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Casey: Physicians look at eye-surgery bill with great skepticism

The sponsor of legislation that would expand the scope of optometry said it's not intended to allow optometrists to perform eye surgery. But the way the proposal is written, eye surgeons -- aka ophthalmologists -- say that's exactly what it would do.

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An ophthalmologist performs cataract surgery.

If you were charged with murder, would you want a paralegal defending you in court? If you needed knee surgery, would you consider having a physical therapist perform it? The prospect of either is more or less inconceivable.

Opponents of a bill before the Virginia General Assembly are making analogous arguments in a matter that’s reawakened a long-simmering rivalry in Richmond. That’s between ophthalmologists, who are medical doctors, and optometrists, who are not. The latter spend a lot of money on lobbying and campaign donations to lawmakers.

The legislative feud dates back decades, to when state law forbade optometrists from using dilating drops during eye exams. Not only can Virginia optometrists now use those, they’re also allowed to treat eye diseases such as glaucoma and prescribe medications to patients. In Kentucky, Oklahoma and Louisiana, they can perform certain kinds of eye surgery.

That’s the rub with the legislation in question, sponsored by Sen. David Suetterlein, R-Roanoke County. As originally proposed, it would allow optometrists to perform some common eye surgeries, even though Suetterlein and other proponents say that was never the intention.

It’s drawn fierce opposition from ophthalmologists, who argue surgery should be performed only by trained physicians.

The bill hasn’t yet had a hearing, but Suetterlein said amendments are already circulating that would dial the measure back and “clarify” it. He told me his intention is “to increase access to eye care and hopefully lower costs.”

Suetterlein said expanding access and lowering costs are themes of other bills he has sponsored this year. The most moving letters he gets as a lawmaker are about the cost of health care and access to it, he added. (But he acknowledged that he opposes Medicaid expansion.)

The bill in question is SB 511. The title is “Optometry, scope of practice.” It’s being pushed by the Virginia Optometric Association and currently has 13 co-patrons in both political parties and legislative chambers — an unusual level of juice. Among them are Sen. John Edwards, D-Roanoke, and Del. Chris Head, R-Botetourt.

Since it first came to the ophthalmologists’ attention, it’s generated a blizzard of calls and emails to lawmakers on the Senate Education and Health Committee. Last week, the Virginia Optometric Association sent around a memo from its lobbyists on the bill, Bruce and Bo Keeney. Suetterlein shared it with me.

“At no time has the VOA, any lobbyist for the VOA, or any optometrist suggested the legislation allows optometrists to perform surgery on the eye. All along, we have clearly stated that the ‘minor surgery’ is limited to styes, chalazions and abnormal lesions on the eyelid,” the memo states. (A chalazion is a painless bump on the eyelid that sometimes results from styes.)

But that’s not what the bill says. As submitted, it would allow optometrists to perform surgery on “anterior segment lesions,” provided no sutures or general anesthesia were used.

Dr. Frank Cotter, a Roanoke ophthalmologist and a friend of mine, said the “anterior segment” is a reference to the front part of the eyeball. Meanwhile, cataracts fit the definition of lesions. Most, but not all, cataract surgery these days requires neither sutures nor general anesthesia, Cotter added.

“Either they don’t know what ‘anterior segment’ means, or they’re trying to pull a fast one on the legislature,” Cotter said. (The Keeney memo notes “we recently learned these terms may be subject to a broader interpretation by their specialty.”)

Further fueling the ophthalmologists’ skepticism are the levels of money optometrists spend in Richmond and efforts the profession has made across the country to expand the kind of procedures they’re allowed to perform.

In 2017, the Virginia Optometric Association made campaign donations totaling $229,000 to Virginia lawmakers, according to the Virginia Public Access Project that tracks money in state politics. (Of that, $54,050 went to lawmakers who put their names on SB 511, including $3,500 to Suetterlein.)

The Virginia Society of Eye Physicians and Surgeons that represents ophthalmologists donated a total of $24,750 to Virginia lawmakers last year.

The difference between the two professions is significant, and is akin to the difference between psychiatrists, who are medical doctors and may prescribe medication, and psychologists, who are not physicians and cannot prescribe meds.

After college, ophthalmologists attend medical school for four years and then spend at least four more years in training — longer if they move into subspecialties such as glaucoma surgery. By contrast, most optometrists spend four years in optometry school after their undergraduate studies.

Last year optometrists in North Carolina sought to expand their scope of practice to include some eye surgery, but the effort failed. Similar efforts have failed in Texas, West Virginia and other states but have succeeded in Kentucky, Louisiana and Oklahoma.

Dr. Joe Blackstock, a retired Roanoke optometrist who’s been involved with the bill, said, “We’re not trying to take away any turf from ophthalmologists.

“That’s a misconception,” Blackstock said. “This bill doesn’t allow optometrists to touch the eye or do any type of eye surgery at all. The eye is a prohibited area that goes to the ophthalmologists, who do a wonderful job at that.”

Dr. Nick Ramey, a Roanoke ophthalmologist who performs eyelid surgery, is among the doubters. He noted the sponsors of the bill have already decided it needs major surgery to correct the wording in the original proposal.

“The imprecision of the language speaks to the inexperience of the writers of the bill,” Ramey told me.

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Dan Casey knows a little bit about a lot of things but not a heck of a lot about most things. That doesn't keep him from writing about them, however. So keep him honest!

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