The state says optometrists can’t do surgeries, including ones they’re trained to do

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As part of their doctorate-level education, optometrists learn how to perform minor surgeries, including some laser eye surgeries. Yet New Hampshire law prohibits optometrists from doing any surgeries, even ones they’re trained to do.

Only ophthalmologists (physicians who specialize in medical and surgical eye care) are permitted by law to perform laser procedures in New Hampshire. This restriction reduces the availability of certain eye care procedures and forces patients to go to specialists when they don’t really need one. 

Optometrists are trying to lift this outdated regulation and make some other changes to their state oversight so they can offer Granite Staters additional services they’re qualified to perform. 

Senate Bill 440 would, in a word, modernize the regulation of optometry in New Hampshire. This includes changing what constitutes the practice of optometry and moving scope of practice decisions and rulemaking authority to the state Board of Optometry (as opposed to relying on state statutes), all to treat optometry like other doctorate-level independently practicing professions in New Hampshire.

Currently, optometrists in 12 states can perform laser surgeries, according to the American Optometric Association: Alaska, Arkansas, Colorado, Indiana, Kentucky, Louisiana, Mississippi, Oklahoma, South Dakota, Virginia, Wisconsin, and Wyoming. 

These procedures include YAG (yttrium aluminum garnet) laser capsulotomy to remove clouded tissue on the back of the lens implant after cataract surgery; LPI (laser peripheral iridotomy) and SLT (selective laser trabeculoplasty) for treating some forms of glaucoma; and excision, removal, drainage, or injection of a variety of “lumps and bumps.”

The New Hampshire Medical Society opposes SB 440, saying it would jeopardize the health and safety of patients. Evidence from other states suggests otherwise.

Russell Laverty, OD, executive director of the Oklahoma Board of Examiners in Optometry, wrote to the Senate Executive Departments and Administration Committee that Oklahoma allowed optometrists to do laser eye surgeries starting in 1998. 

“Since 1998 there have been an additional estimated over 50,000 laser surgery procedures in which there were no complaints registered,” he wrote.

Since 2011, optometrists have performed more than 60,000 laser procedures in Kentucky, according to Joe E. Ellis, OD, president of the Kentucky Board of Optometric Examiners. The board hasn’t received any complaints or been notified of any adverse effects related to the surgeries, according to Dr. Ellis.

Dr. Nate Lighthizer, optometrist and associate dean at the Northeastern State University Oklahoma College of Optometry, testified in writing that more than 30,000 laser procedures in total have been performed by optometrists in Louisiana since 2014, Alaska since 2017, and Arkansas from 2021–22 combined. How many negative outcomes have been reported across all three states? Zero.

The reason for the shortage of complaints is simple. Optometrists are trained to perform minor laser and traditional surgeries. According to Laverty and Lighthizer, laser procedure is taught to every optometry student in every college of optometry in the United States, where students earn Doctor of Optometry (OD) degrees after roughly four years of graduate study. 

By keeping professionally licensed optometrists from doing what they were specially trained to do, Granite Staters’ access to necessary eye care has been severely limited, especially in rural New Hampshire. 

According to data from the American Optometric Association, the U.S. Census Bureau, and the American Medical Association, there are optometrists currently practicing in all 10 New Hampshire counties. In Coos and Sullivan counties, however, optometrists are the only local eye care providers for the 26,163 urban residents and 48,682 rural residents between these two jurisdictions. 

That means that residents of Coos and Sullivan counties have to travel to neighboring counties to find the nearest ophthalmologist to perform some surgeries that could be performed by a resident optometrist.

In Carroll County, which is 90% rural, there are 1.7 optometrists per 10,000 people but only 0.2 ophthalmologists per 10,000. 

Moreover, each of the four New Hampshire counties with more than 100,000 residents (Hillsborough, Merrimack, Rockingham, and Strafford) has at least one optometrist per 10,000 people, but not one has at least one ophthalmologist per 10,000. 

With few ophthalmologists statewide, wait times for these laser procedures, that only they can legally perform, are very long in New Hampshire. 

The average total wait time for YAG, LPI, SLT, and “lumps and bumps” operations, both for the consultation and the actual procedure combined, are 3.8 months, 3.6 months, 4.6 months, and 4.2 months, respectively, per the New Hampshire Optometric Association (NHOA). 

Anecdotes gathered by an NHOA survey of member-owned practices across the state lend credence to these statistics:

“Recently what was a 1–3 month wait for SLT (selective laser trabeculoplasty) has turned into a 10-month wait, a disturbing access problem for my patients.” – Conway Eye Care, North Conway

As of January 1st this year Mt. Ascutney has 1 cataract surgeon who stopped taking new patients over 1.5 years ago. The one and only cataract surgeon in Montpelier booking 6 months out for the consult. ANY referral to DHMC ophthalmology (which is less than 10 minutes from our office) is a minimum of 4 months but usually longer. But DHMC stopped accepting new patients for ANY glaucoma related issues 2 months ago. The oculoplastics MD left DHMC, hasn’t been replaced yet so patients have to go to Concord or Burlington, VT. DHMC has not been accepting new patients in the retina clinic for ~ 2 years, they now have 1 retina specialist (intravitreal injections).” – Dr. Sheila Hastie, Lebanon

“Patients are frustrated when they cannot see properly to drive, waiting for a YAG procedure that takes 2–4 months to get into the surgeon’s office. I recently had a patient who waited over three months for evaluation and then an additional two months for both eyes to be treated.” – Dr. Chris Daldine and Dr. Pattie Samuel Daldine, Nashua

“We have referred to Dartmouth-Hitchcock for many different types of visits and they are not accepting referrals of any kind and asking us to send patients elsewhere. We have also sent referrals to Concord Eye Center, Medical Eye, and NH Eye and they will run redundant diagnostic tests/visits confirming that the patient needs the referral even though they have received all visit notes and testing data in the referral. This adds unnecessary financial burden on patients and insurance companies.” – Capital Vision Center, Concord 

These problems will only worsen as the supply of ophthalmologists continues to shrink, as it’s projected to do. As Edward Timmons, director of the Knee Center for the Study of Occupational Regulation at West Virginia University, cites, 450 ophthalmologists became eligible to start working in 2022, but 550 ophthalmologists retired that year—a net loss of 100 providers nationwide in 2022 alone.  

Research published in Ophthalmology, the journal of the American Academy of Ophthalmology, estimates “a sizeable shortage of ophthalmology supply relative to demand by the year 2035, with substantial geographic disparities.”

The monopoly that ophthalmologists in New Hampshire have over eye surgeries, including minor ones optometrists are trained to do, has led to limited access to eye care, longer wait times and delayed procedures for Granite Staters. 

When supply of a service is artificially limited, but demand remains constant or increases, costs for that service inevitably increase. 

In the face of these facts, the opposition to SB 440 looks less like concern for patient health, safety and well-being and more like ophthalmologists protecting their turf by limiting competition. 

Simply permitting optometrists to do what they were trained to do would be an obvious way to address many of these problems.