The Optometry Practice Act provides for the licensure and regulation of the practice of optometry by the State Board of Optometry, and defines the practice of optometry to include, among other things, the prevention and diagnosis of disorders and dysfunctions of the visual system, and the treatment and management of certain disorders and dysfunctions of the visual system, as well as the provision of rehabilitative optometric services, and doing certain things, including, but not limited to, the examination of the human eyes, the determination of the powers or range of human vision, and the prescribing of contact and spectacle lenses. Existing law authorizes an optometrist certified to use therapeutic pharmaceutical agents to diagnose and treat specified conditions, use specified pharmaceutical agents, and order specified diagnostic tests. The act requires optometrists treating or diagnosing eye disease, as specified, to be held to the same standard of care to which physicians and surgeons and osteopathic physician and surgeons are held. The act requires an optometrist, in certain circumstances, to refer a patient to an ophthalmologist or a physician and surgeon, including when a patient has been diagnosed with a central corneal ulcer and the central corneal ulcer has not improved within 48 hours of the diagnosis. The act makes a violation of any of its provisions a crime. All moneys collected pursuant to the act, except where otherwise provided, are deposited in the Optometry Fund and continuously appropriated to the board to carry out the act.

This bill would revise and recast those provisions. The bill would delete certain requirements that an optometrist refer a patient to an ophthalmologist or a physician and surgeon, including when a patient has been diagnosed with a central corneal ulcer and the central corneal ulcer has not improved within 48 hours of the diagnosis. The bill would additionally define the practice of optometry as the provision of habilitative optometric services, and would authorize the board to allow optometrists to use nonsurgical technology to treat any authorized condition under the act. The bill would additionally authorize an optometrist certified to use therapeutic pharmaceutical agents to collect blood by skin puncture or venipuncture, to perform skin tests, as specified, to diagnose ocular allergies, and to use mechanical lipid extraction of meibomian glands and nonsurgical techniques. The bill would require the board to grant an optometrist certified to treat glaucoma a certificate for the use of specified immunizations if certain conditions are met, including, among others, that the optometrist is certified in basic life support. The bill would additionally authorize an optometrist certified to use therapeutic pharmaceutical agents to, among other things, be certified to use anterior segment lasers, as specified, and to be certified to perform specified minor procedures, as specified, if certain requirements are met.

The bill would require the board to charge a fee of not more than $150 to cover the reasonable regulatory cost of certifying an optometrist to use anterior segment lasers, a fee of not more than $150 to cover the reasonable regulatory cost of certifying an optometrist to use minor procedures, and a fee of not more than $100 to cover the reasonable regulatory cost of certifying an optometrist to use immunizations. Because this bill would increase those moneys deposited in a continuously appropriated fund, it would make an appropriation.

Existing law establishes the Office of Statewide Health Planning and Development, which is vested with all the duties, powers, responsibilities, and jurisdiction of the State Department of Public Health relating to health planning and research development.

This bill would declare the intent of the Legislature that the Office of Statewide Health Planning and Development designate a pilot project to test, demonstrate, and evaluate expanded roles for optometrists in the performance of management and treatment of diabetes mellitus, hypertension, and hypercholesterolemia.

Because a violation of the act is a crime, this bill would expand the scope of an existing crime and would, therefore, result in a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

The Optometry Practice Act provides for the licensure and regulation of the practice of optometry by the State Board of Optometry, and defines the practice of optometry to include, among other things, the prevention and diagnosis of disorders and dysfunctions of the visual system, and the treatment and management of certain disorders and dysfunctions of the visual system, as well as the provision of rehabilitative optometric services, and doing certain things, including, but not limited to, the examination of the human eyes, the determination of the powers or range of human vision, and the prescribing of contact and spectacle lenses. Existing law authorizes an optometrist certified to use therapeutic pharmaceutical agents to diagnose and treat specified conditions, use specified pharmaceutical agents, and order specified diagnostic tests. The act requires optometrists treating or diagnosing eye disease, as specified, to be held to the same standard of care to which physicians and surgeons and osteopathic physician and surgeons are held. The act requires an optometrist, in certain circumstances, to refer a patient to an opthamologist ophthalmologist or a physician and surgeon, including when a patient has been diagnosed with a central corneal ulcer and the central corneal ulcer has not improved within 48 hours of the diagnosis. The act makes a violation of any of its provisions a crime. All moneys collected pursuant to the act, except where otherwise provided, are deposited in the Optometry Fund and continuously appropriated to the board to carry out the act.

This bill would revise and recast those provisions. The bill would delete certain requirements that an optometrist refer a patient to an opthamologist ophthalmologist or a physician and surgeon, including when a patient has been diagnosed with a central corneal ulcer and the central corneal ulcer has not improved within 48 hours of the diagnosis. The bill would additionally define the practice of optometry as the provision of habilitative optometric services, and would authorize the board to allow optometrists to use nonsurgical technology to treat any authorized condition under the act. The bill would additionally authorize an optometrist certified to use therapeutic pharmaceutical agents to collect a blood specimen by finger prick method, skin puncture or venipuncture, to perform skin tests, as specified, to diagnose ocular allergies, and to use mechanical lipid extraction of meibomian glands and nonsurgical techniques. The bill would require the board to grant an optometrist certified to treat glaucoma a certificate for the use of specified immunizations if certain conditions are met, including, among others, that the optometrist is certified in basic life support. The bill would additionally authorize an optometrist certified to use therapeutic pharmaceutical agents to, among other things, be certified to use anterior segment lasers, as specified, and to be certified to perform specified minor procedures, as specified, if certain requirements are met.

The bill would require the board to charge a fee of not more than $150 to cover the reasonable regulatory cost of certifying an optometrist to use anterior segment lasers, a fee of not more than $150 to cover the reasonable regulatory cost of certifying an optometrist to use minor procedures, and a fee of not more than $100 to cover the reasonable regulatory cost of certifying an optometrist to use immunizations. Because this bill would increase those moneys deposited in a continuously appropriated fund, it would make an appropriation.

Existing law establishes the Office of Statewide Health Planning and Development, which is vested with all the duties, powers, responsibilities, and jurisdiction of the State Department of Public Health relating to health planning and research development.

This bill would declare the intent of the Legislature that the Office of Statewide Health Planning and Development designate a pilot project to test, demonstrate, and evaluate expanded roles for optometrists in the performance of management and treatment of diabetes mellitus, hypertension, and hypercholesterolemia.

Because a violation of the act is a crime, this bill would expand the scope of an existing crime and would, therefore, result in a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

The Optometry Practice Act provides for the licensure and regulation of the practice of optometry by the State Board of Optometry, and defines the practice of optometry to include, among other things, the prevention and diagnosis of disorders and dysfunctions of the visual system, and the treatment and management of certain disorders and dysfunctions of the visual system, as well as the provision of rehabilitative optometric services, and doing certain things, including, but not limited to, the examination of the human eyes, the determination of the powers or range of human vision, and the prescribing of contact and spectacle lenses. Existing law authorizes an optometrist certified to use therapeutic pharmaceutical agents to diagnose and treat specified conditions, use specified pharmaceutical agents, and order specified diagnostic tests. The act requires optometrists treating or diagnosing eye disease, as specified, to be held to the same standard of care to which physicians and surgeons and osteopathic physician and surgeons are held. The act requires an optometrist, in certain circumstances, to refer a patient to an opthamologist or a physician and surgeon, including when a patient has been diagnosed with a central corneal ulcer and the central corneal ulcer has not improved within 48 hours of the diagnosis. The act makes a violation of any of its provisions a crime. All moneys collected pursuant to the act, except where otherwise provided, are deposited in the Optometry Fund and continuously appropriated to the board to carry out the act.

This bill would revise and recast those provisions. The bill would delete certain requirements that an optometrist refer a patient to an opthamologist or a physician and surgeon, including when a patient has been diagnosed with a central corneal ulcer and the central corneal ulcer has not improved within 48 hours of the diagnosis. The bill would additionally define the practice of optometry as the provision of habilitative optometric services, and would authorize the board to allow optometrists to use nonsurgical technology to treat any authorized condition under the act. The bill would additionally authorize an optometrist certified to use diagnostic therapeutic pharmaceutical agents, as specified, including, but not limited to, oral and topical diagnostic pharmaceutical agents that are not controlled substances. agents to collect a blood specimen by finger prick method, to perform skin tests, as specified, to diagnose ocular allergies, and to use mechanical lipid extraction of meibomian glands and nonsurgical techniques. The bill would authorize an optometrist to independently initiate and administer vaccines, as specified, for a person 3 years of age and older, if the optometrist meets certain requirements, including, but not limited to, require the board to grant an optometrist certified to treat glaucoma a certificate for the use of specified immunizations if certain conditions are met, including, among others, that he or she the optometrist is certified in basic life support for health care professionals. support. The bill would additionally authorize an optometrist certified to use therapeutic pharmaceutical agents to, among other things, be certified to use anterior segment lasers, as specified, and to be certified to perform specified minor procedures, as specified, if certain requirements are met.

The bill would require the board to charge a fee of not more than $150 to cover the reasonable regulatory cost of certifying an optometrist to use anterior segment lasers. lasers, a fee of not more than $150 to cover the reasonable regulatory cost of certifying an optometrist to use minor procedures, and a fee of not more than $100 to cover the reasonable regulatory cost of certifying an optometrist to use immunizations. Because this bill would increase those moneys deposited in a continuously appropriated fund, it would make an appropriation.

Because a violation of the act is a crime, this bill would expand the scope of an existing crime and would, therefore, result in a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

The Vocational Nursing Practice Act provides for the licensure and regulation of the practice of vocational nursing by the Board of Vocational Nursing and Psychiatric Technicians within the Department of Consumer Affairs. The act requires the board to consist of 11 members, including one member that is a licensed vocational nurse or registered nurse who has had no less than 5 years experience as a teacher or administrator in an accredited school of vocational nursing.

This bill would require that the vocational nurse or registered nurses experience be in an accredited school of vocational nursing approved by the board.

Date of Hearing:

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Rudy Salas, Chair

SBPCA Bill Id:

Author:() – As Ver:

SENATE VOTE:

SUBJECT:

SUMMARY: This bill expands the scope of practice for optometrists to include the use noninvasive, nonsurgical technology to treat a condition authorized by the Optometric Act (Act), perform laser and minor procedures, and administer certain vaccines.

EXISTING LAW:

1. Establishes the California Board of Optometry (Board), within the Department of Consumer Affairs (DCA), which licenses optometrists and regulates the practice of optometry. (BPC § 3010.5)
2. Authorizes the Board to establish educational and examination requirements for licensure. (BPC § 3041.2)
3. Defines the practice of optometry as follows:
   1. Prevention and diagnosis of disorders and dysfunctions of the visual system;
   2. Treatment and management of certain disorders and dysfunctions of the visual systems;
   3. Provision of rehabilitative optometric services;
   4. Examination of the human eyes;
   5. Determination of the powers or range of human vision;
   6. Prescribing or directing the use of any optical device in connection with ocular exercises, visual training, vision training or orthoptics;
   7. Prescribing of contact lenses and glasses; and,
   8. Use of topical pharmaceutical agents for the purpose of the examination of the human eye or eyes for any disease or pathological condition. (BPC § 3041)
4. Specifies that an optometrist who is certified to use therapeutic pharmaceutical agents may also diagnose and treat the human eye or eyes or any of its appendages for the following conditions:
   1. Infections;
   2. Ocular allergies;
   3. Ocular inflammation, non-surgical in cause except when co-managed with the treating physician and surgeon;
   4. Traumatic or recurrent conjunctival or corneal abrasions and erosions;
   5. Corneal surface disease and dry eyes;
   6. Ocular pain, non-surgical in cause except when co-managed with the treating physician and surgeon; and,
   7. Glaucoma in patients over the age of 18. (BPC § 3041(b)(1))
5. Permits optometrists to use the following therapeutic pharmaceutical agents:
   1. Topical miotics;
   2. Topical lubricants;
   3. Anti-allergy agents;
   4. Topical and oral anti-inflammatories;
   5. Topical antibiotic agents;
   6. Topical hyperosmotics;
   7. Topical and oral anti-glaucoma agents;
   8. Non-prescription medications;
   9. Oral antihistamines;
   10. Prescription oral non-steroidal anti-inflammatory agents;
   11. Oral antibiotics for treatment of ocular disease;
   12. Topical and oral antiviral medication for treatment of:
       1. Herpes;
       2. Viral Keratitis;
       3. Herpes Simplex Viral conjunctivitis;
       4. Periocular herpes simplex viral dermatitis;
       5. Varicella zoster viral keratitis;
       6. Varicella zoster viral conjunctivitis; and,
       7. Periocular varicella zoster viral dermatitis;
   13. Oral analgesics that are not controlled substances; and,
   14. Codeine with compounds and hydrocodone with compounds with specific restrictions regarding usage timeframe. (BPC § 3041(c))
6. Specifies that an optometrist who is certified to use therapeutic pharmaceutical agents may also perform the following:
   1. Corneal scraping with cultures;
   2. Debridement of corneal epithelia;
   3. Mechanical epilation;
   4. Venipuncture for testing patients suspected of having diabetes;
   5. Suture removal, with prior consultation with the treating physician and surgeon;
   6. Treatment or removal of sebaceous cysts by expression;
   7. Administration of oral fluorescein to patients suspected as having diabetic retinopathy;
   8. Use of an auto-injector to counter anaphylaxis;
   9. Ordering of smears, cultures, sensitivities, complete blood count, mycobacterial culture, acid fast stain, urinalysis, tear fluid analysis and X-rays necessary for the diagnosis of conditions or diseases of the eye or adnexa;
   10. A clinical laboratory test or examination classified as waived under CLIA

necessary for the diagnosis of conditions and diseases of the eye or adnexa;

• 1. Punctal occlusion by plugs, excluding laser, diathermy, cryotherapy or other means constituting surgery;
  2. The prescription of therapeutic contact lenses, including lenses or devices that incorporate a medication or therapy the optometrist is certified to prescribe or provide;
  3. Removal of foreign bodies from the cornea, eyelid and conjunctiva with any appropriate instrument other than a scalpel or needle; and,
  4. Lacrimal irrigation and dilation, excluding probing of the nasal lacrimal tract for patients over 12 years of age. (BPC § 3401(e))

THIS BILL:

1. Requires the Board to establish educational and examination requirements for licensure to ensure the competence of optometrists to use anterior segment lasers and perform minor procedures. Specifies that satisfactory completion of the required educational and examination requirements shall be a condition for the issuance of an original optometrist license or required certifications. 
2. Specifies that the Board may promulgate regulations authorizing optometrists to use noninvasive, nonsurgical technology to treat conditions, as specified. Further states that the Board shall require a licensee to take a minimum of four hours of education courses on the new technology and perform an appropriate number of complete clinical procedures on live human patients to qualify to use each new technology authorized by the Board. 
3. Indicates that an optometrist who is certified to use therapeutic pharmaceutical agents may also diagnose and treat the human eye or eyes, or any of its or their appendages, for all of the following conditions:
   1.  Through medical treatment, infections of the anterior segment and adnexa;
   2. Ocular allergies of the anterior segment and adnexa;
   3. Ocular inflammation, nonsurgical in cause except when comanaged with the treating physician and surgeon, limited to inflammation resulting from traumatic iritis, peripheral corneal inflammatory keratitis, episcleritis, and unilateral nonrecurrent nongranulomatous idiopathic iritis in patients over 18 years of age;
   4. Traumatic or recurrent conjunctival or corneal abrasions and erosions;
   5.  Corneal and conjunctival surface disease and dry eyes disease;
   6. Ocular pain that is nonsurgical in cause, except when comanaged with the treating physician and surgeon; and,
   7. Hypotrichosis and blepharitis;
4. Defines “adnexa” to mean ocular adnexa.
5. Specifies that in diagnosing and treating the conditions listed above, an optometrist certified to use therapeutic pharmaceutical agents may use all of the following therapeutic pharmaceutical agents:
   1.  Topical pharmaceutical agents for the purpose of the examination of the human eye or eyes for any disease or pathological condition, including, but not limited to, topical miotics;
   2.  Topical lubricants;
   3.  Antiallergy agents. In using topical steroid medication for the treatment of ocular allergies, an optometrist shall consult with an ophthalmologist if the patient’s condition worsens 21 days after diagnosis;
   4. Topical and oral anti-inflammatories;
   5. Topical antibiotic agents;
   6. Topical hyperosmotics;
   7. Topical and oral antiglaucoma agents pursuant to the certification process, as specified;
   8. Nonprescription medications used for the rational treatment of an ocular disorder;
   9. Oral antihistamines;
   10. Prescription oral nonsteroidal anti-inflammatory agents;
   11. Oral antibiotics for medical treatment of ocular disease;
   12. Topical and oral antiviral medication for the medical treatment of herpes simplex viral keratitis, herpes simplex viral conjunctivitis, periocular herpes simplex viral dermatitis, varicella zoster viral keratitis, varicella zoster viral conjunctivitis, and periocular varicella zoster viral dermatitis;
   13. Oral analgesics that are not controlled substances; and,
   14. Codeine with compounds and hydrocodone with compounds—the use of these agents shall be limited to five days, with a referral to an ophthalmologist if the pain persists.
6. Authorizes an optometrist who is certified to use therapeutic pharmaceutical agents to perform all of the following:
   1. Corneal scraping with cultures;
   2. Debridement of corneal epithelia;
   3. Mechanical epilation;
   4. Collection of blood by skin puncture or venipuncture for testing patients suspected of having diabetes;
   5. Suture removal, with prior consultation with the treating health care provider;
   6. Treatment or removal of sebaceous cysts by expression;
   7. Administration of oral fluorescein to patients suspected as having diabetic retinopathy;
   8. Use of an auto-injector to counter anaphylaxis;
   9. Ordering of smears, cultures, sensitivities, complete blood count, mycobacterial culture, acid fast stain, urinalysis, tear fluid analysis, and X-rays necessary for the diagnosis of conditions or diseases of the eye or adnexa. An optometrist may order other types of images subject to prior consultation with an ophthalmologist or appropriate physician and surgeon;
   10. A clinical laboratory test or examination classified as waived under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) (42 U.S.C. Sec. 263a; Public Law 100-578) necessary for the diagnosis of conditions and diseases of the eye or adnexa, to detect systemic disease with ocular effects;
   11. Skin test to diagnose ocular allergies. Skin tests shall be limited to the superficial layer of the skin;
   12. Punctal occlusion by plugs, excluding laser, diathermy, cryotherapy, or other means constituting surgery as specified;
   13. The prescription of therapeutic contact lenses, diagnostic contact lenses, or biological or technological corneal devices that diagnose or treat a condition, as specified;
   14. Removal of foreign bodies from the cornea, eyelid, and conjunctiva with any appropriate instrument other than a scalpel. Corneal foreign bodies shall be nonperforating, be no deeper than the midstroma, and require no surgical repair upon removal;
   15. For patients over 12 years of age, lacrimal irrigation and dilation, excluding probing of the nasal lacrimal tract;
       1. The Board shall certify any optometrist who graduated from an accredited school of optometry before May 1, 2000, to perform this procedure after submitting proof of satisfactory completion and confirmation of 10 procedures under the supervision of an ophthalmologist or optometrist who is certified in lacrimal irrigation and dilation. Any optometrist who graduated from an accredited school of optometry on or after May 1, 2000, shall be exempt from the certification requirement.
   16. Use of mechanical lipid extraction of meibomian glands and nonsurgical techniques.
7.  Specifies that In order to be certified to use therapeutic pharmaceutical agents and authorized to diagnose and treat the conditions listed above, an optometrist shall apply for a certificate from the Board and meet all requirements imposed by the Board.
8. Authorizes the Board to grant a certificate to use therapeutic pharmaceutical agents to any applicant who graduated from a California accredited school of optometry prior to January 1, 1996, is licensed as an optometrist in California, and meets specified education and training requirements
9. Authorizes the Board to grant a certificate to use therapeutic pharmaceutical agents to any applicant who graduated from a California accredited school of optometry on or after January 1, 1996, who is licensed as an optometrist in California, and who meets specified training and education requirements:
10.  Indicates that other than for prescription ophthalmic devices as specified, any dispensing of a therapeutic pharmaceutical agent by an optometrist shall be without charge.
11.  Specifies that the practice of optometry does not include performing surgery. “Surgery” means any procedure in which human tissue is cut, altered, or otherwise infiltrated by mechanical or laser means, as specified.
12. Specifies an optometrist’s authority to utilize diagnostic laser and ultrasound technology within his or her scope of practice.
13. States that in an emergency, an optometrist shall stabilize, if possible, and immediately refer any patient who has an acute attack of angle closure to an ophthalmologist.
14. Defines “glaucoma” as:
    1. All primary open-angle glaucoma;
    2. Exfoliation and pigmentary glaucoma;
    3. Increase in intraocular pressure caused by steroid medication prescribed by the optometrist; and,
    4. Increase in intraocular pressure caused by steroid medication not prescribed by the optometrist, after consultation and treatment approval by the prescribing physician.
15. Specifies requirements for optometrists certified for the treatment of glaucoma, in patients over 18 years of age.
16. Defines “anterior segment laser” as any of the following:
    1. Therapeutic lasers appropriate for treatment of glaucoma;
    2. Peripheral iridotomy for the prophylactic treatment of angle closure glaucoma; and,
    3. Therapeutic lasers used for posterior capsulotomy secondary to cataract surgery.
17. States that an optometrist certified to treat glaucoma shall be additionally certified for the use of anterior segment lasers after submitting proof of satisfactory completion of a course that is approved by the Board, provided by an accredited school of optometry, and developed in consultation with an ophthalmologist who has experience educating optometric students. The Board shall issue a certificate only to an optometrist that has graduated from an approved school of optometry.
18. Indicates that the Board-approved course shall be at least 25 hours in length, and include a test for competency of the following:
    1. Laser physics, hazards, and safety;
    2. Biophysics of laser;
    3. Laser application in clinical optometry;
    4. Laser tissue interactions;
    5. Laser indications, contraindications, and potential complications;
    6. Gonioscopy;
    7. Laser therapy for open-angle glaucoma;
    8. Laser therapy for angle closure glaucoma;
    9. Posterior capsulotomy;
    10. Common complications of the lids, lashes, and lacrimal system;
    11. Medicolegal aspects of anterior segment procedures;
    12. Peripheral iridotomy; and,
    13. Laser trabeculoplasty.
19. States that the school of optometry shall require each applicant for certification to perform a sufficient number of complete anterior segment laser procedures to verify that the applicant has demonstrated competency to practice independently. At a minimum, each applicant shall complete 24 anterior segment laser procedures on live humans as follows:
    1. Eight YAG capsulotomy procedures;
    2. Eight laser trabeculoplasty procedures; and,
    3. Eight peripheral iridotomy procedures.
20. Requires the Board, by regulation, to set the fee for issuance and renewal of a certificate authorizing the use of anterior segment lasers at an amount no higher than the reasonable cost of regulating anterior segment laser certified optometrists, as specified. The fee shall not exceed one hundred fifty dollars ($150).
21. Requires an optometrist certified to use anterior segment lasers to complete four hours of continuing education on anterior segment lasers as part of the required 50 hours of continuing education required to be completed every two years on the diagnosis, treatment, and management of glaucoma.
22.  Defines “minor procedure” as any of the following:
    1. Removal, destruction, or drainage of lesions of the eyelid and adnexa clinically evaluated by the optometrist to be noncancerous, not involving the eyelid margin, lacrimal supply or drainage systems, no deeper than the orbicularis muscle, and smaller than five millimeters in diameter;
    2. Closure of a wound resulting from a procedure, as specified; or,
    3. Administration of injections for the diagnoses or treatment of conditions of the eye and adnexa authorized by this chapter, excluding intraorbital injections and injections administered for cosmetic effect.
23. Specifies that “minor procedures” do not include blepharoplasty or other cosmetic surgery procedures that reshape normal structures of the body in order to improve appearance and self-esteem.
24. Indicates that an optometrist certified to treat glaucoma shall be additionally certified to perform minor procedures after submitting proof of satisfactory completion of a course that is approved by the Board, provided by an accredited school of optometry, and developed in consultation with an ophthalmologist who has experience teaching optometric students. The Board shall issue a certificate pursuant to this section only to an optometrist that has graduated from an approved school of optometry.
25. Requires that the Board-approved course be at least 25 hours in length and include a test for competency of the following:
    1. Minor surgical procedures;
    2. Overview of surgical instruments, asepsis, and the state and federal Occupational Safety and Health Administrations;
    3. Surgical anatomy of the eyelids;
    4. Emergency surgical procedures;
    5. Chalazion management;
    6. Epiluminescence microscopy;
    7. Suture techniques;
    8. Local anesthesia techniques and complications;
    9. Anaphylaxsis and other office emergencies;
    10. Radiofrequency surgery;
    11. Postoperative wound care; and,
    12. Injection techniques.
26. Requires the school of optometry to require each applicant for certification to perform a sufficient number of minor procedures to verify that the applicant has demonstrated competency to practice independently. At a minimum, each applicant shall perform 32 complete minor procedures on live humans.
27. Authorizes the Board, by regulation, to set the fee for issuance and renewal of a certificate authorizing the use of minor procedures at an amount no greater than the reasonable cost of regulating minor procedure certified optometrists pursuant to this section. The fee shall not exceed one hundred fifty dollars ($150).
28. Requires an optometrist certified to perform minor procedures to complete five hours of continuing education on the diagnosis, treatment, and management of lesions of the eyelid and adnexa as part of the 50 hours of continuing education required every two years.
29.  Authorizes the Board to grant to an optometrist a certificate for the use of immunizations, if the optometrist is certified and has met all of the following requirements:
    1. Completes an immunization training program endorsed by the federal Centers for Disease Control and Prevention (CDC) that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and maintains that training;
    2. Is certified in basic life support; and,
    3. Complies with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient’s primary care provider and entering information in the appropriate immunization registry designated by the immunization branch of the State Department of Public Health.
30. Defines “immunization” as the administration of immunizations for influenza, herpes zoster virus, and pneumococcus in compliance with individual Advisory Committee on Immunization Practices (ACIP) vaccine recommendations published by the CDC for persons 18 years of age or older.
31. Authorizes the Board, by regulation, to set the fee for issuance and renewal of a certificate for the use of immunizations at the reasonable cost of regulating immunization certified optometrists. The fee shall not exceed one hundred dollars ($100).
32.  Subjects optometrists to laws regarding the purposes of practicing telehealth.
33. Indicates that optometrists diagnosing or treating eye disease shall be held to the same standard of care to which physicians and surgeons and osteopathic physicians and surgeons are held. An optometrist shall consult with and, if necessary, refer to a physician and surgeon or other appropriate health care provider when a situation or condition occurs that is beyond the optometrist’s scope of practice.
34. Declares that it is the intent of the Legislature that the Office of Statewide Health Planning and Development, under the Health Workforce Pilot Projects Program, designate a pilot project to test, demonstrate, and evaluate expanded roles for optometrists in the performance of management and treatment of diabetes mellitus, hypertension, and hypercholesterolemia.

FISCAL EFFECT: Unknown. This bill has been keyed fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the author. According to the author, “While merely 16 of California’s 58 counties meet the needed supply range for primary care physicians, we do have a robust network of providers that are well-trained, evenly distributed throughout the state, regulated by the [DCA] and well positioned to pay particular attention to currently underserved areas. Optometrists are one such provider group who receive a doctorate level training preparing them to be primary eye care providers, and independently diagnose and treat conditions of the eye. [This bill] will remove restrictions in current law to permit optometrists to examine, prevent, diagnose, and treat conditions and disorders of the visual system and the human eye to the full extent of their training. This includes the use of two types of therapeutic lasers by optometrists with postdoctoral advanced certification that have been developed for treatment of glaucoma and post-surgical cataract care, conditions that disproportionately affect patient groups that generally lack sufficient access to physicians. [This bill] is a limited expansion of scope for optometrists that is consistent with their education and training, and is a logical advancement of the profession that has been proven safe in other states. Moreover, the educational requirements contained in this bill are substantially greater than those required of optometrists in other states and exceed the minimum number of these procedures required for ophthalmologists by the Accreditation Council for Graduate Medical Education.”

Background. According to a report prepared by the Center for the Health Professions at the University of California San Francisco, the number of optometrist licenses in California has declined, but the number of licensees with a secondary practice location has increased. According to the Board, there are over 7,000 licensed optometrists in California, the largest population of optometrists in the United States. The majority of the licensed optometrists are generally concentrated in coastal counties, the Bay Area and counties in the Sacramento region. Several counties have no licensed optometrists with an address of record in those counties, and a number of other counties have ratios that indicate there is approximately one optometrist for every 10,000 people.

Optometrists’ and Ophthalmologists’ Education, Training, and Scope.  This bill would expand the types of procedures an optometrist is authorized to perform.  This would include some tasks that have been traditionally performed by ophthalmologists.  As such, the current education, training and scope of each profession is outlined below. 

• Optometrists.  Optometrists are trained to diagnose mild to severe eye problems such as serious eye infections, inflammations of the eye, trauma, foreign bodies and glaucoma.  They also examine the eye for vision prescription and corrective lenses. 

After completion of an undergraduate degree, optometrists complete four years of and accredited optometry college after which they are awarded the Doctor of Optometry degree. Some optometrists also undertake an optional one year non-surgical residency program to enhance their experience in a particular area.  Students graduate with 2500 to 3000 patient encounters; these include a mix of post-surgical, medical and routine visits.

Optometrists who graduated from an accredited school or college of optometry on or after May 1, 2008 receive certifications to use diagnostic pharmaceutical agents (DPA); to administer therapeutic pharmaceutical agents (TPA); to perform lacrimal irrigation and dilation (TPL); and to diagnose and treat primary open angle glaucoma (TLG).  Optometrists who did not receive these certifications upon licensure may apply for these certifications after meeting the necessary requirements. In order to be certified, the optometrist must pass an exam, obtain a license to practice optometry, be certified by and accredited school of optometry that they are competent in the diagnosis, treatment and management of ocular systemic disease, and complete 10 hours of supervised practice with an ophthalmologist.

• Ophthalmologists. The central focus of ophthalmology is surgery and management of complex eye diseases. An ophthalmologist specializes in the refractive, medical and surgical care of the eyes and visual system and in the prevention of disease and injury.

After obtaining an undergraduate degree, ophthalmologists complete four years at an accredited medical school and earn a Medical Degree. This is followed by a one year internship and a three or four year surgical residency. Many ophthalmologists pursue additional fellowship training in specialized areas such as retina, glaucoma, or cornea. Ophthalmologists may become certified by the American Board of Ophthalmology, which requires, serving as the primary surgeon or first assistant to the primary surgeon for a minimum of 364 eye surgeries.

Other States. Since 1997, there have been over 45 attempts in over 20 states by optometry associations to expand the scope of practice for optometrists including legislating surgery privileges. However, with the exception of Oklahoma and West Virginia, most states continue to prohibit optometrists from performing surgery, and their statutes specify that the license to practice optometry does not include the right to practice medicine. States such as Colorado and North Carolina specifically exclude surgery from their definition of the practice of optometry. Other states have statutes that delineate between laser and non-laser surgery. Optometrists are authorized to prescribe oral medications in all 50 states, they may prescribe oral steroids in 34 states, injections in 15 states and use lasers in 1 state.

Prior Related Legislation. SB 492 (Hernandez) of 2013, would have permitted an optometrist to diagnose treat and manage additional conditions with ocular manifestations, directed the Board to establish educational and examination requirements and would have permitted optometrists to perform vaccinations and surgical and non-surgical primary care procedures. NOTE: This bill died on the Assembly inactive file.

SB 668 (Polanco) Chapter 13, Statutes of 1996, expanded the scope of practice of optometrists to provide for the diagnosis and treatment of specified conditions or diseases of the human eye or its appendages, and to use other therapeutic pharmaceutical agents.

SB 929 (Polanco) Chapter 676, Statutes of 2000, expanded the scope of lawful practice for optometrists by specifying additional diseases and conditions that optometrists may treat (in particular certain types of glaucoma) with specified medications, and by specifying the extent of physician involvement that is required under various circumstances.

SB 1406 (Correa) Chapter 352, Statutes of 2008, specified permissible procedures for certified optometrists, and created the Glaucoma Diagnosis and Treatment Advisory Committee to establish glaucoma certification requirements.

AMENDMENTS:

1. The author outlines the need for additional health care practitioners to be permitted to administer vaccines to patients. As such, the author should strike all contents of the bill, with the exception of the provisions authorizing an optometrist to, after completing training as specified in the bill, be certified by the Board to provide the following vaccinations: 1) influenza, 2) herpes zoster virus, and 3) pneumococcus for persons 18 years of age or older.
2. The current bill specifies the number of hours of training that an optometrist must complete in order to enjoy an expanded scope of practice. As there has been much debate about training, education, competence, and appropriateness of expanding the scope of practice for optometrists, the author should instead amend the bill to create a task force under the Board, including those most qualified to review the education and training of optometrists, and determine the hours of training and education needed to perform the following procedures: 1) YAG capsulotomy procedures, 2) laser trabeculoplasty procedures, and 3) peripheral iridotomy procedures.

The members of the task force should be appointed by the Director of the Department of Consumer Affairs by May 1, 2017. The task force should include: one professor of optometry, one practicing optometrist, one professor of ophthalmology, one practicing ophthalmologist, and one member of the public who has never been licensed by, or appointed to, the Board or the Medical Board of California.

The taskforce shall submit a report with recommendations on what the expanded scope for optometrists should include, as it pertains to the three specified procedures above, to the Governor, the President pro Tempore of the Senate, the Speaker of the Assembly, the Assembly Committee on Business and Professions, and the Senate Committee on Business, Professions and Economic Development, by May 1, 2018, on which date the task force shall cease to exist.

REGISTERED SUPPORT:

California Optometric Association

747 individuals

REGISTERED OPPOSITION:

American Academy of Dermatology Association

American Academy of Ophthalmology

American Association for Pediatric Ophthalmology and Strabismus

American College of Surgeons

American Glaucoma Society

American Medical Association

American Society of Cataract and Refractive Surgery

American Society of Ophthalmic Plastic and Reconstructive Surgery

American Society of Retina Specialists

Blind Children's Center

California Academy of Eye Physicians and Surgeons (unless amended)

California Academy of Family Physicians

California Black Chamber of Commerce

California Black Health Network

California Medical Association

California Society of Plastic Surgeons, Inc.

Capitol City Church

CB Communications

Faith in Action

Health & Human Resource Education Center

Inner Beauty

International Black Health Alliance

Let’s Face it Together

Lighthouse for Christ Mission

Medical Board of California (unless amended)

Sacramento Black Chamber of Commerce

Sacramento Cultural Hub

San Diego Black Health Associates

Stanford University School of Medicine

The Green Foundation

Over 400 individuals

Analysis Prepared by: Le Ondra Clark Harvey, Ph.D. / B. & P. / (916) 319-3301

Date of Hearing: July 14, 2015

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Susan Bonilla, Chair

SBPCA Bill Id:SB 622

Author:(Hernandez) – As Amended Ver:May 4, 2015

SENATE VOTE: 33-4

SUBJECT: Optometry

SUMMARY: This bill expands the scope of practice for optometrists to include the expanded ability to order Clinical Laboratory Improvement Amendments (CLIA)-waived tests, use noninvasive, nonsurgical technology to treat a condition authorized by the Optometric Act (Act), perform laser and minor procedures, and administer certain vaccines.

EXISTING LAW:

1. Establishes the California Board of Optometry (Board), within the Department of Consumer Affairs (DCA), which licenses optometrists and regulates the practice of optometry. (BPC § 3010.5)

2. Authorizes the Board to establish educational and examination requirements for licensure. (BPC § 3041.2)

3. Defines the practice of optometry as follows: (BPC § 3041)

1. Prevention and diagnosis of disorders and dysfunctions of the visual system;

2. Treatment and management of certain disorders and dysfunctions of the visual systems;

3. Provision of rehabilitative optometric services;

4. Examination of the human eyes;

5. Determination of the powers or range of human vision;

6. Prescribing or directing the use of any optical device in connection with ocular exercises, visual training, vision training or orthoptics;

7. Prescribing of contact lenses and glasses; and,

8. Use of topical pharmaceutical agents for the purpose of the examination of the human eye or eyes for any disease or pathological condition.

4. Specifies that an optometrist who is certified to use therapeutic pharmaceutical agents may also diagnose and treat the human eye or eyes or any of its appendages for the following conditions: (BPC § 3041(b)(1))

1. Infections;

2. Ocular allergies;

3. Ocular inflammation, non-surgical in cause except when co-managed with the treating physician and surgeon;

4. Traumatic or recurrent conjunctival or corneal abrasions and erosions;

5. Corneal surface disease and dry eyes;

6. Ocular pain, non-surgical in cause except when co-managed with the treating physician and surgeon; and,

7. Glaucoma in patients over the age of 18.

5. Permits optometrists to use the following therapeutic pharmaceutical agents: (BPC § 3041(c))

1. Topical miotics;

2. Topical lubricants;

3. Anti-allergy agents;

4. Topical and oral anti-inflammatories;

5. Topical antibiotic agents;

6. Topical hyperosmotics;

7. Topical and oral anti-glaucoma agents;

8. Non-prescription medications;

9. Oral antihistamines;

10. Prescription oral non-steroidal anti-inflammatory agents;

11. Oral antibiotics for treatment of ocular disease;

12. Topical and oral antiviral medication for treatment of:

1. Herpes;

2. Viral Keratitis;

3. Herpes Simplex Viral conjunctivitis;

4. Periocular herpes simplex viral dermatitis;

5. Varicella zoster viral keratitis;

6. Varicella zoster viral conjunctivitis; and,

7. Periocular varicella zoster viral dermatitis;

13. Oral analgesics that are not controlled substances; and,

14. Codeine with compounds and hydrocodone with compounds with specific restrictions regarding usage timeframe.

6. Specifies that an optometrist who is certified to use therapeutic pharmaceutical agents may also perform the following: (BPC § 3401(e))

1. Corneal scraping with cultures;

2. Debridement of corneal epithelia;

3. Mechanical epilation;

4. Venipuncture for testing patients suspected of having diabetes;

5. Suture removal, with prior consultation with the treating physician and surgeon;

6. Treatment or removal of sebaceous cysts by expression;

7. Administration of oral fluorescein to patients suspected as having diabetic retinopathy;

8. Use of an auto-injector to counter anaphylaxis;

9. Ordering of smears, cultures, sensitivities, complete blood count, mycobacterial culture, acid fast stain, urinalysis, tear fluid analysis and X-rays necessary for the diagnosis of conditions or diseases of the eye or adnexa;

10. A clinical laboratory test or examination classified as waived under CLIA necessary for the diagnosis of conditions and diseases of the eye or adnexa;

11. Punctal occlusion by plugs, excluding laser, diathermy, cryotherapy or other means constituting surgery;

12. The prescription of therapeutic contact lenses, including lenses or devices that incorporate a medication or therapy the optometrist is certified to prescribe or provide;

13. Removal of foreign bodies from the cornea, eyelid and conjunctiva with any appropriate instrument other than a scalpel or needle; and,

14. Lacrimal irrigation and dilation, excluding probing of the nasal lacrimal tract for patients over 12 years of age.

THIS BILL:

1. Requires the Board to establish educational and examination requirements by regulation for licensure to ensure the competence of optometrists to practice pursuant to the Act, except as specified in the sections related to certification for minor procedures and lasers.

2. Adds “habilitative services” to the definition of the practice of optometry.

3. Authorizes the Board to promulgate regulations authorizing optometrists to use noninvasive, nonsurgical technology to treat a condition authorized by the Act. To qualify to use each new technology authorized, the Board shall require a licensee to take a minimum of four hours of education and perform an appropriate number of complete clinical procedures on live human patients.

4. Removes referral requirements related to the treatment of ocular inflammation, as specified.

5. Allows an optometrist to treat hypotrichosis and blepharitis.

6. Adds “conjunctival” to the types of surface diseases that an optometrist who is certified to use therapeutic pharmaceutical agents may diagnose and treat.

7. Removes exceptions to the types of infections of the anterior segment and adnexa that an optometrist may treat.

8. Removes referral protocols for the use of certain drugs.

9. Expands ability to order CLIA waived tests.

10. Extends from three to five days the time that codeine with compounds and hydrocodone with specified compounds may be used.

11. Allows an optometrist to collect a blood specimen by finger prick method.

12. Permits an optometrist to perform a skin test on the superficial layer of the skin to diagnose ocular allergies.

13. Allows an optometrist to prescribe biological or technological corneal devices.

14. Allows an optometrist to use a needle to remove objects from the cornea, eyelid, and conjunctiva.

15. Authorizes an optometrist to use mechanical lipid extraction on meibomian glands and nonsurgical techniques.

16. Authorizes an optometrist, as part of additional “minor procedures,” to administer injections for the diagnosis or treatment of conditions of the eye and adnexa authorized by the Act, excluding intraorbital injections and injections administered for cosmetic effect.

17. Expands the definition of glaucoma to include an “increase in intraocular pressure caused by steroid medication,” but specifies that an optometrist may only treat this type of glaucoma if the optometrist has prescribed the steroid, or has consulted with and received approval from the prescriber.

18. Expands the definition of glaucoma to include an “increase in intraocular pressure caused by steroid medication.”

19. Establishes a certification process for an optometrist to perform certain laser procedures, requiring 25 hours of education and 24 complete clinical procedures on live human patients.

20. Establishes continuing education hours for optometrists certified to perform laser procedures.

21. Establishes a certification course for an optometrist to perform minor procedures.

22. Defines minor procedures as removal, destruction, or drainage of lesions of the eyelid and adnexa clinically evaluated by the optometrist to be non-cancerous, not involving the eyelid margin, lacrimal supply or drainage systems, no deeper than the orbicularis muscle, and smaller than five millimeters in diameter, and closure of a wound, as specified. Specifies that minor procedures do not include blepharoplasty or other cosmetic surgery procedures that reshape normal structures of the body in order to improve appearance and self-esteem.

23. Requires 25 hours of education and 32 complete clinical procedures on live human patients.

24. Establishes continuing education requirements for optometrists certified to perform minor procedures.

25. Authorizes an optometrist to earn a certificate to administer immunizations for influenza, herpes zoster, and pneumococcus if the optometrist does all of the following:

1. Completes an immunization training program endorsed by the Centers for Disease Control and Prevention, or the Accreditation Council for Pharmacy Education that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and shall maintain that training;

2. Is certified in basic life support for health care professionals; and,

3. Complies with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient’s primary care provider and entering information in the appropriate immunization registry designated by the immunization branch of the State Department of Public Health.

26. Defines unprofessional conduct to include failure for an optometrist to refer a patient to an appropriate physician if an examination of the eyes indicates a substantial likelihood of any pathology that requires the attention of that physician.

FISCAL EFFECT: According to the May 4, 2015 Senate Appropriations Committee analysis, this bill will result in costs of less than $150,000 to develop and update regulations by the Board. The bill will also result in minor costs to grant certifications to certain optometrists and enforce licensing regulations on those optometrists. The Board anticipates that a small number of optometrists will seek additional, post-graduate certification to perform additional procedures under the bill. Therefore, the additional licensing cost to issue those certifications and any additional enforcement activities relating to those new duties are expected to be minor. Minor costs are also anticipated for the Office of Statewide Health Planning and Development (OSHPD) to oversee a future Health Workforce Pilot Project relating to optometry. Under current practice, the costs of developing and managing a pilot project are borne by the sponsoring academic institution. The costs to the OSHPD to authorize and review any new pilot project are minor.

COMMENTS:

Purpose. This bill is sponsored by the author. According to the author, “While merely 16 of California’s 58 counties meet the needed supply range for primary care physicians, we do have a robust network of providers that are well-trained, evenly distributed throughout the state, regulated by the [DCA] and well positioned to pay particular attention to currently underserved areas. Optometrists are one such provider group who receive a doctorate level training preparing them to be primary eye care providers, and independently diagnose and treat conditions of the eye. [This bill] will remove restrictions in current law to permit optometrists to examine, prevent, diagnose, and treat conditions and disorders of the visual system and the human eye to the full extent of their training. This includes the use of two types of therapeutic lasers by optometrists with postdoctoral advanced certification that have been developed for treatment of glaucoma and post-surgical cataract care, conditions that disproportionately affect patient groups that generally lack sufficient access to physicians. [This bill] is a limited expansion of scope for optometrists that is consistent with their education and training, and is a logical advancement of the profession that has been proven safe in other states. Moreover, the educational requirements contained in this bill are substantially greater than those required of optometrists in other states and exceed the minimum number of these procedures required for ophthalmologists by the Accreditation Council for Graduate Medical Education.”

Background. According to a report prepared by the Center for the Health Professions at the University of California San Francisco, the number of optometrist licenses in California has declined, but the number of licensees with a secondary practice location has increased. According to the Board, there are approximately 7,565 licensed optometrists in California, the largest population of optometrists in the United States. Approximately 7,500 of these optometrists are certified to administer diagnostic pharmaceutical agents. The majority of the licensed optometrists are generally concentrated in coastal counties, the Bay Area and counties in the Sacramento region. Several counties have no licensed optometrists with an address of record in those counties, and a number of other counties have ratios that indicate there is approximately one optometrist for every 10,000 people.

Optometrists’ and Ophthalmologists’ Education, Training and Scope.  This bill would expand the types of procedures an optometrist is authorized to perform.  This would include some tasks that have been traditionally performed by ophthalmologists.  As such, the current education, training and scope of each profession is outlined below. 

Optometrists.  Optometrists are trained to diagnose mild to severe eye problems such as serious eye infections, inflammations of the eye, trauma, foreign bodies and glaucoma.  They also examine the eye for vision prescription and corrective lenses. 

After completion of an undergraduate degree, optometrists complete four years of and accredited optometry college after which they are awarded the Doctor of Optometry degree. Some optometrists also undertake an optional one year non-surgical residency program to enhance their experience in a particular area.  Students graduate with 2500 to 3000 patient encounters; these include a mix of post-surgical, medical and routine visits.

Optometrists who graduated from an accredited school or college of optometry on or after May 1, 2008 receive certifications to use diagnostic pharmaceutical agents (DPA); to administer therapeutic pharmaceutical agents (TPA); to perform lacrimal irrigation and dilation (TPL); and to diagnose and treat primary open angle glaucoma (TLG).  Optometrists who did not receive these certifications upon licensure may apply for these certifications after meeting the necessary requirements. In order to be certified, the optometrist must pass an exam, obtain a license to practice optometry, be certified by and accredited school of optometry that they are competent in the diagnosis, treatment and management of ocular systemic disease and complete 10 hours of experience with an ophthalmologist.

Ophthalmologists. The central focus of ophthalmology is surgery and management of complex eye diseases. An ophthalmologist specializes in the refractive, medical and surgical care of the eyes and visual system and in the prevention of disease and injury.

After obtaining an undergraduate degree, ophthalmologists complete four years at an accredited medical school and earn a Medical Degree. This is followed by a one year internship and a three or four year surgical residency. Many ophthalmologists pursue additional fellowship training in specialized areas such as retina, glaucoma or cornea. Ophthalmologists may become certified by the American Board of Ophthalmology, which requires, serving as primary surgeon or first assistant to the primary surgeon on a minimum of 364 eye surgeries.

Changes to Current Scope of Practice. This bill would expand the scope of practice for optometrists. The following chart illustrates some of the salient changes that would be made to the current scope of practice for optometrists.

Other States. Since 1997, there have been over 45 attempts in over 20 states by optometry associations to expand the scope of practice for optometrists including legislating surgery privileges. However, with the exception of Oklahoma and West Virginia, most states continue to prohibit optometrists from performing surgery, and their statutes specify that the license to practice optometry does not include the right to practice medicine. States such as Colorado and North Carolina specifically exclude surgery from their definition of the practice of optometry. Other states have statutes that delineate between laser and non-laser surgery. Optometrists are authorized to prescribe oral medications in all 50 states, they may prescribe oral steroids in 34 states, injections in 15 states and use lasers in 1 state.

Prior Related Legislation. SB 492 (Hernandez) of 2013, would have permitted an optometrist to diagnose treat and manage additional conditions with ocular manifestations, directed the California Board of Optometry to establish educational and examination requirements and would have permitted optometrists to perform vaccinations and surgical and non-surgical primary care procedures. NOTE: This bill died on the Assembly inactive file.

SB 668 (Polanco) Chapter 13, Statutes of 1996, expanded the scope of practice of optometrists to provide for the diagnosis and treatment of specified conditions or diseases of the human eye or its appendages, and to use other therapeutic pharmaceutical agents.

SB 929 (Polanco) Chapter 676, Statutes of 2000, expanded the scope of lawful practice for optometrists by specifying additional diseases and conditions that optometrists may treat (in particular certain types of glaucoma) with specified medications, and by specifying the extent of physician involvement that is required under various circumstances.

SB 1406 (Correa) Chapter 352, Statutes of 2008, specified permissible procedures for certified optometrists, and created the Glaucoma Diagnosis and Treatment Advisory Committee to establish glaucoma certification requirements.

ARGUMENTS IN SUPPORT:

The Board of Optometry supports the bill and writes, “The Board is supportive of the intent and direction of the bill, specifically the utilization of the extensive training an education of optometrists to expand access to health care for millions of Californians.”

The California Association for Nurse Practitioners supports the bill and writes, “This bill would allow optometrists to practice more consistently with their education and training by authorizing them to treat and manage additional visual system conditions, administer flue, pneumonia and shingles vaccinations, and perform certain noninvasive procedures.”

The United Nurses Associations of California/Union of Health Care Professionals supports the bill and writes, “[This bill] is a very modest expansion of the types of services that an optometrist can provide and ensures that only qualified, trained and competent O.D.s are permitted to offer the expanded services. [This bill] specifically prohibits O.D.s from performing surgery, and instead authorizes O.D.s only to perform relatively minor procedures.”

ARGUMENTS IN OPPOSITION:

The California Academy of Eye Physicians and Surgeons opposes the bill and writes in their letter, “We are particularly concerned that the bill has moved away from the ‘comprehensive’ concept of a single certification in ‘advanced procedures.’ We believe someone training to be a surgeon needs to develop the surgical judgment common to performing all surgical procedures: understanding when (and when not to) do surgery, being able to anticipate, avoid, and recognize complications, and knowing how to address these complications when they do happen. It is unreasonable to expect these skills to be developed after the minimal experience called for in [this bill].”

The California Medical Association opposes the bill and writes, “The CMA opposes [this bill] because patient safety and quality of care demand that patients be assured that individuals who perform invasive procedures have appropriate medical education and education. The safe use of lasers and scalpels requires extensive medical education and training… In addition, the safe administration of immunizations requires extensive education, training, experience and the ability to monitor for side effects that far exceed an optometrist’s training in visual systems.”

The Medical Board of California also opposes this measure. They write in their opposition letter, “Although the services that optometrists are authorized to provide have been narrowed down compared to SB 492 from last year, the Board still has concerns with the length of additional training and the number of procedures required. The 25 hours of training and the specified number of procedures required by this bill are not enough to ensure that consumers are protected and that certified optometrists are properly trained.”

AMENDMENTS:

1. The following technical amendments should be made:

On page 7, line 34 strike: lawyer and insert: layer

On page 14, line 17, strike: “injections” and after “intraorbital” insert: injections, intraocular injections

On page 7, lines 9, strike: a, strike: specimen, strike: finger prick method and insert: skin puncture

2. In order to ensure that this bill will not expand the scope of laboratory tests that an optometrist can order, the following amendment should be made:

On page 7, line 30 after “CLIA” insert: and designated as waived in paragraph (9)

2. A complete minor procedure includes: 1) injections of medication, 2) removal or destruction of lesions and 3) any required wound closures. This bill defines minor procedures to be “either” of the 3 previously listed. The following amendment should be made in order to ensure that a complete procedure includes numbers 1 through 3 above:

On page 14, line 6, amend the bill as follows: For purposes of this chapter, “minor procedure” means completion of all of the following

2. In order to ensure that the courses outlined in this bill are taken post-graduation, the following amendment should be made:

On page 12, line 38, amend the bill as follows:

(b) An optometrist certified to treat glaucoma pursuant to Section 3041.2, after successful completion of a degree from an approved school of optometry, shall be additionally certified for the use of anterior segment lasers after submitting proof of satisfactory completion of a course that is approved by the board, provided by an accredited school of optometry, and developed in consultation with an ophthalmologist who has experience educating optometric students. The board shall issue a certificate pursuant to this section only to an optometrist that has graduated from an approved school of optometry.

2. In order to ensure that inspection authority for the Board of Optometry is consistent with other DCA healing arts boards’ inspection authority, the following should be added to the bill:

The board may at any time inspect any place of practice in which optometry is being practiced. The board’s inspection authority does not extend to premises that are not registered with the board. Nothing in this section shall be construed to affect the board’s ability to investigate alleged unlicensed activity or to inspect place of practice for which registration has lapsed or is delinquent.

REGISTERED SUPPORT:

Blue Shield of California

Board of Optometry

California Association for Nurse Practitioners

California Optometric Association

United Nurses Associations of California/Union of Health Care Professionals

REGISTERED OPPOSITION:

Academy of Eye Physicians and Surgeons

American Academy of Dermatology Association

American Academy of Ophthalmology

American Academy of Pediatrics

American Association of Orthopaedic Surgeons

American Association for Pediatric Ophthalmology and Strabismus

American College of Surgeons

American Glaucoma Society

American Medical Association

American Osteopathic Association

American Society of Cataract and Refractive Surgery

American Society of Ophthalmic Plastic and Reconstructive Surgery

American Society of Retina Specialists

Blind Children’s Center

California Academy of Eye Physicians and Surgeons

California Academy of Family Physicians

California Association for Medical Laboratory Technology

California Black Health Network

California Educators of Ophthalmology for Quality Care

California Medical Association

California Society of Dermatology and Dermatologic Surgery

California Society of Plastic Surgeons

Latino Physicians of California

Lighthouse for Christ Mission

Medical Board of California

Union of American Physicians and Dentists

Ventura County American Chinese Medical Dental Association

Over 600 physicians and individuals

Analysis Prepared by: Le Ondra Clark Harvey, Ph.D. / B. & P. / (916) 319-3301

Date of Hearing: July 7, 2015

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Susan Bonilla, Chair

SBPCA Bill Id:SB 622

Author:(Hernandez) – As Amended Ver:May 4, 2015

SENATE VOTE: 33-4

SUBJECT: Optometry

SUMMARY: This bill expands the scope of practice for optometrists to include the expanded ability to order Clinical Laboratory Improvement Amendments (CLIA)-waived tests, use noninvasive, nonsurgical technology to treat a condition authorized by the Optometric Act (Act), perform laser and minor procedures, and administer certain vaccines.

EXISTING LAW:

1. Establishes the California Board of Optometry (Board), within the Department of Consumer Affairs (DCA), which licenses optometrists and regulates the practice of optometry. (BPC § 3010.5)

2. Authorizes the Board to establish educational and examination requirements for licensure. (BPC § 3041.2)

3. Defines the practice of optometry as follows: (BPC § 3041)

1. Prevention and diagnosis of disorders and dysfunctions of the visual system;

2. Treatment and management of certain disorders and dysfunctions of the visual systems;

3. Provision of rehabilitative optometric services;

4. Examination of the human eyes;

5. Determination of the powers or range of human vision;

6. Prescribing or directing the use of any optical device in connection with ocular exercises, visual training, vision training or orthoptics;

7. Prescribing of contact lenses and glasses; and,

8. Use of topical pharmaceutical agents for the purpose of the examination of the human eye or eyes for any disease or pathological condition.

4. Specifies that an optometrist who is certified to use therapeutic pharmaceutical agents may also diagnose and treat the human eye or eyes or any of its appendages for the following conditions: (BPC § 3041(b)(1))

1. Infections;

2. Ocular allergies;

3. Ocular inflammation, non-surgical in cause except when co-managed with the treating physician and surgeon;

4. Traumatic or recurrent conjunctival or corneal abrasions and erosions;

5. Corneal surface disease and dry eyes;

6. Ocular pain, non-surgical in cause except when co-managed with the treating physician and surgeon; and,

7. Glaucoma in patients over the age of 18.

5. Permits optometrists to use the following therapeutic pharmaceutical agents: (BPC § 3041(c))

1. Topical miotics;

2. Topical lubricants;

3. Anti-allergy agents;

4. Topical and oral anti-inflammatories;

5. Topical antibiotic agents;

6. Topical hyperosmotics;

7. Topical and oral anti-glaucoma agents;

8. Non-prescription medications;

9. Oral antihistamines;

10. Prescription oral non-steroidal anti-inflammatory agents;

11. Oral antibiotics for treatment of ocular disease;

12. Topical and oral antiviral medication for treatment of:

1. Herpes;

2. Viral Keratitis;

3. Herpes Simplex Viral conjunctivitis;

4. Periocular herpes simplex viral dermatitis;

5. Varicella zoster viral keratitis;

6. Varicella zoster viral conjunctivitis; and,

7. Periocular varicella zoster viral dermatitis;

13. Oral analgesics that are not controlled substances; and,

14. Codeine with compounds and hydrocodone with compounds with specific restrictions regarding usage timeframe.

6. Specifies that an optometrist who is certified to use therapeutic pharmaceutical agents may also perform the following: (BPC § 3401(e))

1. Corneal scraping with cultures;

2. Debridement of corneal epithelia;

3. Mechanical epilation;

4. Venipuncture for testing patients suspected of having diabetes;

5. Suture removal, with prior consultation with the treating physician and surgeon;

6. Treatment or removal of sebaceous cysts by expression;

7. Administration of oral fluorescein to patients suspected as having diabetic retinopathy;

8. Use of an auto-injector to counter anaphylaxis;

9. Ordering of smears, cultures, sensitivities, complete blood count, mycobacterial culture, acid fast stain, urinalysis, tear fluid analysis and X-rays necessary for the diagnosis of conditions or diseases of the eye or adnexa;

10. A clinical laboratory test or examination classified as waived under CLIA necessary for the diagnosis of conditions and diseases of the eye or adnexa;

11. Punctal occlusion by plugs, excluding laser, diathermy, cryotherapy or other means constituting surgery;

12. The prescription of therapeutic contact lenses, including lenses or devices that incorporate a medication or therapy the optometrist is certified to prescribe or provide;

13. Removal of foreign bodies from the cornea, eyelid and conjunctiva with any appropriate instrument other than a scalpel or needle; and,

14. Lacrimal irrigation and dilation, excluding probing of the nasal lacrimal tract for patients over 12 years of age.

THIS BILL:

1. Requires the Board to establish educational and examination requirements by regulation for licensure to ensure the competence of optometrists to practice pursuant to the Act, except as specified in the sections related to certification for minor procedures and lasers.

2. Adds “habilitative services” to the definition of the practice of optometry.

3. Authorizes the Board to promulgate regulations authorizing optometrists to use noninvasive, nonsurgical technology to treat a condition authorized by the Act. To qualify to use each new technology authorized, the Board shall require a licensee to take a minimum of four hours of education and perform an appropriate number of complete clinical procedures on live human patients.

4. Removes referral requirements related to the treatment of ocular inflammation, as specified.

5. Allows an optometrist to treat hypotrichosis and blepharitis.

6. Adds “conjunctival” to the types of surface diseases that an optometrist who is certified to use therapeutic pharmaceutical agents may diagnose and treat.

7. Removes exceptions to the types of infections of the anterior segment and adnexa that an optometrist may treat.

8. Removes referral protocols for the use of certain drugs.

9. Expands ability to order CLIA waived tests.

10. Extends from three to five days the time that codeine with compounds and hydrocodone with specified compounds may be used.

11. Allows an optometrist to collect a blood specimen by finger prick method.

12. Permits an optometrist to perform a skin test on the superficial layer of the skin to diagnose ocular allergies.

13. Allows an optometrist to prescribe biological or technological corneal devices.

14. Allows an optometrist to use a needle to remove objects from the cornea, eyelid, and conjunctiva.

15. Authorizes an optometrist to use mechanical lipid extraction on meibomian glands and nonsurgical techniques.

16. Authorizes an optometrist, as part of additional “minor procedures,” to administer injections for the diagnosis or treatment of conditions of the eye and adnexa authorized by the Act, excluding intraorbital injections and injections administered for cosmetic effect.

17. Expands the definition of glaucoma to include an “increase in intraocular pressure caused by steroid medication,” but specifies that an optometrist may only treat this type of glaucoma if the optometrist has prescribed the steroid, or has consulted with and received approval from the prescriber.

18. Expands the definition of glaucoma to include an “increase in intraocular pressure caused by steroid medication.”

19. Establishes a certification process for an optometrist to perform certain laser procedures, requiring 25 hours of education and 24 complete clinical procedures on live human patients.

20. Establishes continuing education hours for optometrists certified to perform laser procedures.

21. Establishes a certification course for an optometrist to perform minor procedures.

22. Defines minor procedures as removal, destruction, or drainage of lesions of the eyelid and adnexa clinically evaluated by the optometrist to be non-cancerous, not involving the eyelid margin, lacrimal supply or drainage systems, no deeper than the orbicularis muscle, and smaller than five millimeters in diameter, and closure of a wound, as specified. Specifies that minor procedures do not include blepharoplasty or other cosmetic surgery procedures that reshape normal structures of the body in order to improve appearance and self-esteem.

23. Requires 25 hours of education and 32 complete clinical procedures on live human patients.

24. Establishes continuing education requirements for optometrists certified to perform minor procedures.

25. Authorizes an optometrist to earn a certificate to administer immunizations for influenza, herpes zoster, and pneumococcus if the optometrist does all of the following:

1. Completes an immunization training program endorsed by the Centers for Disease Control and Prevention, or the Accreditation Council for Pharmacy Education that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and shall maintain that training;

2. Is certified in basic life support for health care professionals; and,

3. Complies with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient’s primary care provider and entering information in the appropriate immunization registry designated by the immunization branch of the State Department of Public Health.

26. Defines unprofessional conduct to include failure for an optometrist to refer a patient to an appropriate physician if an examination of the eyes indicates a substantial likelihood of any pathology that requires the attention of that physician.

FISCAL EFFECT: According to the May 4, 2015 Senate Appropriations Committee analysis, this bill will result in costs of less than $150,000 to develop and update regulations by the Board. The bill will also result in minor costs to grant certifications to certain optometrists and enforce licensing regulations on those optometrists. The Board anticipates that a small number of optometrists will seek additional, post-graduate certification to perform additional procedures under the bill. Therefore, the additional licensing cost to issue those certifications and any additional enforcement activities relating to those new duties are expected to be minor. Minor costs are also anticipated for the Office of Statewide Health Planning and Development (OSHPD) to oversee a future Health Workforce Pilot Project relating to optometry. Under current practice, the costs of developing and managing a pilot project are borne by the sponsoring academic institution. The costs to the OSHPD to authorize and review any new pilot project are minor.

COMMENTS:

Purpose. This bill is sponsored by the author. According to the author, “While merely 16 of California’s 58 counties meet the needed supply range for primary care physicians, we do have a robust network of providers that are well-trained, evenly distributed throughout the state, regulated by the [DCA] and well positioned to pay particular attention to currently underserved areas. Optometrists are one such provider group who receive a doctorate level training preparing them to be primary eye care providers, and independently diagnose and treat conditions of the eye. [This bill] will remove restrictions in current law to permit optometrists to examine, prevent, diagnose, and treat conditions and disorders of the visual system and the human eye to the full extent of their training. This includes the use of two types of therapeutic lasers by optometrists with postdoctoral advanced certification that have been developed for treatment of glaucoma and post-surgical cataract care, conditions that disproportionately affect patient groups that generally lack sufficient access to physicians. [This bill] is a limited expansion of scope for optometrists that is consistent with their education and training, and is a logical advancement of the profession that has been proven safe in other states. Moreover, the educational requirements contained in this bill are substantially greater than those required of optometrists in other states and exceed the minimum number of these procedures required for ophthalmologists by the Accreditation Council for Graduate Medical Education.”

Background. According to a report prepared by the Center for the Health Professions at the University of California San Francisco, the number of optometrist licenses in California has declined, but the number of licensees with a secondary practice location has increased. According to the Board, there are approximately 7,565 licensed optometrists in California, the largest population of optometrists in the United States. Approximately 7,500 of these optometrists are certified to administer diagnostic pharmaceutical agents. The majority of the licensed optometrists are generally concentrated in coastal counties, the Bay Area and counties in the Sacramento region. Several counties have no licensed optometrists with an address of record in those counties, and a number of other counties have ratios that indicate there is approximately one optometrist for every 10,000 people.

Optometrists’ and Ophthalmologists’ Education, Training and Scope.  This bill would expand the types of procedures an optometrist is authorized to perform.  This would include some tasks that have been traditionally performed by ophthalmologists.  As such, the current education, training and scope of each profession is outlined below. 

Optometrists.  Optometrists are trained to diagnose mild to severe eye problems such as serious eye infections, inflammations of the eye, trauma, foreign bodies and glaucoma.  They also examine the eye for vision prescription and corrective lenses. 

After completion of an undergraduate degree, optometrists complete four years of and accredited optometry college after which they are awarded the Doctor of Optometry degree. Some optometrists also undertake an optional one year non-surgical residency program to enhance their experience in a particular area.  Students graduate with 2500 to 3000 patient encounters; these include a mix of post-surgical, medical and routine visits.

Optometrists who graduated from an accredited school or college of optometry on or after May 1, 2008 receive certifications to use diagnostic pharmaceutical agents (DPA); to administer therapeutic pharmaceutical agents (TPA); to perform lacrimal irrigation and dilation (TPL); and to diagnose and treat primary open angle glaucoma (TLG).  Optometrists who did not receive these certifications upon licensure may apply for these certifications after meeting the necessary requirements. In order to be certified, the optometrist must pass an exam, obtain a license to practice optometry, be certified by and accredited school of optometry that they are competent in the diagnosis, treatment and management of ocular systemic disease and complete 10 hours of experience with an ophthalmologist.

Ophthalmologists. The central focus of ophthalmology is surgery and management of complex eye diseases. An ophthalmologist specializes in the refractive, medical and surgical care of the eyes and visual system and in the prevention of disease and injury.

After obtaining an undergraduate degree, ophthalmologists complete four years at an accredited medical school and earn a Medical Degree. This is followed by a one year internship and a three or four year surgical residency. Many ophthalmologists pursue additional fellowship training in specialized areas such as retina, glaucoma or cornea. Ophthalmologists may become certified by the American Board of Ophthalmology, which requires, serving as primary surgeon or first assistant to the primary surgeon on a minimum of 364 eye surgeries.

Changes to Current Scope of Practice. This bill would expand the scope of practice for optometrists. The following chart illustrates some of the salient changes that would be made to the current scope of practice for optometrists.

Other States. Since 1997, there have been over 45 attempts in over 20 states by optometry associations to expand the scope of practice for optometrists including legislating surgery privileges. However, with the exception of Oklahoma and West Virginia, most states continue to prohibit optometrists from performing surgery, and their statutes specify that the license to practice optometry does not include the right to practice medicine. States such as Colorado and North Carolina specifically exclude surgery from their definition of the practice of optometry. Other states have statutes that delineate between laser and non-laser surgery. Optometrists are authorized to prescribe oral medications in all 50 states, they may prescribe oral steroids in 34 states, injections in 15 states and use lasers in 1 state.

Prior Related Legislation. SB 492 (Hernandez) of 2013, would have permitted an optometrist to diagnose treat and manage additional conditions with ocular manifestations, directed the California Board of Optometry to establish educational and examination requirements and would have permitted optometrists to perform vaccinations and surgical and non-surgical primary care procedures. NOTE: This bill died on the Assembly inactive file.

SB 668 (Polanco) Chapter 13, Statutes of 1996, expanded the scope of practice of optometrists to provide for the diagnosis and treatment of specified conditions or diseases of the human eye or its appendages, and to use other therapeutic pharmaceutical agents.

SB 929 (Polanco) Chapter 676, Statutes of 2000, expanded the scope of lawful practice for optometrists by specifying additional diseases and conditions that optometrists may treat (in particular certain types of glaucoma) with specified medications, and by specifying the extent of physician involvement that is required under various circumstances.

SB 1406 (Correa) Chapter 352, Statutes of 2008, specified permissible procedures for certified optometrists, and created the Glaucoma Diagnosis and Treatment Advisory Committee to establish glaucoma certification requirements.

ARGUMENTS IN SUPPORT:

The Board of Optometry supports the bill and writes, “The Board is supportive of the intent and direction of the bill, specifically the utilization of the extensive training an education of optometrists to expand access to health care for millions of Californians.”

The California Association for Nurse Practitioners supports the bill and writes, “This bill would allow optometrists to practice more consistently with their education and training by authorizing them to treat and manage additional visual system conditions, administer flue, pneumonia and shingles vaccinations, and perform certain noninvasive procedures.”

The United Nurses Associations of California/Union of Health Care Professionals supports the bill and writes, “[This bill] is a very modest expansion of the types of services that an optometrist can provide and ensures that only qualified, trained and competent O.D.s are permitted to offer the expanded services. [This bill] specifically prohibits O.D.s from performing surgery, and instead authorizes O.D.s only to perform relatively minor procedures.”

ARGUMENTS IN OPPOSITION:

The California Academy of Eye Physicians and Surgeons opposes the bill and writes in their letter, “We are particularly concerned that the bill has moved away from the ‘comprehensive’ concept of a single certification in ‘advanced procedures.’ We believe someone training to be a surgeon needs to develop the surgical judgment common to performing all surgical procedures: understanding when (and when not to) do surgery, being able to anticipate, avoid, and recognize complications, and knowing how to address these complications when they do happen. It is unreasonable to expect these skills to be developed after the minimal experience called for in [this bill].”

The California Medical Association opposes the bill and writes, “The CMA opposes [this bill] because patient safety and quality of care demand that patients be assured that individuals who perform invasive procedures have appropriate medical education and education. The safe use of lasers and scalpels requires extensive medical education and training… In addition, the safe administration of immunizations requires extensive education, training, experience and the ability to monitor for side effects that far exceed an optometrist’s training in visual systems.”

The Medical Board of California also opposes this measure. They write in their opposition letter, “Although the services that optometrists are authorized to provide have been narrowed down compared to SB 492 from last year, the Board still has concerns with the length of additional training and the number of procedures required. The 25 hours of training and the specified number of procedures required by this bill are not enough to ensure that consumers are protected and that certified optometrists are properly trained.”

AMENDMENTS:

1. The following technical amendments should be made:

On page 7, line 34 strike: lawyer and insert: layer

On page 14, line 17, strike: “injections” and after “intraorbital” insert: injections, intraocular injections

On page 7, lines 9, strike: a, strike: specimen, strike: finger prick method and insert: skin puncture

2. In order to ensure that this bill will not expand the scope of laboratory tests that an optometrist can order, the following amendment should be made:

On page 7, line 30 after “CLIA” insert: and designated as waived in paragraph (9)

2. A complete minor procedure includes: 1) injections of medication, 2) removal or destruction of lesions and 3) any required wound closures. This bill defines minor procedures to be “either” of the 3 previously listed. The following amendment should be made in order to ensure that a complete procedure includes numbers 1 through 3 above:

On page 14, line 6, amend the bill as follows: For purposes of this chapter, “minor procedure” means completion of all of the following

2. In order to ensure that the courses outlined in this bill are taken post-graduation, the following amendment should be made:

On page 12, line 38, amend the bill as follows:

(b) An optometrist certified to treat glaucoma pursuant to Section 3041.2, after successful completion of a degree from an approved school of optometry, shall be additionally certified for the use of anterior segment lasers after submitting proof of satisfactory completion of a course that is approved by the board, provided by an accredited school of optometry, and developed in consultation with an ophthalmologist who has experience educating optometric students. The board shall issue a certificate pursuant to this section only to an optometrist that has graduated from an approved school of optometry.

2. In order to ensure that inspection authority for the Board of Optometry is consistent with other DCA healing arts boards’ inspection authority, the following should be added to the bill:

The board may at any time inspect any place of practice in which optometry is being practiced. The board’s inspection authority does not extend to premises that are not registered with the board. Nothing in this section shall be construed to affect the board’s ability to investigate alleged unlicensed activity or to inspect place of practice for which registration has lapsed or is delinquent.

REGISTERED SUPPORT:

Blue Shield of California

Board of Optometry

California Association for Nurse Practitioners

California Optometric Association

United Nurses Associations of California/Union of Health Care Professionals

REGISTERED OPPOSITION:

Academy of Eye Physicians and Surgeons

American Academy of Dermatology Association

American Academy of Ophthalmology

American Academy of Pediatrics

American Association of Orthopaedic Surgeons

American Association for Pediatric Ophthalmology and Strabismus

American College of Surgeons

American Glaucoma Society

American Medical Association

American Osteopathic Association

American Society of Cataract and Refractive Surgery

American Society of Ophthalmic Plastic and Reconstructive Surgery

American Society of Retina Specialists

Blind Children’s Center

California Academy of Eye Physicians and Surgeons

California Association for Medical Laboratory Technology

California Black Health Network

California Educators of Ophthalmology for Quality Care

California Medical Association

California Society of Plastic Surgeons

Latino Physicians of California

Lighthouse for Christ Mission

Medical Board of California

Union of American Physicians and Dentists

Ventura County American Chinese Medical Dental Association

Over 600 physicians and individuals

Analysis Prepared by: Le Ondra Clark Harvey, Ph.D. / B. & P. / (916) 319-3301

 THIRD READING  

Bill No: SB 622

Author: Hernandez (D)

Amended: 5/4/15

Vote: 21

SENATE BUS, PROF. & ECON. DEV. COMMITTEE: 9-0, 4/27/15

AYES: Hill, Bates, Berryhill, Block, Galgiani, Hernandez, Jackson, Mendoza, Wieckowski

SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/18/15

AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen

SUBJECT: Optometry

SOURCE: Author

DIGEST: This bill expands the scope of practice for optometrists to include expanded ability to order the Clinical Laboratory Improvement Amendments (CLIA)-waived tests, use noninvasive, nonsurgical technology to treat a condition authorized by the Optometric Act (Act), perform laser and minor procedures, and administer certain vaccines.

ANALYSIS:

Existing law:

1. Establishes the State Board of Optometry (Board) within the Department of Consumer Affairs, which licenses optometrists and regulates the practice of optometry. (Business and Professions Code (BPC) § 3010.5)

2. Defines the practice of optometry as follows:

1. The prevention and diagnosis of disorders and dysfunctions of the visual system;

2. Treatment and management of certain disorders and dysfunctions of the visual systems;

3. Provision of rehabilitative optometric services;

4. Examination of the human eyes;

5. Determination of the powers or range of human vision;

6. The prescribing or directing the use of any optical device in connection with ocular exercises, visual training, vision training or orthoptics;

7. Prescribing of contact lenses and glasses; and

8. The use of topical pharmaceutical agents for the purpose of the examination of the human eye or eyes for any disease or pathological condition.
   (BPC § 3041)

This bill:

1. Authorizes the Board to establish educational and examination requirements by regulation for licensure to ensure the competence of optometrists to practice pursuant to the Act, except as specified in the sections related to certification for minor procedures and lasers.

2. Adds “habilitative services” to the definition of the practice of optometry.

3. Authorizes the Board to promulgate regulations authorizing optometrists to use noninvasive, nonsurgical technology to treat a condition authorized by the Act. To qualify to use each new technology authorized, the Board shall require a licensee to take a minimum of four hours’ education and perform an appropriate number of complete clinical procedures on live human patients.

4. Removes referral requirements related to the treatment of ocular inflammation, as specified.

5. Allows an optometrist to treat hypotrichosis and blepharitis.

6. Adds “conjunctival” to the types of surface diseases that an optometrist who is certified to use therapeutic pharmaceutical agents may diagnose and treat.

7. Removes exceptions to the types of infections of the anterior segment and adnexa that an optometrist may treat.

8. Removes referral protocols for the use of certain drugs.

9. Expands ability to order CLIA waived tests.

10. Extends from three to five days the time that codeine with compounds and hydrocodone with specified compounds may be used.

11. Allows an optometrist to collect a blood specimen by finger prick method.

12. Permits an optometrist to perform a skin test on the superficial layer of the skin to diagnose ocular allergies.

13. Allows an optometrist to prescribe biological or technological corneal devices.

14. Allows an optometrist to use a needle to remove objects from the cornea, eyelid, and conjunctiva.

15. Authorizes an optometrist to use mechanical lipid extraction on meibomian glands and nonsurgical techniques.

16. Authorizes an optometrist, as part of additional “minor procedures,” to administer injections for the diagnosis or treatment of conditions of the eye and adnexa authorized by the Act, excluding intraorbital injections and injections administered for cosmetic effect.

17. Expands the definition of glaucoma by including that caused by an “increase in intraocular pressure caused by steroid medication,” but specifies that an optometrist may only treat this type of glaucoma if the optometrist has prescribed the steroid, or has consulted with and received approval from, the prescriber.

18. Establishes a certification process for an optometrist to perform certain laser procedures, requiring 25 hours of education and 24 complete clinical procedures on live human patients.

19. Expands the definition of glaucoma by including an “increase in intraocular pressure caused by steroid medication.”
    
    

20. Establishes continuing education hours for optometrists certified to perform laser procedures.

21. Establishes a certification course for an optometrist to perform minor procedures. Minor procedures are defined as removal, destruction, or drainage of lesions of the eyelid and adnexa clinically evaluated by the optometrist to be noncancerous, not involving the eyelid margin, lacrimal supply or drainage systems, no deeper than the orbicularis muscle, and smaller than five millimeters in diameter, and closure of a wound, as specified. Specifies that minor procedures do not include blepharoplasty or other cosmetic surgery procedures that reshape normal structures of the body in order to improve appearance and self-esteem. Requires 25 hours of education and 32 complete clinical procedures on live human patients.

22. Establishes continuing education requirements for optometrists certified to perform minor procedures.

23. Authorizes an optometrist to earn a certificate to administer immunizations for influenza, herpes zoster, and pneumococcus if the optometrist does all of the following:

1. Completes an immunization training program endorsed by the Centers for Disease Control and Prevention, or the Accreditation Council for Pharmacy Education that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and shall maintain that training.

2. Is certified in basic life support for health care professionals.

3. Complies with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient’s primary care provider and entering information in the appropriate immunization registry designated by the immunization branch of the State Department of Public Health.

24. Declares as unprofessional conduct the failure for an optometrist to refer a patient to an appropriate physician if an examination of the eyes indicates a substantial likelihood of any pathology that requires the attention of that physician.

Background

The practice of optometry. An optometrist (Doctor of Optometry or O.D.) is an independent primary health care professional for the eye.  Optometrists examine, diagnose, treat, and manage diseases, injuries, and disorders of the visual system, the eye, and associated structures, as well as identify related systemic conditions affecting the eye. O.D.s prescribe medications, low vision rehabilitation, vision therapy, spectacle lenses, contact lenses, and perform certain surgical procedures. Optometrists have a narrower scope of practice than do ophthalmologists, but are held to the identical standard of care for the same treatments they provide.

An O.D. degree requires both an undergraduate education and four years of professional education at a college of optometry. Some optometrists also undertake an optional one year non-surgical residency program to enhance their experience in a particular area. Students graduate with 2,500-3,000 patient encounters, which include a mix of post-surgical, medical and routine visits.

In order to be licensed to practice by the Board, an individual must obtain an O.D. degree, pass the three part National Board of Examiners in Optometry examination, and the California Optometric State Law Examination. There are currently 9,100 optometrists practicing in California.

The practice of ophthalmology. An ophthalmologist is a physician and surgeon who has specialty training in the anatomy, function and diseases of the eye. The central focus of ophthalmology is surgery and management of complex eye diseases. An ophthalmologist specializes in the refractive, medical and surgical care of the eyes and visual system, and in the prevention of disease and injury.

To become an ophthalmologist, an individual must obtain an undergraduate degree, complete four years of graduate education at an accredited medical school and earn a Medical Degree, complete a one year internship, and a three or four year residency. There are currently 1,800-2,100 ophthalmologists in California, not all of whom are in active practice.

FISCAL EFFECT: Appropriation: Yes Fiscal Com.: Yes Local: Yes

According to the Senate Appropriations Committee:

• Costs of less than $150,000 to develop and update regulations by the Board (State Optometry Fund).

• Minor costs to grant certifications to certain optometrists and enforce licensing regulations on those optometrists (State Optometry Fund). The Board anticipates that a small number of optometrists will seek additional, post-graduate certification to perform additional procedures under this bill. Therefore, the additional licensing cost to issue those certifications and any additional enforcement activities relating to those new duties are expected to be minor.

• Minor costs for the Office of Statewide Health Planning and Development to oversee a future Health Workforce Pilot Project relating to optometry. Under current practice, the costs of developing and managing a pilot project are borne by the sponsoring academic institution. The costs to the Office to authorize and review any new pilot project are minor.

SUPPORT: (Verified 5/19/15)

California Association of Health System Pharmacists

California Optometric Association

VSP Vision Care

Western University of Health Sciences

Numerous individuals

OPPOSITION: (Verified 5/19/15)

American Federation of State, County and Municipal Employees

Blind Childrens Center

California Academy of Eye Physicians & Surgeons

California Academy of Family Physicians

California Medical Association

California Society of Plastic Surgeons

Latino Physicians of California

Medical Board of California

Ventura County American Chinese Medical Dental Association

Numerous Individuals

ARGUMENTS IN SUPPORT: The California Optometric Association writes, “Doctors of optometry have a critical role to play in providing primary care and making the promise of the Affordable Care Act a reality. They already provide the vast majority of eye care in the Medi-Cal program and they are located in all but one California county (Alpine). In order to improve access to health care in California, we must provide timely care where and when it’s needed by utilizing the full complement of our clinical abilities.”

ARGUMENTS IN OPPOSITION: The California Academy of Family Physicians write, “Physicians see many benefits from working collaboratively with other health care professionals to meet patient care demand, but the framework of care delivery should be within the scope of practice that each health care professional is qualified to perform. Arbitrarily allowing allied health care professionals to render services that are beyond a provider’s scope can lead to increased costs through over-utilization of tests, over prescribing of medications, and excess referrals to specialists; and in this case, the potential for incredible harm to patients.”

Prepared by: Sarah Huchel / B., P. & E.D. / (916) 651-4104

5/20/15 11:44:31

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

SB 622 (Hernandez) - Optometry

This bill does not meet the criteria for referral to the Suspense File.

Bill Summary:

SB 622 would expand the scope of practice for optometrists by authorizing specially certified optometrists to perform certain tests, provide certain immunizations, and to use lasers for certain procedures.

Fiscal Impact:

• Costs of less than $150,000 to develop and update regulations by the Board of Optometry (State Optometry Fund).

• Minor costs to grant certifications to certain optometrists and enforce licensing regulations on those optometrists (State Optometry Fund). The Board of Optometry anticipates that a small number of optometrists will seek additional, post-graduate certification to perform additional procedures under the bill. Therefore, the additional licensing cost to issue those certifications and any additional enforcement activities relating to those new duties are expected to be minor.

• Minor costs for the Office of Statewide Health Planning and Development to oversee a future Health Workforce Pilot Project relating to optometry. Under current practice, the costs of developing and managing a pilot project are borne by the sponsoring academic institution. The costs to the Office to authorize and review any new pilot project are minor.

Background:

Under current law, optometrists are licensed and regulated by the California Optometry Board. Current law establishes the scope of practice for optometrists and indicates what services an optometrist is authorized to provide to patients. In general, optometrists are trained and authorized to diagnose mild to severe eye problems, to prescribe corrective lenses, and provide other, specified services. An optometrist may apply for certification to provide certain additional services, such as the treatment of primary open angle glaucoma.

Proposed Law:

SB 622 would expand the scope of practice for optometrists by authorizing specially certified optometrists to perform certain tests, provide certain immunizations, and to use lasers for certain procedures.

Specific provisions of the bill would:

• Add the provision of habilitative services to the practice of optometry;

• Authorize the Board of Optometry to allow optometrists to use nonsurgical technology to treat any authorized condition under the Optometry Practice Act;

• Authorize an optometrist certified to use therapeutic pharmaceutical agents to collect a blood specimen, perform skin tests, and to use mechanical lipid extraction of certain glands;

• Require the Board to grant an optometrist certified to treat glaucoma a certificate for the use of specified immunizations;

• Authorize an optometrist to be certified to use anterior segment lasers and to be certified to perform minor procedures;

• Require the Board to charge specified fees to cover its costs;

• State legislative intent that the Office of Statewide Health Planning and Development authorize a health workforce pilot project relating to expanded roles for optometrists with respect to diabetes, hypertension, and hypercholesterolemia.

Related Legislation:

SB 492 (Hernandez, 2014) would have created an advance practice certificate for optometrists, allowing certificated optometrists to perform additional procedures. That bill died on the Assembly Floor.

Staff Comments:

By expanding the scope of practice for optometrists, this bill will allow optometrists to provide more care to patients. Additional care provided by optometrists may increase overall utilization of health care, to the extent that patients are currently unable to get care from other practitioners, such as ophthalmologists or primary care physicians. On the other hand, patients may substitute care from an optometrist for care from another practitioner. In addition, to the extent that patients are currently unable to access primary care services, those patients may ultimately end up receiving care in another setting, such as an emergency room, urgent care facility, or community clinic. Care provided in those settings is likely to be more costly than primary care (for those patients who require such care). The overall impact on health care spending (including for state-funded programs) from this bill is not likely to result in significant costs or savings.

-- END --

SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Jerry Hill, Chair

2015 - 2016 Regular

Bill No: SB 622 Hearing Date: April 27, 2015

Subject: Optometry.

SUMMARY:

Expands the scope of practice for optometrists to include expanding ability to order tests, use pharmaceuticals -- including for off-label use, and perform laser and minor procedures, and administer vaccines.

Existing law:

1. Establishes the State Board of Optometry (Board) within the Department of Consumer Affairs, which licenses optometrists and regulates the practice of optometry. (Business and Professions Code (BPC) § 3010.5)

2. Authorizes the Board to establish educational and examination requirements for licensure. (BPC § 3041.2)

3. Defines the practice of optometry as follows:

1. The prevention and diagnosis of disorders and dysfunctions of the visual system;
   
   

2. Treatment and management of certain disorders and dysfunctions of the visual systems;
   
   

3. Provision of rehabilitative optometric services;
   
   

4. Examination of the human eyes;
   
   

5. Determination of the powers or range of human vision;
   
   

6. The prescribing or directing the use of any optical device in connection with ocular exercises, visual training, vision training or orthoptics;
   
   

7. Prescribing of contact lenses and glasses; and
   
   

8. The use of topical pharmaceutical agents for the purpose of the examination of the human eye or eyes for any disease or pathological condition. (BPC 3041)

4. Specifies that an optometrist who is certified to use therapeutic pharmaceutical agents may also diagnose and treat the human eye or eyes or any of its appendages for the following conditions: infections; ocular allergies; ocular inflammation, non-surgical in cause except when co-managed with the treating physician and surgeon; traumatic or recurrent conjunctival or corneal abrasions and erosions; corneal surface disease and dry eyes; ocular pain, non-surgical in cause except when co-managed with the treating physician and surgeon; and glaucoma in patients over the age of 18. (BPC § 3041(b)(1))

5. Permits optometrists to use specified therapeutic pharmaceutical agents, including codeine with compounds and hydrocodone with compounds provided that use does not exceed three days. (BPC § 3041(c))

6. Specifies that an optometrist who is certified to use therapeutic pharmaceutical agents may also perform the following:

1. Corneal scraping with cultures;
   
   

2. Debridement of corneal epithelia;
   
   

3. Mechanical epilation;
   
   

4. Venipuncture for testing patients suspected of having diabetes;
   
   

5. Suture removal, with prior consultation with the treating physician and surgeon;
   
   

6. Treatment or removal of sebaceous cysts by expression;
   
   

7. Administration of oral fluorescein to patients suspected as having diabetic retinopathy;
   
   

8. Use of an auto-injector to counter anaphylaxis;
   
   

9. Ordering of smears, cultures, sensitivities, complete blood count, mycobacterial culture, acid fast stain, urinalysis, tear fluid analysis and X-rays necessary for the diagnosis of conditions or diseases of the eye or adnexa;
   
   

10. A clinical laboratory test or examination classified as waived under CLIA [Clinical Laboratory Improvement Amendments] necessary for the diagnosis of conditions and diseases of the eye or adnexa;
    
    

11. Punctal occlusion by plugs, excluding laser, diathermy, cryotherapy or other means constituting surgery;
    
    

12. The prescription of therapeutic contact lenses, including lenses or devices that incorporate a medication or therapy the optometrist is certified to prescribe or provide;
    
    

13. Removal of foreign bodies from the cornea, eyelid and conjunctiva with any appropriate instrument other than a scalpel or needle; and
    
    

14. Lacrimal irrigation and dilation, excluding probing of the nasal lacrimal tract for patients over 12 years of age. (BPC § 3041(e))

This bill:

1. Adds “habilitative services” to the definition of the practice of optometry.

2. Authorizes the Board to establish educational and examination requirements for practices authorized in the Optometry Practice Act, including determining education and examination requirements for the certifications established in the bill.

3. Authorizes the Board to allow optometrists to use nonsurgical technology to treat a condition authorized by the Act.

4. Adds “conjunctival” to the types of surface diseases that an optometrist who is certified to use therapeutic pharmaceutical agents may diagnose and treat.

5. Removes exceptions to the types of infections of the anterior segment and adnexa that an optometrist may treat.

6. Removes exceptions to the types of ocular inflammation, nonsurgical in cause, that an optometrist may treat.

7. Allows an optometrist to treat eyelid disorders, including, but not limited to, hypotrichosis and blepharitis.

8. Expands the number and type of drugs an optometrist certified to use therapeutic pharmaceutical agents may use to include:

   1. All oral and topical diagnostic and therapeutic pharmaceutical agents that are not controlled substances. The use of pharmaceutical agents shall be limited to the use for which the drug has been approved for marketing by the federal Food and Drug Administration (FDA).

   2. Permits off-label drug use if all of the following requirements are met:

      1. The drug is approved by the FDA.

      2. The drug has been recognized for treatment of the condition by either of the following:

      3. The American Hospital Formulary Service’s Drug Information.

      4. Two articles from major peer reviewed medical journals that present data supporting the proposed off-label use or uses as generally safe and effective, unless there is clear and convincing contradictory evidence presented in a major peer reviewed medical journal.

9. Extends from three to five days the time that codeine with compounds and hydrocodone with specified compounds may be used.

10. Allows an optometrist to collect a blood specimen by finger prick method.

11. Authorizes an optometrist to order any clinical laboratory and imaging tests, including those waived by CLIA, related to the practice of optometry, rather than just specified types.

12. Permits an optometrist to perform a skin test on the superficial lawyer of the skin to diagnose ocular allergies.

13. Allows an optometrist to prescribe biological or technological corneal devices.

14. Allows an optometrist to use a needle to remove objects from the cornea, eyelid, and conjunctiva.

15. Authorizes an optometrist to use mechanical lipid extraction on meibomian glands and nonsurgical techniques.

16. Authorizes an optometrist to administer injections for the diagnoses or treatment of conditions of the eye and adnexa, excluding intraorbital injections and injections administered for cosmetic effect, provided that the optometrist has satisfactorily received four hours of continuing education.

17. Expands the definition of glaucoma by including an “increase in intraocular pressure caused by steroid medication.”

18. Establishes a certification process for an optometrist to perform certain laser procedures.

19. Establishes a certification course for an optometrist to perform minor procedures. Minor procedures are defined as removal, destruction, or drainage of lesions of the eyelid and adnexa clinically evaluated by the optometrist to be noncancerous, not involving the eyelid margin, lacrimal supply or drainage systems, no deeper than the orbicularis muscle, and smaller than five millimeters in diameter, and closure of a wound, as specified.

20. Authorizes an optometrist to independently initiate and administer vaccines listed on the routine immunization schedules recommended by the federal Advisory Committee on Immunization Practices (ACIP), in compliance with individual ACIP vaccine recommendations, and published by the federal Centers for Disease Control and Prevention (CDC) for persons three years of age and older, if the optometrist does all of the following:

1. Complete an immunization training program endorsed by the CDC or the Accreditation Council for Pharmacy Education that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and shall maintain that training.

2. Be certified in basic life support for health care professionals.

3. Comply with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient’s primary care provider and entering information in the appropriate immunization registry designated by the immunization branch of the State Department of Public Health.

FISCAL EFFECT:

Unknown. This bill is keyed “fiscal” by Legislative Counsel.

COMMENTS:

1. Purpose. This bill is sponsored by the Author. According to the Author’s office, “As a result of implementation of the ACA, about 3 million additional Californians are eligible for health insurance and the recently insured are increasing demand for health care on an already strained system. Californians deserve timely access to high quality care offered by a range of safe, efficient, and regulated providers. In California we have a robust network of providers that are well-trained, evenly distributed throughout the state, regulated by the Department of Consumer Affairs and well positioned to pay particular attention to currently underserved areas. Optometrists are one such provider group who receive a doctorate level training preparing them to be primary eye care providers, and independently diagnose and treat conditions of the eye. SB 622 will remove restrictions in current law to permit optometrists to examine, prevent, diagnose, and treat conditions and disorders of the visual system and the human eye to the full extent of their training. This includes the use of two types of therapeutic lasers by optometrists with postdoctoral advanced certification that have been developed for treatment of glaucoma and post- surgical cataract care, conditions that disproportionately affect patient groups that generally lack sufficient access to physicians. SB 622 is a limited expansion of scope for optometrists that is consistent with their education and training, and is a logical advancement of the profession that has been proven safe in other states.”

2. The Practice of Optometry. An optometrist (Doctor of Optometry or O.D.) is an independent primary health care professional for the eye.  Optometrists examine, diagnose, treat, and manage diseases, injuries, and disorders of the visual system, the eye, and associated structures, as well as identify related systemic conditions affecting the eye. ODs prescribe medications, low vision rehabilitation, vision therapy, spectacle lenses, contact lenses, and perform certain surgical procedures. Optometrists have a narrower scope of practice than do ophthalmologists, but are held to the identical standard of care for the same treatments they provide.

An O.D. degree requires both an undergraduate education in a college or university and four years of professional education at a college of optometry. Some optometrists also undertake an optional one year non-surgical residency program to enhance their experience in a particular area. Students graduate with 2,500-3,000 patient encounters; these include a mix of post-surgical, medical and routine visits.

In order to be licensed to practice by the California Board of Optometry, an individual must obtain an O.D. degree, pass the three part National Board of Examiners in Optometry examination, and the California Optometric State Law Examination. There are currently 9,100 optometrists in practice in California.

Optometrists are trained to diagnose mild to severe eye problems such as serious eye infections, inflammations of the eye, trauma, foreign bodies and glaucoma (pressure inside the eyeball). They also examine the eye for vision prescription and corrective lenses. Optometrists may also pursue any of five additional state certifications to perform certain advanced procedures: use of diagnostic pharmaceutical agents (DPA); use of therapeutic pharmaceutical agents (TPA); lacrimal irrigation and dilation for individuals over the age of 12 + TPA (TPL); diagnosis and treatment of open angle glaucoma for adults + TPA (TPG); and a combination of TPA, TPL and TPG.

3. The Practice of Ophthalmology. An ophthalmologist is a physician and surgeon who has specialty training in the anatomy, function and diseases of the eye. The central focus of ophthalmology is surgery and management of complex eye diseases. An ophthalmologist specializes in the refractive, medical and surgical care of the eyes and visual system, and in the prevention of disease and injury.
   
   To become an ophthalmologist, an individual must obtain an undergraduate degree, complete four years of graduate education at an accredited medical school and earn a Medical Degree, complete a one year internship, and a three or four year residency. Many ophthalmologists pursue additional fellowship training in specialized areas such as the retina, glaucoma treatment or the cornea. Ophthalmologists may become certified by the American Board of Ophthalmology, which requires serving as primary surgeon or first assistant to the primary surgeon on a minimum of 364 eye surgeries.
   
   There are currently 1,800-2,100 ophthalmologists in California, not all of whom are in active practice.

4. Prior Legislation. SB 492 (Hernandez) would have created an advanced practice certificate, enabling optometrists to perform a limited range of therapeutic laser procedures for the eye and surgical procedures related to the eyelid, as well as certain injections and immunizations, and generally revised the Optometry Practice Act to clarify and expand the range of an optometrist's scope of practice.
   (Status: Held on the Assembly Floor.)

SB 1406 (Correa) (Chapter 352, Statutes of 2008) specified permissible procedures for certified optometrists, and created the Glaucoma Diagnosis and Treatment Advisory Committee to establish glaucoma certification requirements.

SB 929 (Polanco) (Chapter 676, Statutes of 2000) expanded the scope of lawful practice for optometrists by specifying additional diseases and conditions that optometrists may treat (in particular certain types of glaucoma) with specified medications, and by specifying the extent of physician involvement that is required under various circumstances.

SB 668 (Polanco) (Chapter 13, Statutes of 1996) expanded the scope of practice of optometrists to provide for the diagnosis and treatment of specified conditions or diseases of the human eye or its appendages, and to use other therapeutic pharmaceutical agents.

5. Arguments in Support. The California Optometric Association writes, “Doctors of optometry have a critical role to play in providing primary care and making the promise of the Affordable Care Act a reality. They already provide the vast majority of eye care in the Medi-Cal program and they are located in all but one California county (Alpine). In order to improve access to health care in California, we must provide timely care where and when it’s needed by utilizing the full complement of our clinical abilities.”

Western University of Health Sciences writes, “[SB 622] makes sense. It requires the same, or higher, standards set by residency education in ophthalmology. It ensures that doctors of optometry will have the appropriate knowledge and skills required to implement the new elements of care that are included in this bill. The legislation has checks and balances in place to ensure that doctors of optometry can safely provide these services to their patients.

6. Arguments in Opposition. The California Academy of Family Physicians write, “Physicians see many benefits from working collaboratively with other health care professionals to meet patient care demand, but the framework of care delivery should be within the scope of practice that each health care professional is qualified to perform. Arbitrarily allowing allied health care professionals to render services that are beyond a provider’s scope can lead to increased costs through over-utilization of tests, over prescribing of medications, and excess referrals to specialists; and in this case, the potential for incredible harm to patients.”
   
   The California Medical Association writes, “Optometrists serve an important function in the health care community. Specifically, optometrists are health practitioners involved exclusively with vision problems, including examining the eyes to determine the presence of vision problems, determining visual acuity, and prescribing spectacles, contact lenses, and eye exercises. SB 622 proposes expanding the optometrist scope of practice to include a wide range of services that optometrists simply do not have the education, training, and experience to provide.”

7. Author’s Proposed Amendments: Following lengthy negotiations with stakeholders, the Author is proposing the following amendments:

1. Authorizes the Board to establish educational and examination requirements by regulation for licensure to ensure the competence of optometrists to practice pursuant to the Act, except as specified in the sections related to certification for minor procedures and lasers.

2. Authorizes the Board to promulgate regulations authorizing optometrists to use noninvasive, nonsurgical technology to treat a condition authorized by the Act. To qualify to use each new technology authorized, the Board shall require a licensee to take a minimum of four hours’ education and perform an appropriate number of complete clinical procedures on live human patients.

3. Removes referral requirements related to the treatment of ocular inflammation, as specified.

4. Allows an optometrist to treat hypotrichosis and blepharitis.

5. Restores current law related to the use of drugs.

6. Removes referral protocols for the use of certain drugs.

7. Restores ordering of additional tests to existing law, but expands ability to order CLIA waived tests.

8. Authorizes an optometrist, as part of additional “minor procedures,” to administer injections for the diagnosis or treatment of conditions of the eye and adnexa authorized by the Act, excluding intraorbital injections and injections administered for cosmetic effect.

9. Expands the definition of glaucoma by including that caused by an “increase in intraocular pressure caused by steroid medication,” but specifies that an optometrist may only treat this type of glaucoma if the optometrist has prescribed the steroid, or has consulted with and received approval from, the prescriber.

10. Establishes a certification process for an optometrist to perform certain laser procedures, requiring 25 hours of education and 24 complete clinical procedures on live human patients.

11. Establishes continuing education hours for optometrists certified to perform laser procedures.

12. Establishes a certification course for an optometrist to perform minor procedures. Minor procedures are defined as removal, destruction, or drainage of lesions of the eyelid and adnexa clinically evaluated by the optometrist to be noncancerous, not involving the eyelid margin, lacrimal supply or drainage systems, no deeper than the orbicularis muscle, and smaller than five millimeters in diameter, and closure of a wound, as specified. Specifies that minor procedures do not include blepharoplasty or other cosmetic surgery procedures that reshape normal structures of the body in order to improve appearance and self-esteem. Requires 25 hours of education and 32 complete clinical procedures on live human patients.

13. Establishes continuing education requirements for optometrists certified to perform minor procedures.

14. Authorizes an optometrist to earn a certificate to administer immunizations for influenza, herpes zoster, and pneumococcus if the optometrist does all of the following:

1. Completes an immunization training program endorsed by the CDC, or the Accreditation Council for Pharmacy Education that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and shall maintain that training.

2. Is certified in basic life support for health care professionals.

3. Complies with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient’s primary care provider and entering information in the appropriate immunization registry designated by the immunization branch of the State Department of Public Health.

4. Declares as unprofessional conduct the failure for an optometrist to refer a patient to an appropriate physician if an examination of the eyes indicates a substantial likelihood of any pathology that requires the attention of that physician.

SUPPORT AND OPPOSITION:

Support:

California Optometric Association

Western University of Health Sciences

Opposition:

American Federation of State, County and Municipal Employees (AFSCME)

Blind Childrens Center

California Academy of Eye Physicians & Surgeons (CAEPS)

California Academy of Family Physicians (CAFP)

California Medical Association (CMA)

California Society of Plastic Surgeons (CSPS)

Latino Physicians of California (LPOC)

Ventura County American Chinese Medical Dental Association (VC AC M/D)

Numerous Individuals

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