Optometry and Arkansas

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DrQuakerJack

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Arkansas is about to allow optometrist to perform injections as well as laser and scalpel surgery.

I know this is a hot topic and has been discussed in other threads, but would love your thoughts.

Have other states where this is allowed seen optometrists taking advantage of their larger scope?

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pretty sure its still alive still. Not sure where it stands in terms of further voting and such
 
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Last I heard, it's on its way to the Governor's desk for signing. Only a miracle can prevent him from signing it now. Ophtho as a field is going to look a lot different 20 years from now.
 
It didn't pass, still no optoms doing injections in Arkansas
 
I would have a big problem with ODs doing intraocular injections, if this is what the bill referred to. I see enough misdiagnosis from ophthalmologists, who do injections. Adding ODs to the docs who can do injections would really exaggerate this problem. Also, if an OD injected pt developed endo……
 
I would have a big problem with ODs doing intraocular injections, if this is what the bill referred to. I see enough misdiagnosis from ophthalmologists, who do injections. Adding ODs to the docs who can do injections would really exaggerate this problem. Also, if an OD injected pt developed endo……
If dry AMD injections come to market, us retina docs will be overwhelmed. The "access to care" debate will strengthen and they will push harder to do injections. nAMD therapuetics are lasting longer but we all know 2-3 months doesn't work for everyone. The port delivery system is a good "proof of concept" but I have very few patients interested in it. And the surgical risk and reimbursement is tricky. I think your comment regarding complications is really critical. If optometrists start doing yag lasers, PRP's or injections and they have a complication they will have no leg to stand on. The opposite of course is an issue: if they do many procedures and prove they can do them safely then expansion will progress. We do some of this to ourselves of course, hiring optometrists and other practitioners (ie MA's, NP's etc) to work in our offices, see patients and even lobbying to have them perform injections under our supervision. It's a short sided money grab. Also marketing/supporting optometry courses, CE's etc where procedures are taught, expert witness support in cases of malpractice etc. Not sure where this is all headed but I feel like the writing is on the wall.
 
Yes, I was hoping the PDS would be the “end all” to monthly injections but not getting a lot of takers once I discuss the elevated endo rate, and other risks, (compared to monthly injections). An injection for dry AMD would simply overwhelm us…….I feel a bit overwhelmed now, with complicated pts and the need for scheduled treatment.
We’ve discussed hiring an OD to train as a “walk in clinic” doc for all the phone calls we get from pts wanting to be seen asap for their various issues (ie, subcontinent heme after an injection). It’s time consuming for staff to deal with these, as many are not emergent/urgent, but pts sure think they are. An OD, trained by us, could handle a lot of these minor problems and free us from the minutiae. Ultimately, we decided it was not the right decision as we did not want to open that door.
I’ve had referring ODs ask my opinion about their abilities to do retinal lasers and I’ve always told them ”I don’t even think general ophthalmologists should be messing with the back of the eye so I don’t support anyone doing it except retina”
 
Yes, I was hoping the PDS would be the “end all” to monthly injections but not getting a lot of takers once I discuss the elevated endo rate, and other risks, (compared to monthly injections). An injection for dry AMD would simply overwhelm us…….I feel a bit overwhelmed now, with complicated pts and the need for scheduled treatment.
We’ve discussed hiring an OD to train as a “walk in clinic” doc for all the phone calls we get from pts wanting to be seen asap for their various issues (ie, subcontinent heme after an injection). It’s time consuming for staff to deal with these, as many are not emergent/urgent, but pts sure think they are. An OD, trained by us, could handle a lot of these minor problems and free us from the minutiae. Ultimately, we decided it was not the right decision as we did not want to open that door.
I’ve had referring ODs ask my opinion about their abilities to do retinal lasers and I’ve always told them ”I don’t even think general ophthalmologists should be messing with the back of the eye so I don’t support anyone doing it except retina”
Do you really feel that way or is that just what you tell ODs? I don't do any intraocular surgery so I am not offended but is it wrong for a comprehensive ophthalmologist from a busy residency to laser a tear or treat mild PDR? We certainly did hundreds of PRPs in my residency.
 
Yes, I was hoping the PDS would be the “end all” to monthly injections but not getting a lot of takers once I discuss the elevated endo rate, and other risks, (compared to monthly injections). An injection for dry AMD would simply overwhelm us…….I feel a bit overwhelmed now, with complicated pts and the need for scheduled treatment.
We’ve discussed hiring an OD to train as a “walk in clinic” doc for all the phone calls we get from pts wanting to be seen asap for their various issues (ie, subcontinent heme after an injection). It’s time consuming for staff to deal with these, as many are not emergent/urgent, but pts sure think they are. An OD, trained by us, could handle a lot of these minor problems and free us from the minutiae. Ultimately, we decided it was not the right decision as we did not want to open that door.
I’ve had referring ODs ask my opinion about their abilities to do retinal lasers and I’ve always told them ”I don’t even think general ophthalmologists should be messing with the back of the eye so I don’t support anyone doing it except retina”
we have tossed around the same idea, and several groups in the area already employ OD's for this purpose. One group across the state has hired NP's to actually do injections (this is being investigated by local and national organizations as it may be outside of scope). We have opted to not do it. It is a hassle but I'd rather take care of my own patients than outsource to someone else. It's very tempting but I feel once the door is opened its hard to shut it without having many others enter.
 
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Do you really feel that way or is that just what you tell ODs? I don't do any intraocular surgery so I am not offended but is it wrong for a comprehensive ophthalmologist from a busy residency to laser a tear or treat mild PDR? We certainly did hundreds of PRPs in my residency.
I did hundreds of glaucoma lasers, hundreds of cataracts and so on in residency. This doesn't make me an expert in those procedures. And if you start a procedure then you better be ready to own it. So if your retinal tear patient detaches will you fix it? If your "mild PDR" pt develops vitreous heme or traction detachment will you fix that? If your routine nAMD patient develops endo after an injection will you handle it?
 
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Do you really feel that way or is that just what you tell ODs? I don't do any intraocular surgery so I am not offended but is it wrong for a comprehensive ophthalmologist from a busy residency to laser a tear or treat mild PDR? We certainly did hundreds of PRPs in my residency.
In poor access areas I would not mind ophthalmologists doing basic PRP but not for tears unless they are very posterior. However, the PRPs I've seen from most general ophthalmologists is way too light and ends up needing to be touched up a few months later by me.

I've seen enough tears lasered by general ophthalmologists that thought they could handle a tear only to see incomplete barricade with some turning into a detachment (and thus delaying care). Many of these tears require laser indirect ophthalmoscopy for complete coverage, which is something almost all residents don't get good training on (or some fellowships for that matter).
 
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I take your point. However the argument of 'if you do a procedure, you should be able to handle the complications' doesn't really hold water. GI cannot 'handle' a perfed colon, general surgery cannot 'handle' a ureteral injury, and comprehensive ophthalmology cannot 'handle' a dropped lens. It doesn't mean they should stop doing cataracts. I think the saying should be amended to 'if you do a procedure, you should be able to recognize the complications expediently'. Perhaps there is a balance that is different from comp ophtho staying away from the posterior segment entirely...
 
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The main reasons optoms should not do injections is not because of technical ability or even complications, it’s because knowing when you need to inject and when you can observe is not as straightforward as people think. Not everything that looks like fluid needs a needle in the eye.
 
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I take your point. However the argument of 'if you do a procedure, you should be able to handle the complications' doesn't really hold water. GI cannot 'handle' a perfed colon, general surgery cannot 'handle' a ureteral injury, and comprehensive ophthalmology cannot 'handle' a dropped lens. It doesn't mean they should stop doing cataracts. I think the saying should be amended to 'if you do a procedure, you should be able to recognize the complications expediently'. Perhaps there is a balance that is different from comp ophtho staying away from the posterior segment entirely...
In your examples, they created a complication as a function of performing a procedure within their scope. Then referred to a specialist who is an expert in that field once outside their scope.

This is very different than what is happening in these scope expansion scenarios where non-experts (ie optometrists) are trying to perform procedures for which experts already exist (ie ophthalmologist). Your example would be more appropriate if you posed a scenario such as a GI doctor performing a Whipple procedure, or a general surgeon performing a nephrectomy, or a cataract surgeon performing a vitrectomy and pars plana lensectomy for lens fragments in the posterior segment. Most of us would agree that's outside of their scope, and if they encountered a complication while doing so would likely find themselves in a lot of trouble.
 
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In your examples, they created a complication as a function of performing a procedure within their scope. Then referred to a specialist who is an expert in that field once outside their scope.

This is very different than what is happening in these scope expansion scenarios where non-experts (ie optometrists) are trying to perform procedures for which experts already exist (ie ophthalmologist). Your example would be more appropriate if you posed a scenario such as a GI doctor performing a Whipple procedure, or a general surgeon performing a nephrectomy, or a cataract surgeon performing a vitrectomy and pars plana lensectomy for lens fragments in the posterior segment. Most of us would agree that's outside of their scope, and if they encountered a complication while doing so would likely find themselves in a lot of trouble.
I know many anterior segment surgeons who can do a decent ppv (myself included). Some of them even put on a biom and go after fragments.
 
I know many anterior segment surgeons who can do a decent ppv (myself included). Some of them even put on a biom and go after fragments.
I said “ most of us” fully expecting this response. I know retina docs who can do a great phaco, myself included. We should all do what we are comfortable doing, and can safely do. My argument still stands, be ready to own it. If I drop a lens or break capsule, I can fix it. Can an cataract doc fix a retina that detaches during a vitrectomy?
 
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In your examples, they created a complication as a function of performing a procedure within their scope. Then referred to a specialist who is an expert in that field once outside their scope.

This is very different than what is happening in these scope expansion scenarios where non-experts (ie optometrists) are trying to perform procedures for which experts already exist (ie ophthalmologist). Your example would be more appropriate if you posed a scenario such as a GI doctor performing a Whipple procedure, or a general surgeon performing a nephrectomy, or a cataract surgeon performing a vitrectomy and pars plana lensectomy for lens fragments in the posterior segment. Most of us would agree that's outside of their scope, and if they encountered a complication while doing so would likely find themselves in a lot of trouble.
I'm not sure this really holds up either. As an FP (non-expert in orthopedics) I do joint injections fairly frequently. There are experts who already exist (orthopedic surgeons) that do the procedure. If something goes wrong when I do it, I'm going to refer to them.

Its worth noting that I'm not advocating for increased OD scope here. But, you do have to be careful in what arguments you make.
 
I said “ most of us” fully expecting this response. I know retina docs who can do a great phaco, myself included. We should all do what we are comfortable doing, and can safely do. My argument still stands, be ready to own it. If I drop a lens or break capsule, I can fix it. Can an cataract doc fix a retina that detaches during a vitrectomy?
No but myself and all the other anterior segment surgeons doing ppv are still doing it. There's even a highly regarded course at AAO called PPV for the anterior segment surgeon. I only mention this as you list ppv as one of those untouchable except by retina fellowship trained surgeons. The argument against prp is even weaker. The comment regarding prp from general ophthalmologist being too light is interesting. When reimbursement structure for prp changed, suddenly the retina specialists were having patients return for multiple rounds of laser. Yag capsulotomy by optometrists is a whole nother show.
 
No but myself and all the other anterior segment surgeons doing ppv are still doing it. There's even a highly regarded course at AAO called PPV for the anterior segment surgeon. I only mention this as you list ppv as one of those untouchable except by retina fellowship trained surgeons. The argument against prp is even weaker. The comment regarding prp from general ophthalmologist being too light is interesting. When reimbursement structure for prp changed, suddenly the retina specialists were having patients return for multiple rounds of laser. Yag capsulotomy by optometrists is a whole nother show.
The reimbursement issue isn’t completely true, in fact it’s a minor reason for more frequent PRPs. What happened was the advent of pattern laser (PASCAL) becoming more frequently used around this time.

If you’ve done old school PRP, you would have known why it reimbursed as much as it did back then. Patients needed to be blocked, it could take 15-30 minutes if you were fast, and if you used a LIO, it was not easy on your neck. However, these PRPs were done on much higher power and duration so these PRPs worked well. With the pattern lasers, you can do the laser much faster with less pain and hassle, but since the duration and power has to be lower for the pattern lasers, the treatment isn’t as good shot per shot. If you use the DRS treatment protocols with pattern lasers, you end up undertreating. This is why so many more patients were brought back more frequently in the former 90 day (now 10 day) post op period.

This is what I’m referring to. Most general ophthalmologists use pattern laser because that’s what they trained with, but they often undertreated because they used the standard 1-1.5k shots when they should be doubling or even tripling the amount of laser put in for many diabetics. Thus, they wonder why their patients still have progressive disease ( and it’s not always the patient’s fault) and need more laser. If you don’t believe me, go read the DRCR Protocol S study - as flawed as it is, it did show how pattern laser isn’t shot per shot as good as old school PRP.

But no that’s not it, we’re all a bunch of greedy d-bags that went into it only for the money.
 
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The main reasons optoms should not do injections is not because of technical ability or even complications, it’s because knowing when you need to inject and when you can observe is not as straightforward as people think. Not everything that looks like fluid needs a needle in the eye.
Amen to this! I’ve seen general ophthalmologist injecting stuff that should not be injected so I can only imagine how bad it would be with ODs. It’s just like surgery in that anyone can do surgical procedures…..with enough training and repetition. But, doing the surgery is not the hardest part. Deciding who needs surgery, when they need surgery, the plan for surgery, any complications during surgery, how to manage the pt after surgery, etc….. These are the hard parts that require the specialized training.
 
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