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Arkansas residents may soon be able to go to optometrists for procedures such as laser capsulotomy and removal of eyelid lesions -- or maybe they won't, depending on what happens with a ballot initiative on the matter.

In 2019, the Arkansas legislature passed what is known as , which would allow optometrists to perform:

• Injections, excluding intravenous or intraocular injections
• Incision and curettage of a chalazion
• Removal and biopsy of skin lesions with low risk of malignancy, excluding lesions involving the lid margin or nasal to the puncta
• Laser capsulotomy
• Laser trabeculoplasty

Such scope-of-practice expansion is natural, William Reynolds, OD, an optometrist in Richmond, Kentucky, and president of the American Optometric Association, said in a phone interview. "Optometry has been expanding their scope since the 1970s. That's what you want out of a profession ... As education and technology evolve, so does our profession." He added that the procedures approved by the legislature "are not invasive procedures. These are procedures done in the office and without general anesthesia; they're procedures that just take a couple of minutes."

Ophthalmologists Fight Back

However, ophthalmologists in the state were not happy about the new law, especially as it relates to the laser procedures.

"They claim these aren't invasive procedures, but you're shooting a highly concentrated beam of light -- like a scalpel on steroids -- into the angle of the iris to try to destroy permanently some part of the eyeball to decrease pressure in the eye," said Laurie Barber, MD, an ophthalmologist in Little Rock, Arkansas, and chair of Safe Surgery Arkansas, a group opposing the law. For the two laser procedures the law would allow optometrists to perform, "I'm a comprehensive ophthalmologist and I tend to send these patients to glaucoma specialists."

The ophthalmologists used a legislative mechanism in Arkansas that allows citizens to put a newly passed law in abeyance while they collect signatures for a ballot referendum on it. And so was born , which seeks to invalidate Act 579. (A "yes" vote on the referendum is to uphold the law, while a "no" vote is to repeal it.) The ophthalmologists hired a canvassing firm that collected more than 80,000 signatures to get the measure on the ballot; however, the optometrists challenged the legitimacy of some of the signatures in court. The issue has made it up to the Arkansas Supreme Court, which is expected to rule on it in the next few weeks, in time for the November election.

If the law is upheld, Arkansas would become the fifth state to allow optometrists to perform such procedures, along with Kentucky, Louisiana, Alaska, and Oklahoma. Reynolds said that in his home state of Kentucky, optometrists have done very well with these procedures. "In Kentucky, there has not been one lawsuit anywhere, there has not been one complaint to the optometric board, not one complaint to the medical board, and there has not been one adverse reaction to all these procedures," he said. "We've got a better safety record than pedicurists have." In addition, "our malpractice rates have not gone up, and the people who figure all that out, they know what the risks are."

Barber is not so sure about the lack of complaints. Although the number of lawsuits filed against optometrists doing these procedures "aren't as high as you might think, we believe that's because they've been settled out of court, and therefore kept in the shadows," she said. In Kentucky, however, that isn't the case, because "even if a suit is settled, it has to be reported to optometric board," according to Reynolds. For her part, Barber said she has "heard many stories from people at the universities in Oklahoma City and Tulsa -- ophthalmologists say, 'We see complications from these procedures frequently when they're done by optometrists.'"

Training at Issue

Training for the procedures is another part of the dispute. Ophthalmologists, said Barber, learn laser procedures during ophthalmology residency. "We start by watching it being done; we're taught about the anatomy, then taught about the laser and its dangers ... We watch it being done several times by a faculty member or the chief resident, and when we've seen it enough, they show you how to do it on a piece of paper and then show you on a plastic eye and watch you do it on a real patient," she explained. "When they think you've done it enough, you do it on your own." This is in contrast to states like Oklahoma where the optometry students "at most optometry colleges may have done it on a plastic eye," she said.

That's not true in Kentucky, according to Reynolds. There, the students -- or practicing optometrists who want to perform the procedure -- "have to go to a proctor, someone who is licensed to do the procedures and is a faculty member at a medical school or optometry school, and they have to observe enough procedures, and then the proctors have to feel comfortable letting you do one, and you have to perform enough of them in their presence where they feel comfortable enough having you do them on your own," he said.

Patient access to the procedures is another issue, according to Reynolds. "When you look at rural states, the majority of ophthalmologists are in large cities, while doctors of optometry are more like primary care providers, so they're distributed much more throughout the state," he said. For a lot of patients, "having to come an hour or two drive and arrange transportation to do that, that's a big drawback and a big problem to a lot of patients." Also, ophthalmologic practices are often quite busy, sometimes with several-month waits to get in. "In our town at one time, the ophthalmologist was booked out for over a year," Reynolds added. "That's a long time to wait to see better."

Barber disagrees with the idea that access is a problem. "A lot of us have satellite clinics, and many of us are a short drive for most patients," she said. Cost is also not an issue, since insurance pays the same no matter who does the procedure. "As far as I know, there is no balance billing for many of these things," she said. "Most of the time we take what insurance pays, plus the copay."

Educating Voters, Legislators Critical

Both sides say that educating the voters -- and the legislators -- is critical. "We're trying very hard; it's a big process," said Barber. "Most people don't understand that optometrists did not go to medical school and did not take surgical training ... Their eye doctor says 'I can do this procedure; come on back' and they think that's OK because the legislature says it's OK." Even if the ballot initiative doesn't work out, "we still spent money to educate people in the state of Arkansas, and may prevent them from going to someone who shouldn't do eye surgery," she added.

But optometrists insist they are fully capable of performing the procedures safely.

"We take a lot of time to explain our education, to explain our history and what we do, and I think that by using our efforts to educate legislators they learn to trust what we're saying and that's the way we move forward," said Reynolds, who added that he expects more states will pass laws similar to Act 579. He pointed out that ophthalmologists also used to object to optometrists using eyedrops to dilate pupils and to optometrists fitting patients for contact lenses -- things that they routinely do today. "None of these arguments are new; a lot of it is a turf war."

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