Eye surgery should be left to the experts

By Dr. Michael Keverline:

In recent years, Virginia lawmakers have reviewed many proposals that would expand certain health care providers’ “scope of practice.” That term refers to the level of care a health care provider can offer, based on education, training, experience and state law. 

Scope rules prohibit your primary care doctor, for example, from performing brain surgery (and they probably wouldn’t want to, anyway).

These bills have been spurred as a result of the health care workforce shortage — the need for more professionals to fill roles commonly performed by physicians or peer providers. It’s why, for example, you are often seen by a nurse practitioner or a physician’s assistant at a primary-care doctor or orthopedic clinic for basic needs or pains.

But clinical boundaries exist for a reason.

The latest scope issue to come to Virginia: primary vision care doctors looking to perform laser-eye surgery. If Senate Bill 375 and House Bill 213 pass, they would lower the professional standards of care without improving access to it, and harm Virginians along the way.

Laser surgery is surgery, according to medical definitions and long-standing, repeatedly confirmed Virginia laws. The Commonwealth’s Code is consistent with the overwhelming majority of states: 43, to be exact, that do not allow optometrists to perform eye surgery. 

And for good reason. Eye doctors — optometrists — are practitioners who diagnose eye conditions and treat vision problems. If you need eyewear prescriptions, or are having problems with your eyes or sight, you visit an optometrist. They play an important role in eye care.

Ophthalmologists are eye physicians and surgeons. They are medical doctors who can treat the entire body, but specialize in eyes — no different than doctors who specialize in gastrointestinal, orthopedics, or neurology. In most cases, an optometrist diagnoses conditions like glaucoma, cataracts, or retinal detachment, then refers the patient to an eye surgeon for treatment.

Similar and confusing names, with one big difference: Training and education. Ophthalmologists require at least 12 years of higher education — which include five in intensive surgery training. They amass nearly 20,000 hours of training before they are certified to perform surgery.

Optometrists, meanwhile, can practice eight or nine years after graduating high school. They don’t attend medical school and receive no surgical training.

Should two bills in the General Assembly pass, optometrists, if certified by the state Board of Optometry, would be allowed to perform laser-eye surgery. It would put Virginia in a small group of states that allow optometrists to perform laser-eye surgery (the Department of Veterans Affairs prohibits optometrists from doing these procedures).

Lasers are a powerful surgical tool that cut or burn through human tissue. They are no different from a scalpel, and in the wrong hands, can do great and lasting damage.

In a laser-eye surgical procedure, patients place their head against a forehead rest. With one hand, the surgeon holds a surgical lens on the patient’s eye. With the other, the surgeon maneuvers, focuses, and fires the laser for each individual laser shot.  

Procedures are performed using a tool called a YAG laser, which works by firing a beam into the eye and vaporizing tissue. In essence, we create microscopic explosions in the eye. And like any explosion, both good and bad impacts occur within the blast radius.

Complications occur even when done properly. When done poorly, damage to the lens can occur that cannot be undone. A qualified surgeon can predict the complications, recognize them when they occur, and has the skills to surgically repair the complication. 

Providing safe surgical care to patients requires rigorous instruction and years of supervised residency training. It remains unclear how optometrists would gain training before claiming they are qualified to perform laser-eye surgery.

Virginians don’t want this bill. An independent poll commissioned by the Virginia Society of Eye Physicians & Surgeons found that only 10 percent of Virginia voters would be comfortable with an optometrist performing a laser-eye treatment.

And Virginians don’t need this bill. Optometrists claim passage will increase access to these procedures. But even in those states where laser surgery is allowed for optometrists, few provide it, and typically not in underserved areas. Eye surgeons are widely available across Virginia.

In fact, expanding scope of practice may lead to over-utilization of laser-eye surgeries and drive up costs and the need for corrective medical care.

Here’s what we know for sure: If this legislation passes, inadequately trained practitioners will be performing surgery on people’s eyes.

Dr. Michael Keverline is president of the Virginia Society of Eye Physicians and Surgeons. He lives in Norfolk and practices in Portsmouth and Chesapeake.