retina job market/salary

[lt1234]

what is the job market for retina in not the major metropolitan cities (outside of new york, california)? what is the starting salary and average 5-10 years out?

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[LightBox]

Alot 🙂

 

[xDNA]

 

[dantt]

Nobody knows what the average will be in 5-10 years.

Do you believe that specialists are losing money with every injection they make?

Eye Injections Cost More Than Payers Think

The expense of each intravitreal injection is higher than the reimbursement rate, and retina specialists worry that one of the most frequently used codes in the specialty is undervalued.

www.medscape.com

Or do you believe that intravitreal injections are one of the highest consumers of medicare dollars and is currently valued at more intensive than everything but emergency intubation and emergency tracheostomy?

Both may be correct to some degree.

 

[OphthoApplicant04]

Nobody knows what the average will be in 5-10 years.

Do you believe that specialists are losing money with every injection they make?

Eye Injections Cost More Than Payers Think

The expense of each intravitreal injection is higher than the reimbursement rate, and retina specialists worry that one of the most frequently used codes in the specialty is undervalued.

www.medscape.com

Or do you believe that intravitreal injections are one of the highest consumers of medicare dollars and is currently valued at more intensive than everything but emergency intubation and emergency tracheostomy?

Both may be correct to some degree.

Gosh I don’t usually argue with other doctors asking for more pay but that’s a joke. I can setup, inject, and chart an injection in 10 minutes. That’s 6x98= 588/hour in labor. Cry a river!

 

[MstaKing10]

What the injection pays is almost nothing. Reason is the overhead to order, store, track and follow up with insurance to get paid costs more than the injection (as the article points out). The labor is not only the doctor but also includes the dozens of ancillary staff needed to perform the above tasks. What’s more critical is how the injection was tied to other codes such as eye exams and OCTs. That can offset at least the visit. Also depending on the drug there may be some margin there too.

What’s a top Medicare consumer is not the injection, it’s the drug. Don’t confuse the two. One goes into the doctors pocket the other goes into the drug companies pocket. The drug company pockets significantly more.

 

[Slide]

Gosh I don’t usually argue with other doctors asking for more pay but that’s a joke. I can setup, inject, and chart an injection in 10 minutes. That’s 6x98= 588/hour in labor. Cry a river!

The injection fee covers an exam if performed to assess if an injection is warranted- you would get paid more to examine the patient only rather than the perform the injection. If you were a one man practice without any techs, sure the injections would be a money maker, but it still would not be a lot since most retina practices have a higher overhead than others.

Whereas Lucentis and Eylea still cost over 1K and yet there is no argument about negotiating the prices of these medications, all the while it is getting harder and harder to get shelf-stable Avastin for patients.

 

[Bgladney]

Retina income guarantees are still the highest of all specialties although the demand for new retina surgeons has gone down a slight bit (I mean slight) in the past year or so. With the initial rise in injections, they were in great demand. Today, most everyone is able to perform them.

Don't worry, the income potential is still high....especially outside of major metros.

@Slide What do you mean that retina practices have higher overhead than others? Retina practices consistantly run lower overheads then a general practice. Little confused by your statement.

 

[MstaKing10]

Retina income guarantees are still the highest of all specialties although the demand for new retina surgeons has gone down a slight bit (I mean slight) in the past year or so. With the initial rise in injections, they were in great demand. Today, most everyone is able to perform them.

Don't worry, the income potential is still high....especially outside of major metros.

@Slide What do you mean that retina practices have higher overhead than others? Retina practices consistantly run lower overheads then a general practice. Little confused by your statement.

In your experience, aside from retina specialists, who is performing injections? Is there a trend I’m not aware of?

Also keep in mind indications for injecting are constantly expanding, and if one is discovered to work for dry AMD we may again be overwhelmed and docs in short supply.

 

[dantt]

Plenty of comprehensive ophthalmologists perform intravitreal injections.

No matter how you sparse it, the reality is there is a finite amount of money for health care and retina specialists take home among the most.

 

[MstaKing10]

Guess I’m practicing in a bubble. I’m in major metro area with plenty of access to retina specialist so perhaps my view is skewed but comprehensive docs managing and injecting retina patients is exceedingly rare. It is likely not standard of care for my area.

Not sure what you're getting at regarding the finite healthcare dollar comment but I would draw your attention to the high expense of pharma/drugs, hospital fees, administrators and CEOs of healthcare systems including insurance companies etc. as the major cause of rising healthcare costs

 

[dantt]

Not trying to get at anything. Just stating facts that should help guide OP on their question about what retina might look like in 5-10 years.

Intravitreal injections were revalued in April. Do you think they increased it because retina specialists are losing money with every injection they make?

 

[lt1234]

with the new proposed 2020 cms cuts, how will it affect retina? does specialization offer any immunity from these cuts or will it eventually affect all of ophthalmology. i understand no one can predict the future but advice from people who have been in the field for longer and have seen a lot of changes happen over the years

 

[Slide]

Retina income guarantees are still the highest of all specialties although the demand for new retina surgeons has gone down a slight bit (I mean slight) in the past year or so. With the initial rise in injections, they were in great demand. Today, most everyone is able to perform them.

Don't worry, the income potential is still high....especially outside of major metros.

@Slide What do you mean that retina practices have higher overhead than others? Retina practices consistantly run lower overheads then a general practice. Little confused by your statement.

I misspoke - after hearing what the overhead of some of my colleagues is, you're absolutely right that some retina practices have lower overhead than a general practice. Retina practices typically run 35-65% overhead, depending on the structure and location.

The hidden cost of what kills us regarding the injections is maintaining the float unless you only carry Avastin and Triescence/Kenalog. If you have a decent supply of brand-name medication available (let's say 15 of each) per month, that's 30K you have to front at the minimum each month on top of your other operating costs. The cost is supposedly budget neutral, but you don't get the revenue right away, and if you unfortunately get screwed by an audit, it can be devastating to a retina practice. That's not even factoring in the inventory and management system needed for this.

That said, while everyone is able to perform injections, most general comp guys I know are wisely not doing them and deferring them to us. The treatment paradigms change too frequently for someone who isn't doing them on a routine basis, and if you have a complication like endophthalmitis, it's harder to defend if there are other retina specialists within a reasonable distance. I don't mind comprehensive guys doing injections (esp in rural areas), but I've inherited several patients in which their treatment regiment was a disaster and definitely a disservice to them.

 

[Slide]

with the new proposed 2020 cms cuts, how will it affect retina? does specialization offer any immunity from these cuts or will it eventually affect all of ophthalmology. i understand no one can predict the future but advice from people who have been in the field for longer and have seen a lot of changes happen over the years

Who knows? Injections are on the table on 2021 so it may come out as a wash.

 

[dantt]

Intravitireal injections were already revalued and awaiting CMS review. Of all procedures with 0 day global periods, only emergency intubation and emergency trach pays more per minute. This is totally independent of the costs of the drugs. What do you think they recommended?

Unfortunately everybody is getting cut. Many people think the proposed cataract surgery cuts will be bad.

with the new proposed 2020 cms cuts, how will it affect retina? does specialization offer any immunity from these cuts or will it eventually affect all of ophthalmology. i understand no one can predict the future but advice from people who have been in the field for longer and have seen a lot of changes happen over the years

 

[Bgladney]

@MstaKing10 Typically see it in more rural locations where specialists are not as available. Usually never really see it in the Metro areas.

Agree that the cost of drugs is the limiting factor for many general groups to doing injections.

Compare it to refractive surgery years ago. When it first started, only cornea surgeons were specializing in it. Today, everyone seems to be a refractive surgeon.

Then, everyone wanted to complete a cornea fellowship.....today, everyone wants to be a retina surgeon. If fees come up on glaucoma, maybe we will finally have enough folks to go around in glaucoma!

 

[Dusn]

Specialization offers some protection: if injections and vitrectomies get cut, retinal surgeons can always just start doing cataracts. They can market that they would be better able to handle the complications of cataract surgery... which is true. The only reason retina does not do cataracts now is because they would lose referrals. For this reason, I can't see retina ever making less or even the same as comprehensive because retina can always simply stop practicing retina and switch back to comprehensive.

Of course as the gov't is cutting everything the solution might not be so simple. They probably will need to go back and do a fellowship in ibanking.

 

[bronx43]

Of course as the gov't is cutting everything the solution might not be so simple. They probably will need to go back and do a fellowship in ibanking.

Investment banking? That’s so 2006, bruh. It’s all about the tech startups now.

 

[LightBox]

Some of most unethical Opthalmologists are retinal specialists. There is so much over-testing in Retina, it is sickening. Patients have no idea whether their "fluid" is really better and really needs to have a FA/ICG/injection at every appointment. I, for one, hope that injections etc get severely limited. There is so much abuse.

 

[dantt]

Maybe there will be less injections now that patients get better vision with some fluid rather than completely dry...only if reimbursement goes down though lol.

 

[hello lady!]

Some of most unethical Opthalmologists are retinal specialists. There is so much over-testing in Retina, it is sickening. Patients have no idea whether their "fluid" is really better and really needs to have a FA/ICG/injection at every appointment. I, for one, hope that injections etc get severely limited. There is so much abuse.

I hope you're not being serious.

This statement is BS. Even if it were true - hoping we slash reimbursements for an entire field because you perceive retina to be unethical? Based on what? Your own recall bias? I have worked with a ton of retina guys - both locally and in different cities via patients traveling to/from my area. I haven't had a bad interaction or had questionable management come to me yet.

I think people would be more likely to throw that unethical stone at the guys doing refractive surgery and FLACS. Pressuring patients (who trust you as their physician) into adopting the "latest laser technology" to throw big bucks into their procedure (to not change the outcome) while running around and calling it the "free market" to help yourself sleep at night.

 

[LightBox]

Yes, I am very serious. And yes, the cost of injections and the drugs are not sustainable. I'm not talking about slashing all of Ophthalmology... just retina 🙂 We would be better served with more Peds ophthos than another injector.

 

[Slide]

Some of most unethical Opthalmologists are retinal specialists. There is so much over-testing in Retina, it is sickening. Patients have no idea whether their "fluid" is really better and really needs to have a FA/ICG/injection at every appointment. I, for one, hope that injections etc get severely limited. There is so much abuse.

Let's not throw stones, shall we (glasses houses and all)? Yes there are retina surgeons that over-test and only treat the imaging and not the patient, but this is not as wide spread as you would think, especially with the younger generation. There are general ophthalmologists out there as well that are just as unethical, pressuring all their patients into premium cash only IOLs, refractive procedures, and ordering extensive testing and work-up that they really have no business doing because they can't interpret them well. That doesn't mean we should punish all comprehensive ophthalmologists for a smaller number of unethical ophthalmologists. There is abuse all around and focusing in on retina specialists with unsubstantiated claims does no one any good.

The cost of drugs are not sustainable, yes I would agree with that. However, the cost of the injection is really the same as a 92014 or 99214 visit; in my region, an injection visit reimburses $100-105, while 92014 and 99214 reimburse at least $120. Even 92012 reimburses mildly less than the injection ($90). And keep in mind, the injection charge covers the dilated eye exam, decision making, and the procedure cost of the injection.

If we are discussing the best way to reduce costs, more umbrage should be directed at the fact that CMS is not allowed to negotiate for drug prices (Why do doctors choose a $2,000 cure when a $50 one is just as good?). In Europe, the costs of Lucentis and Eylea are much less due to the prices being negotiated down. The majority of us use Avastin as much as possible to save costs for all parties but even this is becoming much more difficult due to compounding pharmacy mishaps. Perhaps your experience with other retina specialists may be poor in your area...but I would not generalize that among the entire retina community without seeing more evidence.

 

[Twoeyes2020]

A round trip business class (not first class) flight from New York to London in 6 weeks time (not tomorrow) is just under $4000. Which is worth more? Your eyesight or a narrow seat that reclines flat? Eyesight.

A big shot lawyer in NYC charges $1200 per hour. A small fry lawyer charges $450 per hour. Which is worth more? Spending maybe $700 and not getting too much done with a lawyer (just some ideas discussed or worked on, not the full problem by any stretch of imagination) or a full and complete eye exam, OCT and return eye exam? Eye exam.

If you have a cataract, you can get the full problem fixed from between under $1000 in reimbursement to the low thousands (with fancy add ons). If you have a legal problem that doesn't even go to trial, you can easily spend $100,000. Medical care is 1% the cost of legal care.

 

[dantt]

And keep in mind, the injection charge covers the dilated eye exam, decision making, and the procedure cost of the injection.

Without painting the entire specialty in one stroke, I know more than a few retina specialists who do not perform any dilated examination or medical decision making during their patients injection visit. I don't know whether they document that they did so. I also know some who do multiple fas a year because they can bill it. I was taught that fas are for diagnosis and there is no role for fa in following a knowm condition.

 

[LightBox]

I've seen more than a few retinal specialist do one or two shots of (unneeded) PRP and bill it out fully. "Fill in PRP" anyone? The difference with retinal specialist abuse and refractive cataract abuse is that the insurance company is bearing the brunt in the former case... and the patient has no clue whether that extra shot of PRP was really needed. In cataract surgery, patients know immediately if their uncorrected near vision is good after a multifocal implant.

I've practiced in several communities and there are always a bunch of retinal specialists who want to be referred every patient with drusen so they can run a million tests and see the patient every 3-4 months. I've even have had a retinal specialist have the gall to tell me I should be referring every patient with drusen to him (e.g. AREDS stage 1)... otherwise, I was doing the patient a disservice. I'm not saying the entire retinal community is unethical... but the lack of checks and balances with that field truly make it easy to get away with fraud/abuse without the patients knowing any better.

 

[MstaKing10]

Some of the comments here are at best laughable, illogical, and biased and at worst inflammatory. There are examples in many fields of medicine of shady docs doing shady things. While these are the minority they give the field a bad name, and chisel away patients trust. It’s a mistake to associate these bad apples with the majority. They are outliers. They should be dealt with and oftentimes are, but to argue that an across the board cut is the only way to prevent these issues misses the mark in a major way. But I suspect judiciousness is not the strength of some.

 

[dantt]

I think people would be more likely to throw that unethical stone at the guys doing refractive surgery and FLACS. Pressuring patients (who trust you as their physician) into adopting the "latest laser technology" to throw big bucks into their procedure (to not change the outcome) while running around and calling it the "free market" to help yourself sleep at night.

Refractive "co-management" = pay to play?

 

[Medicalretina]

Best place is to be is working at Kaiser. I know retina specialist there make over a half million dollars a year. Easy 9-3 schedules, little call etc... General ophthalmologist make 300-400,000 with the same set up. No worrying about reimbursement, drug costs etc... General ophthalmologist see a lot of routine, glaucoma suspects, cataract amd f/u etc... in my opinion, it is the best place to work.

 

[LightBox]

Kidding me? Kaiser salaries are a joke compared to private practice. I know several retinal specialists making 2MM/year working 4 days a week as practice owners. Dont have to answer to anyone. Same deal with anterior segment.

 

[EyeGuy15]

I've seen more than a few retinal specialist do one or two shots of (unneeded) PRP and bill it out fully. "Fill in PRP" anyone? The difference with retinal specialist abuse and refractive cataract abuse is that the insurance company is bearing the brunt in the former case... and the patient has no clue whether that extra shot of PRP was really needed. In cataract surgery, patients know immediately if their uncorrected near vision is good after a multifocal implant.

I've practiced in several communities and there are always a bunch of retinal specialists who want to be referred every patient with drusen so they can run a million tests and see the patient every 3-4 months. I've even have had a retinal specialist have the gall to tell me I should be referring every patient with drusen to him (e.g. AREDS stage 1)... otherwise, I was doing the patient a disservice. I'm not saying the entire retinal community is unethical... but the lack of checks and balances with that field truly make it easy to get away with fraud/abuse without the patients knowing any better.

The most dangerous doctors are the ones that don't know what they don't know. Do a retina fellowship and then speak on what you think is in the best interest of patients with retinal diseases.

 

[LightBox]

I know that a FA/ICG/microperimetry on every single patient (e.g. mac pucker) is not in the best interest of the patient's (or society's) wallet.

 

[MstaKing10]

I know that a FA/ICG/microperimetry on every single patient (e.g. mac pucker) is not in the best interest of the patient's (or society's) wallet.

You must be practicing in the most corrupt community in the country. Been practicing for a long time and these testing scams you keep mentioning are unheard of aside from some shady doc, who in my community ended up audited and is currently in jail. Or maybe you’re just a full of it. I see more shady practices from optoms, general ophthos, neurosurgeons and pain specialist to name a few

 

[speyeder]

I know that a FA/ICG/microperimetry on every single patient (e.g. mac pucker) is not in the best interest of the patient's (or society's) wallet.

Every single patient? I'm sure your statement is not exaggerated in the least bit.

 

[LightBox]

Every single patient? I'm sure your statement is not exaggerated in the least bit.

Yes. Surprised, right? I sure was. Ok, ok.. it was 90% Happy now?

 

[speyeder]

Yes. Surprised, right? I sure was. Ok, ok.. it was 90% Happy now?

It's hard to take you seriously when you engage in hyperbole.

 

[LightBox]

It's hard to take you seriously when you engage in hyperbole.

Ok fine, all retinal specialists are saints and make their 2MM with only necessary testing and not ablating the entire retina with PRP. Please forgive me for suggesting that bad apples are more common than you think since there are no safeguards to protect patients from unnecessary diagnostics and procedures.

Btw, all my interactions with academic retinal specialists have been superb. Perhaps the feedback from trainees prevents the bad apples from acting out.

 

[MstaKing10]

Your comments are nonsensical and almost comical if it weren’t for the fact that, at least based on your profile, you’re an actual doctor in practice. I don’t know every retina specialist in the country, but I do know a lot of them, we are a pretty tight knit community and especially when your part of a large retina group you end of making a lot of friends. I have no idea where your pulling these stories from, seriously sounds like the blabberings of a paranoid schizophrenic, but I can tell you this is not based on reality at least for a large portion of retina specialists. I only hope you don’t convince some poor med student or resident that the retina community is what you seem to think it is.

 

[VA Hopeful Dr]

Your comments are nonsensical and almost comical if it weren’t for the fact that, at least based on your profile, you’re an actual doctor in practice. I don’t know every retina specialist in the country, but I do know a lot of them, we are a pretty tight knit community and especially when your part of a large retina group you end of making a lot of friends. I have no idea where your pulling these stories from, seriously sounds like the blabberings of a paranoid schizophrenic, but I can tell you this is not based on reality at least for a large portion of retina specialists. I only hope you don’t convince some poor med student or resident that the retina community is what you seem to think it is.

I can't comment on retina specifically, but I think you'd be surprised at how crooked many doctors are

 

[Slide]

Without painting the entire specialty in one stroke, I know more than a few retina specialists who do not perform any dilated examination or medical decision making during their patients injection visit. I don't know whether they document that they did so. I also know some who do multiple fas a year because they can bill it. I was taught that fas are for diagnosis and there is no role for fa in following a knowm condition.

Yes, I do the same if I know the patient well and under certain circumstances. If I'm loading up a patient that is treatment-naive, I'll perform the subsequent injections without dilation per FDA recommendations for a total of 3 loading doses. If I can't extend a patient out more than a month or so, I'll at least dilate every other visit, more for patient convenience. I personally do not think dilation is 100% necessary for every injection visit if the patient is well known to you. For FAs, many of it will perform it a few times a year (2, 3 max for me) to follow many conditions. The most common ones for me are patients with rapidly progressing DR or other retinopathy with severe non-perfusion, or posterior uveitis/hemangiomas that need to be assessed fairly frequently due to complications. There is absolutely a role for repeat FA in following known conditions - many academic and private leaders in the field will be happy to have a way too long debate on the necessity of it for management, and the literature supports it.

Yes. Surprised, right? I sure was. Ok, ok.. it was 90% Happy now?

Ok fine, all retinal specialists are saints and make their 2MM with only necessary testing and not ablating the entire retina with PRP. Please forgive me for suggesting that bad apples are more common than you think since there are no safeguards to protect patients from unnecessary diagnostics and procedures.

Btw, all my interactions with academic retinal specialists have been superb. Perhaps the feedback from trainees prevents the bad apples from acting out.

First, if someone is performing simultaneous FA/ICGs repeatedly, that person is a fool because the cost of materials doesn't cover the reimbursement - both materials' cost have significantly increased in the past few years to the point where some of my private colleagues cannot perform it simultaneously anymore due to the cost. Second, there is a limit on how much you can perform these a year without being refused reimbursement or being picked up on the audit trail. Something in retina is audited nearly every year by Medicare RACs, and as much as we would to believe the amount of foolishness exists in CMS, when it comes to actual dollars they are savants in figuring out where that money may be fraudulently flowing. And last, there are some cases where I've had to perform that extensive of a work-up on some patients that were referred with just an ERM and turned out having something else like pars planitis, trauma, an infection, or a previous vascular event.

It may not seem like it at least where youare , but as a whole we do also try to police our own and try to stop retina specialists who are over-ordering or are fraudulently practicing. Jay Sridhar has an excellent podcast on such an issue where Julia Haller and other colleagues did what they could to prove Salomen Melgen racking up fraudulent charges. My former older partner have had to do similar for other such retina specialists in our area that were billing or practicing unethically.

And last, I please hope you don't think so little of us academic retina surgeons behind held in line by our residents and other less than noble motives. 🙁 We're by no means shining knights, but we're not in academics for the money, that's for sure. Believe me, it would be much less work and more money for me to go into private practice.

I can't comment on retina specifically, but I think you'd be surprised at how crooked many doctors are

Yes, there are plenty of crooked health care providers out there in general (not just limited to the MDs, I've seen the same for ODs/NPs/CRNAs), but with respect the earlier discussion, there are better ways to address this issue rather than cutting reimbursement. If anything, if you cut reimbursement, you may even promote more unethical behavior by making these same actors make up for lost income with volume unnecessarily.

 

[dantt]

I personally do not think dilation is 100% necessary for every injection visit if the patient is well known to you.

I don't disagree with you there. I just wanted to point out the inconsistency of saying the fee covers the exam and decision making when in many cases it is not being done

It may not seem like it at least where youare , but as a whole we do also try to police our own

Not a knock on retina but all physicians in general are very poor at policing their own. There is an obviously unethical retina doc in my town and the ongoing joke among the other retina docs in town is the doc has multiple planes to pay for. Within my own practice in the past I've heard of docs trying to cover each other and nobody wants to make it their business and say anything.

 

[speyeder]

Ok fine, all retinal specialists are saints and make their 2MM with only necessary testing and not ablating the entire retina with PRP. Please forgive me for suggesting that bad apples are more common than you think since there are no safeguards to protect patients from unnecessary diagnostics and procedures.

Btw, all my interactions with academic retinal specialists have been superb. Perhaps the feedback from trainees prevents the bad apples from acting out.

Sorry but you sound like you have an axe to grind.

 

[hurdlepup]

Holy crap—there is a ton of hating on retina specialists on here. We are usually the ones sacrificing our time to help patients with emergency conditions and seeing the most complex patients. It’s why I went into retina. There have been some unethical retinal specialists out there just as there have been in other fields as well but there are a lot of broad strokes being painted here.

 

[Dusn]

I also find the retina-hating bizarre. Personally I find the two areas with the most questionable ethics in ophthalmology: are co-management fees with optoms (essentially legalized kickbacks) and multifocal lenses. I was just reading a throwaway journal (maybe Ophthalmology Times?) where an ophthalmologist was arguing that it was acceptable to put a multifocal lens in a patient with wet AMD.
It should NEVER be considered OK to put a multifocal lens in a patient with wet AMD (or really any vision threatening pathology).

Comprehensive ophthalmologists really should not be hoping for a drastic cut in the reimbursement of intravitreal injections. Should doing cataracts ever pay more than doing retina, retina specialists will simply start doing the cataracts themselves and may stop accepting referrals for retinal emergencies.

 

[dantt]

I don't think anybody is hoping for anybody else to be cut. I'm just laying out the facts for OP and they can draw their own conclusions about which way reimbursements are likely to go.

I wonder what the medico-legal implications of retina specialists not accepting referrals for retinal emergencies will be. It is part of the job description.

 

[Slide]

I wonder what the medico-legal implications of retina specialists not accepting referrals for retinal emergencies will be. It is part of the job description.

I can answer for that you right now. Ethically, it’s not good. Illegal? For the most part, not at all. In fact, it is fairly common out in the private community. It's the same reasons why many comprehensive ophthalmologists send open globes out to academic centers.

In PP, as long as there is no previously established relationship with a referred patient, and if there is not a consistent pattern of discrimination based on age, ethnicity, religion, etc., you can refuse to see emergent patients if there is somewhere else or an emergency room the patient can be sent to, even if it’s 5-6 hours away. This is actually already fairly common. There are a number of reasons (insurance or non-insured, religious or personal reasons, inability to provide safe or optimal working conditions, etc) already. If a retina specialist states "I don't have the resources/OR block space to handle this emergency after hours" or something similar ("I don't have the skills to handle this emergently" is one I've heard), he/she can send it out with little repercussion.

Walk into any major academic/tertiary care ER and you’ll likely find a patient with an eye sent there for this reason. As long as there is are academic/tertiary centers with ophthalmology coverage, any retina emergency can be shipped out there with little consequence. In fact, this policy is the backbone of how many retina fellows get their cases across the country (it's how I got a lot of my RDs! 😀 ). To your original point, yes it's in the job description, and I do think its very unethical and demeaning to the profession if someone constantly sent RDs/dropped lenses out if they can handle them, but it is definitely not illegal. The analogy on the comprehensive side is that if it were illegal for retina specialists to do this, then it would be just as much so for a comprehensive ophthalmologist to ship off an open globe.