Ophthalmologists Oppose Optometrist Scope Expansion for Surgeries

A significant debate is unfolding across Canada, pitting two essential eye care professions against each other in a dispute that could reshape how patients receive surgical treatments. At the heart of the issue is a push in several provinces to expand the scope of practice for optometrists, allowing them to perform certain laser eye surgeries and other procedures. While optometrists argue this is a necessary step to improve access to care, ophthalmologists are raising serious concerns about patient safety and the depth of training required for such interventions.

This conflict is more than a simple turf war; it’s a fundamental discussion about medical standards, specialized training, and what is best for the long-term health of patients’ vision.

The Core of the Controversy: Defining the Roles

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

Ophthalmologists are medical doctors (MDs) who specialize in eye and vision care. Their educational path is extensive:

Complete a four-year undergraduate degree.

Graduate from four years of medical school.

Undergo a year of internship (general medical training).

Complete a residency in ophthalmology for a minimum of five years, which includes intensive surgical training.

Many then pursue further sub-specialty fellowships in areas like retina, cornea, or glaucoma.

This path equips them to diagnose and treat all eye diseases, perform complex eye surgery, and manage systemic conditions that affect vision.

Optometrists are healthcare professionals who provide primary vision care. They are Doctors of Optometry (ODs), not medical doctors. Their training includes:

A four-year undergraduate degree.

Graduation from a four-year school of optometry.

Their expertise lies in performing eye exams, prescribing corrective lenses, diagnosing common eye abnormalities, and managing certain eye conditions with medications.

The proposed scope expansion would allow ODs to move from a diagnostic and medical management role into a surgical one.

The Argument for Expansion: Improving Access to Care

Proponents of the change, led by provincial optometry associations, present a compelling case centered on patient access. They argue that in many parts of Canada, particularly in rural and remote areas, patients face long wait times to see an ophthalmologist for procedures that are often considered routine.

The specific procedures in question include laser peripheral iridotomies (LPI), used to treat or prevent narrow-angle glaucoma, and YAG laser capsulotomies, which correct clouding that can occur after cataract surgery. Optometrists contend that these are low-risk, highly standardized procedures that they are fully capable of learning and performing safely.

Key Points from Optometry Advocates:

Reduced Wait Times: By allowing optometrists to perform these lasers, patients could receive treatment faster, potentially preventing vision loss from conditions like acute angle-closure glaucoma.

Geographic Equity: It would bring essential procedures to underserved communities that may not have a local ophthalmologist.

Proven Success: They point to other jurisdictions, like certain states in the U.S. and the United Kingdom, where optometrists already perform these procedures with good outcomes.

Efficiency: It streamlines the patient journey, allowing for diagnosis and treatment to happen in one place without a referral.

The Opposition: A Matter of Patient Safety and Training

The Canadian Ophthalmological Society (COS) and practicing ophthalmologists are pushing back vigorously. Their opposition is not based on protecting territory, they insist, but on a fundamental principle: the level of training required to handle the full spectrum of surgical outcomes.

Dr. Phil Hooper, president of the COS, encapsulates the concern, stating, “The issue is not the 99 times that things go well… It’s the one time that things go badly and having the background and the training to manage that complication.”

Key Concerns Raised by Ophthalmologists:

Insufficient Surgical Training: The core of their argument is that optometry school does not provide the foundational medical and surgical residency that is the bedrock of safe practice. An ophthalmology residency involves thousands of hours in the operating room, managing complex cases and, crucially, dealing with complications in real-time under supervision.

Managing Complications: Even a “simple” laser procedure can have serious complications, such as a sustained spike in eye pressure, inflammation, corneal damage, or retinal issues. Ophthalmologists are trained to diagnose and manage these complications immediately, which may require additional surgical intervention or complex medical management. They argue that a short, targeted training course cannot replicate the depth of experience needed for this.

Diagnostic Nuance: The line between who is a suitable candidate for a procedure and who is not can be subtle. A comprehensive medical background allows ophthalmologists to understand systemic factors and rare presentations that could make a procedure risky. They fear that without this deep diagnostic training, optometrists could inadvertently treat the wrong patients.

Fragmentation of Care: Ophthalmologists are concerned that splitting care between multiple providers could lead to communication gaps and a lack of continuity, which is not in the patient’s best interest.

A Clash of Perspectives on Training and Standards

The debate often centers on what constitutes adequate training. Optometry associations proposing the expansion have outlined rigorous training pathways, including supervised practice and certification processes. They believe this is sufficient for the specific lasers in question.

Ophthalmologists, however, view this as a dangerous dilution of standards. They compare a short certification course to their own five-plus years of hospital-based surgical residency and argue that there is no substitute for that level of immersive, comprehensive training. For them, the title “surgeon” must be reserved for those who have completed a formal surgical residency accredited by the Royal College of Physicians and Surgeons of Canada.

The Path Forward: Collaboration or Conflict?

As provinces like Ontario, Alberta, and Saskatchewan consider these regulatory changes, the path forward remains uncertain. The ideal solution would be one that balances the genuine need for improved access with the non-negotiable imperative of patient safety.

Some potential middle grounds have been suggested, such as creating integrated care models where optometrists work more closely under the supervision of ophthalmologists in a team-based approach. However, the fundamental divide on the issue of independent surgical practice remains wide.

For patients caught in the middle, the advice from both sides is the same: be informed. Understand the qualifications of the person treating you. Ask about their training and experience with a specific procedure, and inquire about their plan for managing potential complications.

The outcome of this professional dispute will have a lasting impact on the landscape of eye care in Canada. It forces a critical question: in the pursuit of greater accessibility, are we willing to compromise on the traditional and rigorous standards of surgical training? The answer will determine who gets to hold the laser, and ultimately, who is responsible for safeguarding one of our most precious senses.