The battle to obtain glaucoma prescribing privileges was an arduous one for optometrists across the country and it is still ongoing in a few states. In those states where these privileges have been recently acquired, each optometrist is working on the best way to incorporate them into his or her practice.
We have known how to treat and prescribe for glaucoma for years, and now we can actually do it, said John Coble, OD, a practitioner in Texas, where ODs acquired glaucoma privileges in 1999. I feel as though we are finally practicing the way we were taught to practice.
Pennsylvanias plans for glaucoma Tx
Pennsylvania is the most recent state to gain glaucoma privileges, with a bill signed into law at the end of 2002.
Were just waiting for the list of drugs to be approved, said Karen M. Wrigley, OD, a Philadelphia-based practitioner.
Along with many other optometrists in Pennsylvania, Dr. Wrigley has been anticipating the opportunity to put this new law to work in her practice. One of her first goals for incorporating the new privileges is to augment her current supply of glaucoma-related equipment.
First of all, we are looking to get a pachymeter, due to the new ocular hypertension study findings, she said. A few Vision Source doctors and I are considering purchasing a new HRT II (Heidelberg Engineering, Vista, Calif.). Buying new equipment will be an important aspect of this.
Dr. Wrigley said she also plans to strengthen her working relationship with her current comanaging glaucoma specialist. I want to develop more of a dialogue and make sure she realizes that Im comfortable seeing patients even more closely than I had in the past, she said.
The fact that some medical insurance companies do not recognize optometrists as participating providers is also a concern that Dr. Wrigley and other Pennsylvania optometrists will need to address, she said. We will now want to be sure we have patients medical insurance information as well as their vision plan information, she said. We need to be able to determine how often we can see them and what their health insurance benefits are.
Dr. Wrigley said from what she has observed recently, many optometrists in her state are looking forward to putting their glaucoma privileges into action.
Texas ODs: applying skills
Although Texas optometrists obtained therapeutic privileges in 1991, the capability to prescribe oral and glaucoma medications did not follow until 1999, Dr. Coble said.
Prior to that, it was comanagement, but the ophthalmologists had to write the prescription for glaucoma meds, he said. Once we got therapeutics, we could treat conjunctivitis and iritis, things like that. But we couldnt treat glaucoma until 1999.
Dr. Coble, who graduated from optometry school in 1986, said he now has more freedom to use the full range of his knowledge as an optometrist. I actually have an ophthalmologist who has been coming to the office one day a week for years, he said. Now, instead of the patient having to wait to see him for prescriptions, I have been able to see the patients from the get-go.
Dr. Coble conceded that the new glaucoma privileges may take some time for optometrists to adjust to, especially those who were not involved in any aspect of glaucoma treatment previously.
I would like it to be a faster change than it appears to be, he said. It will take some time for ODs to get comfortable with it and to change their mode of practice.
Californias numbers game
Although California gained its glaucoma privileges in 2000, that legislation is considered limited by some.
Lets call it a small step, said David Sendrowski, OD, a practitioner in Fullerton and a faculty member of Southern California College of Optometry. The restrictions that are put on optometry from the California legislation make it very difficult for optometrists to achieve their independence to treat glaucoma in a reasonable time period.
According to Californias law, each optometrist must treat 50 patients in conjunction with an ophthalmologist before he or she can treat glaucoma independently.
It really is a numbers game. It is difficult for an independent practitioner to gather 50 patients in a short amount of time, Dr. Sendrowski said. The average practitioner would get to that 50th patient, if they were lucky, in about 3 to 6 years.
Despite these restrictions, Dr. Sendrowski said he has seen some positive changes in private practice as a result of the legislation.
As far as our practice at the college, it hasnt changed much, because we have been diagnosing and using therapeutic medications in conjunction with our ophthalmologic staff prior to the bill, he said. But as far as private practice, I think optometrists are taking a very intelligent approach to looking at glaucoma. They are using more modern technologies than a lot of their medical counterparts.
For example, Dr. Sendrowski said he has noticed an increase in referrals for instruments such as the HRT II. Basically, practitioners are looking to get good baseline data on the optic nerve for glaucoma suspects, he said. They are using more advanced visual field interpretation such as the SITA technology (Humphrey Carl Zeiss Corp., Dublin, CA).
In addition, Dr. Sendrowski said he has noticed increased interest in areas such as corneal thickness and pachymetry readings. They are using the newest information from the recent glaucoma studies, he said. I think that California optometrists are ready to treat glaucoma independently. They are just waiting for the opportunity.
New York: full-spectrum management
Glaucoma privileges in New York are being implemented very effectively, according to Roy Kline, OD, a Glens Falls-based practitioner.
In our office, when we have a glaucoma suspect, we do a complete workup including tonometry, gonioscopy, digital retinal photography and threshold visual fields, Dr. Kline said. At that point, if we determine the patient has glaucoma, we refer that patient to one of our glaucoma consultants and he or she will start the patient on medication or other alternatives. We will then follow that patient, comanaging every 6 months with the ophthalmologist.
In New York State, however, there are more than 1,000 doctors of optometry who start treatment and follow patients without referring, Dr. Kline said. New York state law allows optometrists to diagnose and treat glaucoma without comanagement, he said.
Prior to New York State conferring glaucoma privileges, many of our elderly patients with glaucoma were being lost after referring them out, Dr. Kline said. The ophthalmologist may have sent the patient back to us for refraction, but not for eye health management.
For Your Information:
- John Coble, OD, can be reached at 3005 A Joe Ramsey Blvd., Greenville, TX 75403; (903) 454-1886; fax: (903) 455-3055; e-mail: firstname.lastname@example.org.
- Karen M. Wrigley, OD, can be reached at 1919 Chestnut St., Philadelphia, PA 19103; (215) 563-8440; fax: (215) 567-4993j; e-mail: email@example.com.
- David Sendrowski, OD, FAAO, can be reached at 38 Pinzon St., Rancho Santa Margarita, CA 92688-2941; (714) 449-7414; e-mail: firstname.lastname@example.org.
- Roy Kline, OD, can be reached at 41 S. Western Ave., Glens Falls, NY 12801-3313; (518) 792-2345; fax: (518) 792-1361.