Optometric scope expansion bills are setting a new precedent across the country

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With the demand in eye care that is projected to only keep growing over the next decade, the question of patient care has led optometrists in many states to begin distributing the weight of this need through introduction of scope expansion bills in their given state. Part of this demand comes from an increased number of ophthalmologists anticipated to age out of the field coupled with an aging patient population,^1,2 according to American Optometric Association (AOA) President Ronald L. Benner, OD.

According to findings from a study that gathered data from the National Center for Health Workforce Analysis, from 2020 to 2035, the number of full-time ophthalmologists is expected to decline by 12%, with a total demand estimate to increase by 24%. This marks a 30% mismatch in workforce inadequacy, with ophthalmology having the second lowest rates of projected workforce adequacy by 2035.³ Benner said a factor in this mismatch is the estimated 32% of cataract surgery demand. “Just the cataract [surgeries] alone are going to overwhelm ophthalmology,” he said.

Benner said that the goal of scope expansion bills is to help alleviate this burden on ophthalmologists by allowing optometrists to take on more minor procedures, including posterior capsulotomies with yttrium aluminum garnet (YAG) lasers, selective laser trabeculoplasties (SLTs), removing lumps and bumps on eyelids, and taking tissue samples. Benner said these procedures are within optometrists’ wheelhouses. “We learned basic anatomy, we learned physiology, we learned histology,” he said. “When you put that all together and then you learn the disease process on top of it, doing minor surgical procedures is not a big deal.”

The need for scope expansion in rural communities

Another factor in the need for scope expansion is ophthalmologic practices’ concentration in more densely populated urban areas, leaving rural communities with less access to specialized care. For instance, West Virginia, a state with a large rural population, recently approved scope modernization in the form of the removal and biopsy of growths around the eye, according to Chad D. Robinson, executive director of the West Virginia Association of Optometric Physicians. He said that of the state’s 55 counties, only 15 to 20 have ophthalmologic offices, with many of those counties being more densely populated. However, optometric offices are found in over 45 counties in the state. “Those [optometrists] are the first line of health care for your eyes in these types of situations,” Robinson said. “Without the access, these patients in rural areas were waiting months to have minor ophthalmologic procedures done that an optometrist can do the same day.”

Benner also noted that by allowing patients into optometric offices for minor surgical procedures, a 2- to 3-month wait can be reduced to a 2- or 3-week wait. This can prove impactful for patients, especially those awaiting biopsies for potentially malignant growths. “It’s about patient care. It’s about patient access,” Benner said. “It’s not about elevating optometry.”

House Bill 1099

The recent passage of South Dakota’s House Bill (HB) 1099 made the state the twelfth state to adopt laser procedure privileges.⁴ According to the South Dakota Optometric Society (SDOS), HB 1099 was introduced in the 2024 legislative session, which then passed on a 48-17 vote in the House of Representatives. The Senate then passed the bill on a 23-11 vote, with Governor Kristi Noem signing the bill into law on March 4, 2024. The bill will become law on July 1. Prior to the 2024 legislative session, SDOS also introduced a scope modernization bill in the 2023 legislative session, which passed the Senate but lost by 1 vote in a House committee.

SDOS President-Elect Ashley Crabtree, OD, stated that she feels pride in the hard work put forward by South Dakota’s optometrists for the bill. “I am optimistic that most independent optometry practices in South Dakota are well prepared to provide these services to our patients,” she said. “We are well trained [and] educated, and as the primary eye care providers in our rural communities, we’ve already established a trusting relationship with our patients.”

HB 1099 includes 3 injection procedures, 2 laser procedures, and intense pulsed light (IPL) therapy for dry eye. The injection procedures include the intradermal injection of a paralytic agent for medicinal use only, the intralesional injection of a steroid to treat a chalazion, and the use of an anesthetic by injection to remove a pedunculated skin tag. The 2 laser procedures included in the bill are SLT and YAG. Additionally, the bill notes that it does not permit an optometrist to perform intraocular injections, intraocular surgery, or refractive surgery.⁵

Additionally, SDOS noted that IPL therapy was allowed by optometrists as determined by the state optometric licensing board, but a lawsuit was issued by the South Dakota State Medical Association to prohibit the therapy. This case was pending when the bill was introduced into legislation, but with the approval of HB 1099, the lawsuit is now null.

Preparation

Now remains the work of educating and preparing eye care providers for expanding their scopes of practice in July. Deni Martin, executive secretary for the South Dakota Board of Examiners in Optometry, said that the board has been working with the SDOS to implement the bill’s 3-part “prove up” process into the advanced procedure licensure. “They [SDOS] did a really good job at laying it out for us, so we had a road map for what we needed to do next,” she said.

Martin said that optometrists can either submit an application to gain certification for all 5 new procedures at once or submit an application for 1 procedure at a time. Those who may be graduating from optometry school after July 1 will still need to submit a separate application for certification of the additional procedures.

To perform the procedures listed in the bill, HB 1099 requires optometrists to pass a national examination on laser procedures as well as a national examination on injection procedures (unless they graduate from a school of optometry before July 1, in which case they will be grandfathered in). Applicants must then pass a 32-hour certification course to demonstrate competency of the added procedure(s) they are aiming to gain certification for. Martin said that the state currently has 1 class that fulfills the required education needed, which optometrists can enroll in before July 1.

The last requirement is that applicants must then perform procedures on at least 5 human eyes for SLT and 10 human eyes for YAG under direct supervision of an ophthalmologist or authorized optometrist. Martin said this may be the most involved certification step for optometrists. “All that is quite a process for them to find somebody with those conditions so that they can practice [SLT and YAG procedures] under the supervision of someone else,” she said.

Martin said that South Dakota’s optometrists and ophthalmologists already work well together and should be in close communication to keep optometrists in the loop about procedural opportunities. “They already have great working relationships, referring patients back and forth to each other,” she said. Crabtree also stated that comanagement within the state has been effective before the passage of the bill. “We don’t anticipate any changes in that relationship going forward,” she said.

Additionally, Crabtree stated that she does not believe that an increase in support staff numbers will be needed to accommodate the advanced procedures, as they will be performed in office. However, changes in scheduling and billing will need to be prepared for and anticipated, according to Benner.

Getting involved in the checks and balances

HB 1099’s passage was a collaborative effort, according to Crabtree. “When asked, they [member doctors] responded and met with legislators, texted, called, and emailed,” she said. “Several optometrists made the trip to the state capital to lobby legislators and testify in committee. Our board also allocated resources to put together a great lobbying team led by our executive director, Deb Mortenson. We also had a robust social media and digital ad campaign to support the effort. AOA’s State Government Relations Center, specifically Jeff Michaels, OD, was a key support.”

Benner said that advocating for scope expansion starts in the chair and in conversations with patients. Being transparent regarding why a patient must be referred out of office for a procedure can help gain witnesses for testimony and can further establish trust with said patient. “Advocacy begins with every patient,” he said. “We should be talking to our patients about what our skills and training are. We should be talking to our patients about procedures that we can and can’t do.”

Additionally, legislative writing and conversations of scope expansion thrive at the grassroots level; cultivating relationships with senators and House representatives as well as the state governor makes a significant impact on a bill’s chance of approval. Benner said that although the AOA has funding and advocates available to aid in a scope expansion’s success, there is still heavy lifting on the local level that needs to be done. “The merit is there, the dollars are there, the patient access arguments are there, but the doctor still has to do a little bit of the lift,” Benner said. “They still have to do that grassroots advocacy, and there are no shortcuts.”

References

1. Hatch WV, Campbell EDL, Bell CM, El-Defrawy SR, Campbell RJ. Projecting the growth of cataract surgery during the next 25 years. Arch Ophthalmol. 2012;130(11):1479-1481. doi:10.1001/archophthalmol.2012.838

2. Wilkinson N. Technology to meet the growing demand for cataract surgery. TTP. Accessed May 2, 2024. https://www.ttp.com/insights/technology-to-meet-the-growing-demand-for-cataract-surgery/

3. Berkowitz ST, Finn AP, Parikh R, Kuriyan AE, Patel S. Ophthalmology workforce projections in the United States, 2020 to 2035. Ophthalmology. 2024;131(2):133-139.doi:10.1016/j.ophtha.2023.09.018

4. South Dakota secures scope expansion for injections, optometric laser procedures. American Optometric Association. March 7, 2024. Accessed May 2, 2024. https://www.aoa.org/news/advocacy/state-advocacy/south-dakota-secures-scope-expansion-for-injections-optometric-laser-procedures?sso=y

5. An Act to Establish Educational Standards for the Expanded Practice of Optometry, HR 1099, 99th Leg (S.Dak 2024). Accessed May 2, 2024. https://sdlegislature.gov/Session/Bill/24412/266241