Guest Editorial

Acting in our patients' best interests

Acting in Our Patients' Best Interests

ODs seek a l
arger role in managing retinal disease. Are quality care and patient safety at risk?

The retina community has a strong record of advocating and acting in the best interests of its patients. It is a record to be admired, it is a record worth maintaining, and now it is a record being tested by optometry.

Consider the retina community's interest in promulgating standards in fellowship training, establishing charitable foundations, or supporting initiatives to address the cost-effective treatment of AMD. All carry consistent themes of concern for quality of care, patient safety, and professionalism.

We, the retina community, must now decide how to respond to optometrists who have decided to engage themselves in the medical and surgical care of retinal diseases. Will we individually and/or collectively ignore it as a non-issue? Or will we consider it a threat to quality of care and patient safety and act to protect the highest standards of patient care — much as we have in other issues?

In my opinion, this is a significant issue. Consider the following differences in training and education alone:

► The path to vitreoretinal subspecialization in ophthalmology requires 4 years of medical school, 4 years of residency, and (nearly universally) 2 years of fellowship — a total of 10 years.

► The path to being an "optometric retina specialist" involves 4 years of optometry school and a period of self-study.

► The path to vitreoretinal subspecialization in ophthalmology requires an RRC-mandated hundreds of cumulative surgical procedures with generally additional hundreds in fellowship.

► There are hardly any requirements in optometry schools, because in almost all states, surgery by optometrists is illegal. In fact, there are no national optometric requirements for licensure or certification.

However, this remarkable educational differential has not stopped those within optometry who seek to change the optometric scope of practice.

Indeed, at a recent national summit hosted by the American Optometric Association, attendees agreed to:

► strive for delivery of care "with no restrictions on ... scope of practice"

► employ new technologies for "treating ocular and systemic conditions/diseases"

► develop nationwide, uniform, self-regulated licensure with a residency program in optometric surgery.


There were 200 attendees at the 2006 Optometric Retina Society meeting in Boston with presentations and courses on OCT, fluorescein angiography, and use of intravitreal medications. The Society's Web site ( refers to it as "The New Optometric Frontier." Additionally, one can easily locate online certificate-bearing courses for optometrists on injection techniques.

In Oklahoma, optometrists are permitted to perform some invasive vitreoretinal procedures. When this was challenged by ophthalmologists at a State Board of Examiners in Optometry meeting, the challenge was ignored. Optometry seeks to expand the "Oklahoma language" to other states.


In discussing this issue with our colleagues, I've heard the statement, "Let the market decide." Some believe that ophthalmology's unique training and expertise will trump optometry in the marketplace. However, experience dictates that the market is not always rational. An independent survey released less than a year ago by the National Consumers League revealed that one-third of respondents believed optometrists had medical degrees. More importantly, to take a caveat emptor approach regarding this issue is to abrogate our responsibility as advocates for our patients' safety.

Others have taken the stance that education can never be a bad thing and that, as subspecialists, we should teach optometrists about the latest in vitreoretinal therapy so that they will be better optometrists. This is, in my opinion, a superficially attractive position, taking the "education for education's sake" perspective. It ignores, however, that some ethicists believe in a fundamental responsibility of the educator — to ensure, to the best of his or her ability, that students have the prior training, expertise, and professional context to use the information provided in a responsible fashion.

Consider this analogy: What if the law permitted anyone to perform surgery? Would you bear ethical (let alone legal) responsibility for delivering a 1-hour skills-transfer course in intravitreal injections to college students? Of course you would. Now consider this: the majority of optometry schools in the United States do not require a college degree.

A recent editorial in Retina Times by Roy Levit, MD, and George Williams, MD, pointed out that at 1 school of optometry, 62% of the students had no more than a high school diploma (Spring 2006, page 7).

Whether it's a "time out" in surgery, an informed consent in the office, or the establishment of guidelines for vitreoretinal fellowships, we strive to act in the best interests of our patients. If you believe that quality care and patient safety demand ophthalmologic training, you must work to ensure it.


This issue will not be decided in the marketplace or in the medical-legal courtrooms. Grassroots political advocacy and personal engagement will determine the outcome. It directly affects us, our profession, and our patients. This is not an issue for "others" — there are no others.

How can you make a dfference? Contribute to the American Academy of Ophthalmology Surgical Scope Fund ( and to your state ophthalmology PAC. Equally important, become personally active in your state society and voice your concerns to your state officials. Recognize that this is not just an ophthalmology issue; build coalitions of other physicians, patients, and community leaders.

What is best for your patients?

David W. Parke II, MD, is president and CEO of the Dean McGee Eye Institute and is Edward L. Gaylord Professor and Chair at the Department of Ophthalmology, University of Oklahoma College of Medicine, Oklahoma City. Dr. Parke has no financial interest in the topic discussed within this article.