the cornea or sclera, other than paracentesis in an emergency situation requiring immediate reduction of the pressure inside the eye. (g) Surgery requiring incision of the iris and ciliary body, including iris diathermy or incision with cryotherapy. (h) Surgery requiring incision of the vitreous. (i) Surgery requiring incision of the retina. (j) Surgical extraction of the crystalline lens. (k) Surgical intraocular prosthetic implants. (l) Incisional or excisional surgery of extraocular muscles. (m) Surgery of the eyelid for suspect eyelid malignancies or for repair of, including plastic surgery for, blepharochalasis or mechanical ptosis. (n) Tarsorrhaphy. (o) Surgery of the boney orbit, including orbital implants. (p) Incisional or excisional surgery of the lacrimal system other than lacrimal probing or related procedures. (q) Surgery requiring full-thickness conjunctivoplasty with graft or flap. (r) Pterygium surgery."

Charles please remove this post as the procedures in question are neither retinal nor cataract surgeries. There are NO cataract nor retinal surgeries in this bill. If you want a copy of the pdf file of the bill very happy to send it to you. Google the short videos for SLT, YAG, PRK and you'll see three very mundane and very superficial procedures that are mere alignment of the laser beams and that's it. Seriously. The ophthalmologists are wiping the public into a frenzy by misleading them and are coming dangerously close to a class action lawsuit by optometrists for slander. One cannot simply lie to the public (like Dr. Mallin did in his interview in Vero Beach) and get away with it.

Votes, money, influence, power -- all the expense of our priceless eyes. Very disturbing.

Legislators like it because they got a ton of cash to approve it. Wait until one of their family members gets a bad eye procedure from an optometrist. An optometrist is not a medical doctor. An optometrist receives a doctor of optometry (OD) degree after completing four years of optometry school, preceded by three years or more years of college. They are licensed to practice optometry, which primarily involves performing eye exams and vision tests, prescribing and dispensing corrective lenses, detecting certain eye abnormalities, and prescribing medications for certain eye diseases. They do not have 8 years of medical training, no training in surgical procedures, no residency with a board certified physician. They are really like a specialist or ARNP in medical terms. They should not be performing any kind of surgical or medical procedures. They are just not trained to do so...

Don't smear ARNPs. They're no comparison to ODs in terms of training, experience and supervision by an MD. Who would supervise ODs? Their for-profit store managers who care nothing about patients but care all about profits?

And in fact, when you say "who would supervise" the OD's you obviously are clueless that optometry is trained side by side and supervised by Ophthalmologists. My residency was at the University of Kentucky Department of Ophthalmology / Lexington VA Medical Center side by side with the ophthalmology residents. My internships were at the number one rated eye hospital in the world the Bascom Palmer Eye Institute. So, when you say who would supervise optometry, you are speaking from a position of extreme ignorance...

As a PRK eye surgeon , Doctor of Optometry and a current medical student in order for me to gain my optometric eye surgery certification I had to be proctor supervised by an ophthalmologist. Exact same training class that the ophthalmologists take. The exact same sequence, exact same wet labs, exact same proctored protocols. So, when you say who would supervise OD's I take it that you have not a clue on how we go through our laser training protocol and are speaking with no factual substantiation? Exactly. If you want a plane ticket up to Oklahoma I'm doing about 20 PRK eye surgeries in between medical school semesters. I invite you to sit in with me so you can appear intelligent in your next post.

The example of a mechanic wanting to be pilot is the perfect analogy. Just because mechanics know how to repair a plane doesn't mean they have skills to fly a plane! Only a fool would entrust themself or family members to fly with a mechanic in the cockpit instead of a pilot! In the same vein, only an incredibly stupid fool would allow an optometrist to perform laser, cataract or any other surgical procedure on their eyes!!

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