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Editors Selection IGR 18-2

Miscellaneous: Optometrists and Laser trabeculoplasty

Comment by Murray Fingeret on:

69903 Comparison of Outcomes of Laser Trabeculoplasty Performed by Optometrists vs Ophthalmologists in Oklahoma, Stein JD; Zhao PY; Andrews C et al., JAMA ophthalmology, 2016; 134: 1095-1101

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The stated objective of this paper was '(…) to compare outcomes of laser trabeculoplasty (LTP) performed by ophthalmologists with those performed by optometrists, to determine whether differences exist in the need for additional LTPs.' A law permitting optometrists to perform LTPs was passed by the Oklahoma legislature in 1998. Despite the presence of the word 'outcome' in its title, this paper does not actually examine outcomes. The authors present no information regarding intraocular pressure reduction, complications, or any other measures of treatment safety or efficacy. Instead, the paper retrospectively compares how often LTPs were repeated by optometrists and ophthalmologists, assuming that repetition was associated with unsatisfactory results. Unfortunately, there is a confounder in the design of this study that renders it useless at best and, perhaps, even misleading.

In contrast to current practice, the data analyzed came from a period when the relative safety of performing LTPs in two sessions with 180 degrees of the angle treated at each session versus a single session with 360 degrees treated was still being assessed. The authors made no attempt to learn if studied LTPs were done in split sessions. If so, this is not repeating a procedure but rather completing a procedure. During the study period, Oklahoma optometrists were trained to perform LTPs in split sessions, as suggested in peer-reviewed papers of the period, including the American Academy of Ophthalmology's preferred practice guidelines, which specifically discuss performing LTPs in split sessions in order to reduce the incidence of IOP spikes.

There is a confounder in the design of this study that renders it useless at best and, perhaps even misleading

Optometry's role in the delivery of LTPs in an important public health topic. However, its use of utilization rates as a surrogate for outcomes did not advance that discussion, and well-designed studies are needed in order to examine this issue.

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