Perspectives on Glaucoma

Minority of states regulate glaucoma comanagement

Osamah Saeedi
Osamah Saeedi

A systematic evaluation of state laws across the U.S. showed that optometrists are permitted to manage glaucoma in most states, except Massachusetts, but only 16 states have defined regulations for comanagement.

State laws and regulations governing optometric scope of practice, guidelines for referral to ophthalmology as well as the number of hours of continuing education required for glaucoma management were reviewed by two trained reviewers in each of the 50 states and the District of Columbia.

In the U.S., optometric scope has expanded over the last 40 years to allow use of diagnostic pharmaceutical agents (DPA) and therapeutic pharmaceutical agents (TPA), including steroids. Glaucoma laser procedures are allowed in Louisiana, Kentucky and Oklahoma.

Optometric management and comanagement of glaucoma is part of optometric training, but only 16 states have specific guidelines for comanagement. Interestingly, comanagement guidelines are more often in place within states with a lower ratio of optometrists to ophthalmologists.

Some of the states, including Pennsylvania, Georgia and Nevada, specify that following diagnosis of glaucoma, patients should be referred in all cases to an ophthalmologist, Other states, such as Arkansas, Florida, Maryland, New Hampshire and New York, advocate cooperation between optometrists and ophthalmologists for comanagement plans, including goals of care and guidelines for the escalation of therapy.

According to the authors, “the patchwork of regulations makes the move toward a national referral guideline challenging.”

They concluded: “As the number of patients with glaucoma continues to increase, such comanagement schemes may become increasingly necessary.”

“This article was meant to describe the varied patterns of optometric management of glaucoma and compare optometric privileges in larger and smaller states and those with more or [fewer] optometrists or ophthalmologists. It highlights the large variation in ability to manage glaucoma and what influences these privileges. Ultimately, one would hope that these privileges were made more on objective measures focusing on patient safety and provider ability as opposed to other factors. The challenge is to know when to refer, and national referral guidelines are hindered by the patchwork of regulations nationwide,” study author, Osamah Saeedi, MD, told Primary Care Optometry News. by Michela Cimberle 

Disclosure: The authors reported no relevant financial disclosures.

Osamah Saeedi
Osamah Saeedi

A systematic evaluation of state laws across the U.S. showed that optometrists are permitted to manage glaucoma in most states, except Massachusetts, but only 16 states have defined regulations for comanagement.

State laws and regulations governing optometric scope of practice, guidelines for referral to ophthalmology as well as the number of hours of continuing education required for glaucoma management were reviewed by two trained reviewers in each of the 50 states and the District of Columbia.

In the U.S., optometric scope has expanded over the last 40 years to allow use of diagnostic pharmaceutical agents (DPA) and therapeutic pharmaceutical agents (TPA), including steroids. Glaucoma laser procedures are allowed in Louisiana, Kentucky and Oklahoma.

Optometric management and comanagement of glaucoma is part of optometric training, but only 16 states have specific guidelines for comanagement. Interestingly, comanagement guidelines are more often in place within states with a lower ratio of optometrists to ophthalmologists.

Some of the states, including Pennsylvania, Georgia and Nevada, specify that following diagnosis of glaucoma, patients should be referred in all cases to an ophthalmologist, Other states, such as Arkansas, Florida, Maryland, New Hampshire and New York, advocate cooperation between optometrists and ophthalmologists for comanagement plans, including goals of care and guidelines for the escalation of therapy.

According to the authors, “the patchwork of regulations makes the move toward a national referral guideline challenging.”

They concluded: “As the number of patients with glaucoma continues to increase, such comanagement schemes may become increasingly necessary.”

“This article was meant to describe the varied patterns of optometric management of glaucoma and compare optometric privileges in larger and smaller states and those with more or [fewer] optometrists or ophthalmologists. It highlights the large variation in ability to manage glaucoma and what influences these privileges. Ultimately, one would hope that these privileges were made more on objective measures focusing on patient safety and provider ability as opposed to other factors. The challenge is to know when to refer, and national referral guidelines are hindered by the patchwork of regulations nationwide,” study author, Osamah Saeedi, MD, told Primary Care Optometry News. by Michela Cimberle 

Disclosure: The authors reported no relevant financial disclosures.

    Perspective
    Carl H. Jacobsen

    Carl H. Jacobsen

    Chodnicki and colleagues in their analysis of U.S. laws governing optometric glaucoma management lament the lack of specific glaucoma referral guidelines. I wonder if they might also advise similar guidelines for general ophthalmologists? How else will our ophthalmology colleagues know when to refer their diabetic patients to a local retinal specialist for persistent vitreal hemorrhage? Their Fuchs’ patient to a corneal specialist for endothelial transplant? Their uveitic glaucoma patient to a glaucoma specialist for a tube-shunt procedure?

    I’m being facetious, but let’s be real. Mandated referral guidelines are in place to hold optometry down and limit our scope of practice. Every practitioner, whether optometrist, ophthalmologist, dentist or primary care doctor, must establish their individual practice limitations within the law and refer when they deem necessary. We must be fully accountable and ensure that our patients are receiving the highest quality care. It is an insult to us as optometrists that other doctors feel we are unable to understand the diseases we are treating and need assistance in defining our limits in managing these conditions. It’s time for our professions to start working together with mutual respect to manage the very real threat glaucoma poses to our ever-aging populace.

    • Carl H. Jacobsen, OD, FAAO
    • University of California Berkeley, School of Optometry

    Disclosures: Jacobsen is on the Alcon speakers bureau and has been an advisor to Sucampo.