Across the United States, patients encounter difficulties in accessing healthcare services, especially in rural regions where lengthy travel to consult specialists is routine. A significant shortage exists in eye care, with rapidly increasing demand exceeding the supply of ophthalmologists. In contrast, a large number of skilled optometrists are underutilized due to regulations preventing them from performing certain necessary procedures.
Notably, over twelve states allow optometrists to conduct YAG laser capsulotomies. This straightforward procedure addresses ‘secondary cataracts,’ which often form after cataract surgery and obscure vision. Annually, over half a million older Americans undergo this procedure, praised for its excellent safety record. Nevertheless, in many states, only ophthalmologists are authorized to perform this procedure.
This restriction on optometrists’ roles has tangible consequences for patients. In 2020, the U.S. had nearly three times more optometrists than ophthalmologists. Ophthalmologists predominantly practice in urban areas, while over 99% of Americans reside in counties with optometrists. Consequently, patients in need of YAG procedures often endure long waits and high travel expenses to see ophthalmologists.
The concern for patient safety is valid; no one wishes to see unqualified practitioners performing risky procedures. Yet, with YAG laser treatments, there is little reason for concern. Optometrists in the U.S. undergo four years of doctoral education in eye care, frequently including YAG surgery. If not included, they must acquire additional training or certification before conducting YAG procedures. A review of nearly 150,000 laser procedures by U.S. optometrists revealed that only 0.001% resulted in adverse outcomes, signifying high safety standards.
In nations like the U.K. and New Zealand, optometrists have safely managed these procedures for years. A policy brief from the Pacific Legal Foundation indicates that when optometrists’ scope of practice includes YAG procedures, utilization substantially rises. Between 2013 and 2023, Medicare patients in states extending optometrists’ scope received 19% more YAG procedures than in restrictive states. Moreover, states that expanded before 2013 observed even higher rates, almost 42% more than restrictive states. This data suggests expanding optometrists’ roles can significantly enhance access to essential eye care.
Patients otherwise untreated due to travel burdens, scheduling delays, or specialty access issues now receive necessary treatments. Two further insights emerge: First, the benefits of expanding practice scopes grow with time, adapting as the market adjusts to new regulations. To achieve maximum long-term gains, states should act promptly. Second, greater increases in YAG utilization relate to non-metropolitan areas, suggesting that isolated patients with severe access barriers benefit most when optometrists are fully utilized.
This reform is not new. Over the last two decades, many states have expanded practice laws for non-physician providers like nurse practitioners, physician assistants, and certified nurse midwives. Evidence overwhelmingly supports these expansions, showing improved access, reduced costs, and more flexible healthcare systems. Optometry should not be excluded from these benefits.
Despite this, opposition from organized ophthalmology groups is expected. These professional disputes are age-old in medicine. The discussion should focus on patient welfare rather than procedural control. As the U.S. population ages, increasing the demand for eye care, the ophthalmologist shortage will escalate. To mitigate care delays, especially in underserved regions, leveraging all available resources is crucial. Giving optometrists more responsibility offers a straightforward and effective way to ensure patients obtain necessary services.
Kihwan Bae, Ph.D. is an assistant professor in the Department of General Business and a research fellow at the Knee Regulatory Research Center in the John Chambers College of Business and Economics at West Virginia University. Liam Sigaud is a research analyst at the Knee Regulatory Research Center at West Virginia University.
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