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Editors Selection IGR 12-3

Miscellaneous: Optometrists and Laser trabeculoplasty

Comment by Tony Realini 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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Stein and colleagues have conducted an analysis of Medicare claims data to explore differences in utilization and outcomes of laser trabeculoplasty among ophthalmologists (MDs) and optometrists (ODs) in Oklahoma, one of a handful of states where ODs are legally able to perform laser surgery. Such an approach provides limited data because there is no access to individual patient records and thus no information on surgical technique or effects on intraocular pressure (IOP). The primary metric by which the investigators assessed differences in outcome was the need for additional laser trabeculoplasty. In this analysis, 15.1% of MD-treated eyes and 35.9% of OD-treated eyes underwent repeat SLT during the period of analysis (2008-2013). Interestingly, roughly 1/3 of the OD-repeated lasers (accounting for half of the MD-OD difference in repeat rates) occurred within the first 30 days after initial SLT. At first glance, one might assume that ODs are too quick to pull the trigger on repeat SLT, potentially due to the additional reimbursement associated with the short (10-day) global period assigned to this procedure. But as the authors point out, there are other less nefarious potential explanations. One is that ODs may be staging the procedure into 2 180-degree treatment sessions for safety reasons as they become more familiar and comfortable with the procedure. When SLT was first introduced 15 years ago, most MDs did the same thing for several years until we came to realize that a single 360-degree SLT treatment was safe and well tolerated. Another possible explanation is that ODs may not appreciate the delay in response to SLT—with IOP often not decreasing for up to 3-4 weeks post-treatment—and are repeating the procedure prematurely believing initial SLT was not effective. In all likelihood, both of these explanations are in play, and each represents a teachable moment. While the emotions run high in the MD-OD turf battle, one fact is indisputable: with cheap glasses and contact lenses only a click away on the Internet, the practice of optometry is becoming more disease-oriented and less vision care-oriented and this trend will continue. Laser surgery by ODs is the new reality and will almost certainly become more common in more regions over time. If MDs' stated justification for opposing OD scope of practice expansion—on the basis of protecting patients from untrained practitioners—is valid, then the only rational course of action in this era of legal laser by ODs is for MDs to educate ODs on proper patient selection, technique, and post-treatment care. This is how we show our commitment to patient safety.

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