Optometrists; Post-operative care of cataract surgery patients; practice of medicine

Subject:

Optometrists; Post-operative care of cataract surgery patients; practice of medicine

Requested By:

Bryant D. Paris, Jr. Executive Director Board of Medical Examiners

Question:

Does post-operative care of cataract surgery patients by a licensed optometrist constitute the unauthorized practice of medicine?

Conclusion:

The procedures identified herein as components of post-operative care of cataract surgery patients fall within the definition of optometry when done by a licensed optometrist and do not constitute the unauthorized practice of medicine.

The question presented is whether post-operative care of cataract surgery patients by a licensed optometrist constitutes the unauthorized practice of medicine. The question arises from Medicare regulations and policies regarding optometric services of aphakia. The regulations and policies allow for surgical follow-up by optometrists provided that the services performed are within the scope of practice of optometry as determined by state law. Related questions concerning ethical considerations of referral and fee-splitting between opthalmologists and optometrists were not asked by the Board of Medical Examiners and are not addressed in this opinion

Aphakia is defined for purposes of Medicare as the absence of the natural crystalline lens of the eye whether or not an intraocular lens has been implanted. Opening and entry into the eye is performed by an opthalmologist who removes the cloudy natural lens, inserts the prosthesis (artificial lens) and then closes the entry would. The opthalmologist examines the eye after surgery to determine whether the eye is healing without complications. If there are complications, the patient remains under the care of the opthalmologist. If there are no complications resulting from the surgery, the patient is ordinarily released from the care of the opthalmologist. If there are no complications, the question is whether and within what limitations an optometrist may provide post-operative care, such as determining the patient’s unaided visual acuity, examining the eye and its adnexa (the surrounding structures), performing a slip lamp (biomicroscopic) examination of the external eye, performing a monocular opthalmoscopic and binocular indirect opthalmoscopic examination of the internal eye, determining the intraocular pressure by use of a tonometer, employing a phoropter (refractor) to determine whether corrective lenses are necessary for optimum vision, and if so, to prescribe the proper lens, and other ancillary procedures.

The Board of Medical Examiners submits that since surgery is excluded from the definition of optometry in G.S. 90-114, post-operative care is beyond the scope of practice of optometry because it is part of the surgery exclusion. The Board argues that post-operative care is a medical matter in that it involves a full range of complex medical judgments and is an essential part of the surgery process. The Board continues that the administration of intravenous fluids and medications and the removal of sutures is beyond the scope of practice of optometry. This Office agrees with the position of the Board of Medical Examiners concerning administration of intravenous fluids and medications and the removal of sutures and believes that the Board of Examiners in Optometry does not contest these matters. The Board of Medical Examiners also submits that prompt decision-making and use of medication during post-operative care does not permit collaboration by an optometrist with a medical doctor which is the prerequisite for prescribing medication, other than topical pharmaceutical agents, by an optometrist.

The Board of Examiners in Optometry takes the position that the practice of optometry as defined in G.S. 90-114 is a recognized exception under G.S. 90-18 to the unauthorized practice of medicine. The Board contends that pursuant to G.S. 90-114 an optometrist, within his or her area of specialized practice, may examine the human eye and its adnexa by any method; may diagnose, treat and refer for consultation or treatment any abnormal condition of the human eye and its adnexa; may employ instruments, devices, pharmaceutical agents and procedures when investigating, examining, treating, diagnosing or correcting visual defects or abnormal conditions of the human eye or its adnexa; and may prescribe and apply pharmaceutical agents and prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa. The Board contends that the scope of practice of optometry includes within it the procedures previously listed as components of post-operative care where there are no complications resulting from the surgery.

Surgery is a principal part of the practice of medicine under G.S. 90-18. Surgery is also specifically excluded from the definition of optometry under G.S. 90-114, which itself, when done by a licensed optometrist, is exempted from the unauthorized practice of medicine under

G.S.

90-18. Therefore, provided there are no complications resulting from the surgery, if a procedure is included within the definition of optometry and not performed by means of surgery, the procedure, when done by a licensed optometrist, does not constitute the unauthorized practice of medicine but falls within the practice of optometry. Although the term "surgery" is not defined in G.S. 90-18, the breadth of the definition cannot prohibit the performance by an optometrist of those procedures reasonably included within the definition of optometry, under circumstances where there are no complications resulting from the surgery. The procedures identified as components of post-operative care fall within G.S. 90-114 in that they are done (i) to examine the human eye, (ii) to diagnose the condition of the eye, (iii) to refer the patient back to the opthalmologist for consultation or treatment (such as administration of intravenous fluids and medications and the removal of sutures), (iv) to investigate, examine, treat, diagnose or correct visual defects and abnormal conditions by the employment of instruments, devices, pharmaceutical agents and procedures, and (v) to prescribe and apply lenses. Furthermore, the procedures do not involve an invasion of the body so as to constitute surgery.

G.S.

90-114 provides that an optometrist may use and prescribe pharmaceutical agents upon collaboration with a medical doctor. The statute does not contain any exclusion for postoperative care.

The premise of the Board of Medical Examiner’s argument is that post-operative care cannot be divorced from the surgical operation, which all agree falls within the practice of medicine. However, the structure of Chapter 90 of the General Statutes, entitled "Medicine, Allied Occupations", grants the entire field of health care to physicians licensed to practice medicine and then carves out specified areas for each of the allied occupations. It is the opinion of this Office that the procedures identified herein as components of post-operative care fall within the definition of optometry when performed by a licensed optometrist, and do not constitute the unauthorized practice of medicine where there are no complications as a result of the surgery.

LACY H. THORNBURG Attorney General

Robert R. Reilly Assistant Attorney General