Injecting politics into delicate eye care

HENDERSON -- Recently reported public records suggest that during the 2000 legislative session, the N.C. Medical Board struck a political deal allowing optometrists (who are not medical doctors and who practice the same profession as House Speaker Jim Black) to perform delicate ocular injections, in order to obtain passage of legislation supported by the Medical Board. The Medical Board later reversed its stance, in large part due to medically based arguments presented by the N.C. Society of Eye Physicians and Surgeons -- ophthalmologists -- about the knowledge, risks and surgical skill necessary to perform these ocular injections.

In 2005, the Medical Board again had legislation stalled in a House committee. Once again, an agreement was reached to allow optometrists to perform some of the same injections that were debated in 2000. The General Assembly then passed the Medical Board's bill.

Two of the three procedures at issue involve injections into the eyelids. One is injection of steroids into inflammatory cysts on the eyelids, called chalazia. An injection is not the preferred method for treating these cysts, which are usually incised and drained surgically in the uncommon instances where they do not respond to conservative medical management.

The other procedure is an injection of botulinum toxin (Botox) into the muscles beneath the lids, ostensibly for "non-cosmetic" purposes. The only non-cosmetic reason to use such an injection is for severe eyelid spasms (blepharospasm), a rare condition usually treated by super-specialists such as oculoplastic surgeons or neuroophthalmologists.

Optometrists, who are prohibited by law from performing surgery, claim that the types of injections described above, as well as other delicate ocular injections, are non-surgical procedures. They argue that the use of needles in and around the tissues of the eye is no different from the shots a nurse gives in the doctor's office.

Ophthalmologists, who routinely perform eye surgery, know otherwise. Deciding when to use these procedures requires extensive knowledge about medical and ocular disease, as well as knowledge of surgical anatomy. Injecting in and around the eye, moreover, requires finely honed surgical skills. In the absence of this knowledge and skill, these procedures could pose devastating consequences to patients' vision.

Another ocular procedure that optometrists wish to perform is called fluorescein angiography. It involves intravenous injection of dye, with photography to examine the blood vessels in the back of the eye. The injection of fluorescein dye has potentially fatal side effects, which increase in risk with repeated exposure. This risk should not be minimized.

This procedure is most commonly performed by retinal specialists (ophthalmologists with several years of additional training specifically in treating the retina) to guide laser or other retinal surgery.

The decision to send a patient to a retinal specialist is based on the clinical examination (i.e., looking into the eye with instruments and lenses). It is not necessary for referring physicians or optometrists to perform a fluorescein angiogram because the retinal specialist will almost always repeat the procedure. Unnecessarily performing fluorescein angiography will not only cost patients more money, but also expose them to additional risk for harm.

The injections discussed above should only be performed by or under the direct supervision of a medical doctor. Because they are rarely used in a routine general ophthalmology practice, objections to optometrists performing these procedures are not motivated by financial concerns.

To become an ophthalmologist, one must not only graduate from medical school but must also spend an additional three to four years in a surgical specialty residency. During a residency in ophthalmology, the physician performs hundreds of eye injections under the supervision of experienced eye surgeons before treating patients independently, without supervision. Optometrists in North Carolina, in contrast, are now being allowed to do these same delicate injections unsupervised on patients after attending one weekend course.

The practice of medicine and surgery is a privilege granted by law to those who have met the stringent educational criteria to become properly licensed medical doctors. The Medical Board regulates medical doctors and the practice of medicine for the sake of public safety. The physicians serving on the Medical Board are wonderful public servants, providing a vital function to protect the citizens of North Carolina. It is a shame that political pressure has forced the board, in an effort to obtain legislation and resources necessary for it to perform its job, to permit non-physicians to perform procedures beyond their educational training and clinical experience.

(Cynthia A. Hampton, M.D., practices general ophthalmology in Henderson. She served as president of the N.C. Society of Eye Physicians and Surgeons in 2000.)