Risk Management

Issues Associated with Therapeutic Optometry

Anne M. Menke, RN, PhD, OMIC Risk Manager

Digest, Summer 2010

According to the American Academy of Ophthalmology, about half of all ophthalmology practices now include an optometrist and nearly all see patients referred by optometrists (ODs). Traditionally, the practice of optometry was “medicine-free.” Nationwide, between 1971 and 1989, optometrists (ODs) lobbied for, and were granted, the legal authority to use topical medications for diagnostic purposes. A second wave of legislative efforts from 1976 to the present resulted in limited prescriptive authority for optometrists in some states, and the development of “therapeutic optometry.”

Q  My group wants to hire an optometrist. How do I determine what care he or she can provide?

A  Patient situations handled by ODs fall into three categories. The first category includes those types of care that the legal scope of practice allows optometrists to provide independently (e.g., refraction and prescribing glasses and contact lenses). In the second category, optometrists with additional types of training and certification may diagnose and treat patients with more complex eye conditions. Depending upon state law, they may be required to consult with an ophthalmologist in certain situations. Finally, there are patients who need to be referred to an ophthalmologist for diagnosis or management (e.g., patients with cataracts or retinal detachments). Your state’s optometric practice act defines the legal scope of practice. It also details the education, training, and certification required for optometrists to diagnose and treat ocular conditions, and usually includes a list of the therapeutic agents they may prescribe and procedures they may perform. Ask the optometrist to provide you with a copy of his or her license, certification, and optometric practice act and verify the licensure/certification directly with the optometric board. You may also wish to contact your state ophthalmology society to obtain a copy of the current regulations and any guidance papers. Contact your underwriter if the optometrist is endorsed on your policy and you have questions about coverage for certain procedures.

Q  Am I required to supervise the therapeutic optometrist in my practice?

A  Not as a general rule. Unlike allied health professionals such as physician assistants and nurse practitioners, optometrists have an independent scope of practice that does not require supervision by a physician. OMIC’s Postoperative Care Exclusion and Refractive Surgery Requirements, however, state that postoperative care that is comanaged with an optometrist must be provided under the surgeon’s supervision (see the lead article, “Comanagement of Surgical Care,” as well as “Coordinating Care with Optometrists,”). Again, these rules do vary between states and there may be state-specific comanagement requirements regarding training, equipment, and communication.

Q  Are therapeutic optometrists required to consult with ophthalmologists and other physicians?

A  Consultations may be required by law or by the standard of care. As noted above, some state optometric practice acts mandate consultations with ophthalmologists or appropriate physicians/surgeons in certain situations. For example, California requires therapeutic optometrists to consult with an ophthalmologist if a patient younger than 16 has glaucoma, and when patients on topical steroids or those with diseases such as episcleritis, herpes simplex infection, or glaucoma are worsening or not responding to treatment. Texas requires therapeutic ODs to consult with an ophthalmologist after an initial diagnosis of glaucoma, and on any patient whose glaucoma is not responding appropriately to treatment. Texas law also requires ODs to refer patients to a physician before prescribing beta blockers if the patient has not had a physical examination within 180 days.

Q  If our state law is does not provide guidance, how can we decide on the need for consultation?

A  Consider situations that could lead to patient harm or liability. Just as with ophthalmologists, the standard of care requires optometrists to seek a consultation or referral when the patient’s condition requires diagnostic or therapeutic skills beyond one’s scope of practice, competency, certification, or training. Consideration might be given to conditions that could lead to severe, imminent vision loss or death, eye conditions associated with a systemic condition (e.g., giant cell arteritis, rheumatoid arthritis, multiple sclerosis, and patients with neurological abnormalities), patients who are not improving or worsening, and cases where there is unexplained vision loss or no clear-cut diagnosis.

Q  The new optometrist in my practice seems uncomfortable asking questions and I worry that he won’t come to us for advice.

A  The best protocol in the world will be ineffective if the practice does not nurture an environment where all members of the health care team feel safe enough to ask questions and seek advice. It may be helpful to hold regular meetings where all have the opportunity to address difficult or interesting patient situations and seek input from others. Modeling an open discussion might encourage your new colleague to be more forthcoming.