Ophthalmologists Oppose Expanding Optometrist Surgical Procedures

A significant debate over the future of eye care in Canada is intensifying, pitting two key professions against each other. A recent proposal to expand the scope of practice for optometrists, allowing them to perform certain minor surgical procedures, is being met with strong opposition from ophthalmologists, who argue that patient safety is at stake.

This conflict, highlighted by a recent call from the Canadian Ophthalmological Society to provincial governments, centers on a fundamental question: where should the line be drawn between the expertise of an optometrist and that of a medical doctor specializing in eye surgery and disease?

The Core of the Controversy: Defining Roles in Eye Care

To understand the disagreement, it’s crucial to distinguish between the two professions.

Optometrists (ODs) are primary eye care providers. They hold a Doctor of Optometry degree and are experts in:

Conducting comprehensive eye exams.

Prescribing and fitting glasses and contact lenses.

Diagnosing common eye conditions like glaucoma, cataracts, and macular degeneration.

Managing certain eye diseases with pharmaceuticals.

Ophthalmologists are medical doctors (MDs) who have completed medical school, a residency in ophthalmology, and often further subspecialty fellowship training. Their expertise includes:

Diagnosing and treating all eye diseases, including complex cases.

Performing a wide range of eye surgeries, from cataract removal to retinal detachments and laser procedures.

Providing comprehensive medical and surgical care for the visual system.

The proposed scope expansion would permit optometrists to perform procedures such as laser surgeries for certain conditions, eyelid lesion removals, and corneal foreign body removals.

The Ophthalmologists’ Stance: A Matter of Training and Safety

Ophthalmologists are urging provinces to reject this expansion, citing deep concerns over patient welfare. Their opposition is not based on territorialism, they argue, but on the vast difference in medical training.

Insufficient Surgical and Medical Training

The central argument from ophthalmologists is that the four-year optometry program, while excellent for primary eye care, does not provide the rigorous, hospital-based surgical training required to handle the complexities and potential complications of surgery.

Medical School Foundation: Ophthalmologists emphasize that their training begins with four years of medical school, providing a deep understanding of systemic health, human physiology, pharmacology, and pathology. This knowledge is critical because eye conditions are often linked to broader health issues like diabetes, hypertension, and autoimmune diseases.

Residency and Fellowships: Following medical school, ophthalmologists undergo a minimum of five years of post-graduate residency training. This period is spent in a hospital setting, managing emergencies, assisting in hundreds of surgeries, and learning to handle life-threatening complications. Many then complete additional fellowships to specialize further.

Managing Complications: A key point of contention is the ability to manage intra-operative and post-operative complications. Ophthalmologists are trained to handle unexpected bleeding, infections, or other surgical emergencies, which are skills honed through years of supervised, high-stakes training.

Risk of Fragmented Care

Another significant concern is the potential for fragmented patient care. Ophthalmologists argue that the eye is not an isolated organ, and its health is intimately connected to the rest of the body. A medical doctor’s holistic training allows them to connect ocular symptoms to systemic conditions, a level of integrative diagnosis that may fall outside the standard scope of optometric practice.

The Potential Rationale for Expansion

While ophthalmologists present a compelling safety argument, the push for expanding optometrists’ scope is likely driven by several practical factors.

Improving Access to Care: In many rural and remote areas of Canada, access to an ophthalmologist can be limited, with patients facing long wait times for non-urgent procedures. Allowing optometrists to perform minor surgeries could potentially improve access and reduce wait times for people in underserved communities.

Workforce Utilization: Proponents may argue that optometrists are a highly skilled and underutilized workforce. With additional, targeted training, they could help alleviate pressure on the healthcare system by taking on a greater share of routine procedures.

International Precedent: Some regions, including certain states in the USA and other countries, have already granted optometrists a broader scope of practice that includes laser and minor surgical procedures.

Finding a Path Forward: Collaboration Over Conflict

The solution to this complex issue may not lie in a simple “yes” or “no” but in a more nuanced approach that prioritizes patient safety while addressing systemic challenges.

The “See One, Do One, Teach One” Standard

Ophthalmologists stress that surgical competence is not achieved through a short course or a set number of supervised procedures. It is cultivated through the time-honored medical model of “see one, do one, teach one,” which is embedded within a multi-year residency. Any proposal for expansion, they argue, must be measured against this gold standard of surgical education.

Potential for a Supervised, Tiered Model

A potential middle ground could involve the creation of a highly regulated, tiered model. This might include:

Enhanced Collaborative Agreements: Formalizing structures where optometrists work directly within ophthalmology practices or hospital systems under the close supervision of surgeons.

Strictly Defined Procedures: Limiting the scope to a very specific list of low-risk procedures, with a clear pathway for immediate referral to an ophthalmologist for any complications or complex cases.

Rigorous Certification: Developing a nationally standardized, rigorous certification program for optometrists that includes significant hands-on surgical simulation and direct supervision, far beyond a weekend course.

Conclusion: Patient Safety Must Remain the Paramount Concern

The debate over expanding optometrists’ surgical scope is a microcosm of larger tensions in healthcare, where the need for increased access must be carefully balanced with the imperative of patient safety. While the goal of improving timely care is laudable, the concerns raised by ophthalmologists are rooted in the fundamental principles of medical training and surgical competency.

As provincial governments consider these proposals, the question remains: can a modified scope of practice for optometrists be developed that truly replicates the depth and rigor of a surgeon’s training? Until that question can be answered with a resounding and evidence-based “yes,” ophthalmologists maintain that the safest path is to preserve the current distinction between the two professions, ensuring that surgical intervention remains firmly in the hands of those with comprehensive medical and surgical education. The health of patients’ vision, they argue, is too precious to risk on a diluted standard of care.