A week ago, Vermont had hoped to join the pantheon of states with expanded scopes of practice: Oklahoma, Kentucky, Alaska and Louisiana. But after a decision by the state’s Office of Professional Regulation (OPR), those hopes have been dashed. The office, which is under the umbrella of Vermont’s Secretary of State, concluded in its final report on the matter that optometrists are not properly trained in, nor can they safely perform, the proposed advanced procedures.

The Vermont Optometric Association (VOA) asked the state to consider adding advanced procedures that, broadly, fall under three categories: anterior segment laser procedures, injections of the lids and adnexa, and removal of benign lid and eye growths. More specifically, these can include nd:YAG laser capsulotomies, laser trabeculoplasties, laser iridotomy, injections into the lid and subconjunctival space (but not into the globe) as well as intramuscular and subcutaneous injections and intravenous injections. Removal of benign growths such as pedunculated lesions, papilloma, keratosis, cutaneous cysts and others are included.

Part of the VOA’s appeal included explaining that the “difficult part” of these procedures is pre- and post-surgical management, which optometrists are charged with handling under the current scope of practice.

Vermont’s report appears to bemoan an unfulfilled request for information about each school’s course offerings, curricula or syllabi from Association of Schools and Colleges of Optometry (ASCO)—all of which is publicly available on the school’s websites, according to ASCO President Elizabeth Hoppe, OD. ASCO offered two additional reports: “Attributes of Students Graduating from Schools and Colleges of Optometry” and “Framework for Developing Optometric Curriculum Guidelines and Educational Standards for Advanced In-Office Primary Care Ophthalmic Procedures.”

“We were never given any indication that it wasn’t sufficient,” explained ASCO Executive Director Dawn Mancuso. 

Opposition

The state’s report explains that the Vermont Ophthalmologist Society’s (VOS) and the Vermont Medical Society’s (VMS) adamant opposition influenced its decision. As evidence they pointed to a JAMA Ophthalmology 2016 report that showed repeat laser trabeculoplasty procedures nearly double when the initial procedure was performed by an optometrist rather than an ophthalmologist.

This particular piece of research is often cited by medical lobbyists contesting optometric scope expansion, but optometrists charge that it is misleading.²

In fact, the study looked into the performance of 27 optometrists, all trained at Northwestern University, a program that recommends performing the 180˚ procedure first and only considering treatment of the other half if intraocular pressure doesn’t sufficiently decrease.³ The JAMA study said nothing in terms of pressure reduction or complications associated with the full 360˚ procedure, instead framing a second procedure as a “risk.”³

A rebuttal letter, printed in the same journal, was also delivered to the Vermont legislature.³ That piece calls the study misleading and explains “it is hard to understand the meaning of their conclusions without knowing whether treatments were performed in more than one session with 180˚ treatments or a single session with 360˚ treatments.”³

Finally, the state’s report shows OPR was not convinced that expanding optometry’s scope would give patients better access to these treatments since “Vermont data shows that there is an ophthalmologist located within 30 miles of most Vermont residents. Even if there is a need for locating these services closer to patients, expanding the optometric scope of practice is unlikely to address this issue. Most Vermont ophthalmologists and optometrists are located in the same places.”