Optometry Scope of Practice.
The practice of optometry is defined as the examination of the human eye, the examination and ascertaining any defects of the human vision system, and the analysis of the process of vision. The practice of optometry includes:
In order to use topical drugs for diagnostic purposes, an optometrist must have at least 60 hours of didactic and clinical instruction in general and ocular pharmacology for optometry and certification from an institution of higher learning. To prescribe topical drugs, the optometrist must be certified to use topical drugs and have an additional 75 hours of didactic and clinical instruction. To use or prescribe oral drugs for diagnostic or therapeutic purposes, the optometrist must be certified to prescribe topical drugs and have an additional 16 hours of didactic and eight hours of supervised clinical instruction and be certified by an institution of higher education to administer, dispense, or prescribe drugs.
Optometrists are prohibited from prescribing, dispensing, or administering oral corticosteroids and from prescribing an oral drug within 90 days following ophthalmic surgery, unless the optometrist consults with the treating ophthalmologist. Except for the administration of epinephrine by injection for anaphylactic shock, no injections or infusions may be administered by an optometrist.
Optometry Board.
The Optometry Board (Board) consists of three members of the examining committee for optometry and two additional optometrists and one consumer member appointed by the Governor. The optometrist members must be Washington residents, must have been in active practice as a licensed optometrist in Washington for at least four years immediately preceding appointment, and may not have any connection with any optical supply business. The Board must develop and administer or approve a licensure examination. The Board must adopt rules and regulations to promote safety, protection, and the welfare of the public; to carry out the Board's purpose; to aid the Board in the performance of its powers and duties; and to govern the practice of optometry.
Sunrise Review.
In 2021 the Department of Health (DOH) conducted a sunrise review to expand the scope of practice for optometrists in Washington. The proposal made changes to the scope of practice for optometrists including: clarifying language regarding what is and is not included in the scope of practice for optometry; granting the Board greater authority over the practice of optometry; expanding the scope of medications and therapeutic procedures an optometrist may prescribe or perform; granting the Board authority for rulemaking regarding educational standards; and specifying in an exclusive list which procedures are not considered the practice of optometry. In the final report, the DOH found that aspects of the proposal meet the sunrise criteria, but that the proposal was too broad and did not adequately describe allowed procedures and issued a number of recommendations for ensure patient safety.
Scope of Practice.
The practice of optometry is expanded to specifically include the following in addition to the existing procedures and services:
Advanced Procedures.
With a license endorsement from the Optometry Board (Board), the practice of optometry may include:
To receive a license endorsement, a licensed optometrist must:
Upon completion of these requirements, proof of training must be submitted to the Board for approval. No optometrist may perform the advanced procedures until the optometrist has received confirmation of the endorsement in writing.
Prescription and Use of Pharmaceutical Agents.
Any optometrist authorized by the Board may purchase diagnostic pharmaceutical agents and is authorized to prescribe therapeutic pharmaceutical agents in the practice of optometry. Optometrists authorized by the Optometry Board to purchase pharmaceutical agents must obtain them from licensed wholesalers or pharmacists, using prescriptions or chart orders placed in the same or similar manner as any physician or other practitioner. Diagnostic and therapeutic pharmaceutical agents are any prescription or nonprescription drug delivered via any route of administration used or prescribed for the diagnosis, treatment, or mitigation of abnormal conditions and pathology of the human eye and its adnexa. Diagnostic and therapeutic pharmaceutical agents do not include Schedule I and Schedule II drugs, except for hydrocodone combination products. The prohibitions on prescribing, dispensing, or administering oral corticosteroids or prescribing an oral drug within 90 days of ophthalmic surgery are removed. If an optometrist prescribes oral corticosteroids, the optometrist must consult with a licensed physician.
In a public health emergency, the State Health Officer may authorize optometrists to administer inoculations for systemic health reasons.
Prohibited Procedures.
The practice of Optometry does not include:
Optometry Board.
A full record of the Board's proceedings must be kept in the office of the Board and must be open to inspection at all reasonable times. The administrative regulations the Board must adopt must include the classification and licensure of optometrists by examination or credentials, retirement of a license, and reinstatement of a license. The Board shall have the authority to provide rulemaking regarding the allowable procedures and their educational requirements for optometry. The Board must keep a registrar containing the name, address, license number, email, and phone number of every licensed optometrist to the best of the Board's ability.
The Board, in coordination with the Department of Health, must issue a report on the outcomes of the advanced procedures authorized through endorsement by December 1, 2026. The report must include any complications to patients receiving the advanced procedures and be posted online.
The amended bill:
(In support) Health care procedures and tools change rapidly and policy makers need to consider a profession's scope of practice on a regular basis to allow for these changes. This bill would be the first change to the scope of practice for optometrists in two decades. While this bill has been hotly contested, it is time to move forward with this modest update. This bill looks different than introduced because there was a lot of concern about laser eye procedures, so there was a lot of work to move forward and remove these procedures from the bill. This bill reflects the sunrise review recommendations and has been thoroughly vetted and worked. The Senate Health and Long-Term Care Committee passed this bill unanimously and it was voted off the floor with a strong bipartisan vote.
Over the last 20 years the level of education in optometric programs has continued to increase. By not updating the optometry scope of practice in 20 years, Washington has fallen behind its neighbors. In border communities residents often need to leave the state to receive care. Optometrists have been authorized to do these procedures for years in other states. Those practicing in Washington sometimes have to refer patients to Oregon, but for those with Medicaid they cannot receive care out of state. By allowing optometrists to practice at the fullest extent of their training, patients can receive this care from optometrists they know and trust in Washington.
This increase has been independently verified by the Department of Health (DOH), which agreed in their sunrise review that optometrists are trained to safely provide these procedures. Optometrists learn with scalpels and already use far more complicated procedures and tools to debride something in an eye. Optometrists are given hundreds of hours of education before they even pick up a needle. Earlier bill drafts were revised to fully align with the sunrise review, which found optometrists have the training to safely complete these procedures.
There is an urgent need for safe, quality vision care and this bill will increase access to care and reduce wait times. While some claim there is no shortage of care, multiple articles have discussed this shortage. Thirteen counties in Washington do not have a practicing ophthalmologist while optometrists cover 94 percent of Washington counties. It currently takes weeks to months for patients to get lid lesions addressed, biopsies, or the prescription of oral steroids.
(Opposed) Ophthalmologists graduate from medical school with a strong foundation in medicine and surgery to care for patients with systemic disease. An ophthalmologist on average has 15,000 more hours of clinical training than an optometrist, including hundreds of hours of hands on, one-on-one directly supervised surgeries during a four year residency. Only 10 percent of optometrists have hands on surgical training on live patients in school. The University of Washington has only five ophthalmologist residents at once, while optometry programs can have up to 150 students per class. There cannot be the necessary one-on-one experience with this many students.
There is only one optometry program that offers this advanced training and it consists of only 32 hours of training to perform scalpel surgery, suturing, and injections. Optometrists are simply not trained to provide surgery. Everyone wants the most qualified person to perform surgery on their eyes. This bill should not be advanced. It is complex, vague, and sometimes contradictory. The reference to eye lid surgery leaves the door open to anything that does not include general anesthesia.
The optometrists have used county maps to claim that there is a shortage of ophthalmologists, but that is very misleading. Medicare data shows 96 percent of Washingtonians live within 30 minutes of an ophthalmologist and the DOH noted in the sunrise review that there is not a documented access to care issue. Optometrists are reimbursed at the same level as ophthalmologists. There are also claims that optometrists are performing these procedures in Oregon, but this is not true as they are prohibited from invasive surgery, suturing, and the use of lasers. The sunrise review suggested that the Medical Commission should be involved in adopting the rules for advanced procedures, but that is not included in the bill.
Doctors train for so many years because its necessary to have a wide breadth of experience to know when to operate and when not to operate and how to prevent and manage complications. No one on the Optometry Board has ophthalmologic experience to set these rules. Only ophthalmologists should be performing eyelid surgery. Misplaced injections can puncture through the eyelid to the eye and cause blindness, could go further and infiltrate the brainstem causing respiratory depression, or cut into cancer and potentially spread cancer throughout the body. These are not theoretical risks, but have happened. If an ophthalmologists causes one of these issues, they have the medical knowledge and experience to quickly respond to the emergency.