(Opinion) Only trained surgeons should perform eye surgery

Donald M. Miller

BY DONALD M. MILLER

What training and experience would you expect your doctor to have before operating on your eye?  Would it be OK if they were not a surgeon, never went to medical school, and then proposed to operate on your eye without supervision? This question is currently before the New Hampshire legislature.

I have practiced ophthalmology in New Hampshire for 25 years, during which I have developed medical education and training for ophthalmologists (medical doctors and surgeons specializing in eye surgery). In 2019, I designed and then directed the ophthalmology residency training program at Dartmouth Hitchcock, the only eye surgical training program north of Boston. I have extensive experience in surgical training.

At issue is House Bill 349, which would permit New Hampshire optometrists — who are not medical doctors or trained surgeons — to perform eye surgery. In New Hampshire, optometrists and ophthalmologists work together to provide eye care to the public, with optometrists providing primary eye care and ophthalmologists managing complex medical eye care and all eye surgery.

There is an essential difference in education: Optometrists spend four to five years in school after college and then go into practice, whereas ophthalmologists train for eight to 10 years after college, first in medical school and then four to six years of postgraduate surgical training known as residency. Optometry is not a surgical specialty.

HB 349 concerns three office-based laser eye surgeries, two for glaucoma (LPI and SLT), and one (YAG capsulotomy) to clear a film that develops in about 30% of eyes after cataract surgery.

Consider YAG capsulotomy, for example. This procedure is painless and takes minutes, but it can also damage the eye, create more floaters or worsen vision if done poorly. The surgeon works through the microscope, and an observer can share the surgeon’s view on a monitor. After observing several procedures, trainees at Dartmouth try their hand at completing capsulotomies started by the faculty.

During this process, residents universally discover how tricky it is to maintain the laser focus, and they learn how differently some eyes respond to the laser compared with others. It may take a dozen partial procedures for a resident to gain preliminary competence. Only after they can open the capsule without damaging the patient’s lens implant can our residents do the whole procedure themselves, with the faculty observing.

This experience accumulated over three years. By the time Dartmouth ophthalmology residents graduate, they will have typically completed three-to-four dozen supervised capsulotomies and two dozen supervised glaucoma laser procedures.

Only two of the 25 optometry schools in the U.S. are in states that permit optometrists to perform laser procedures; the vast majority of optometrists have never lasered a human eye. It isn’t easy to determine how New Hampshire optometrists could acquire adequate supervised surgical experience outside a multi-year residency. HB 349 states that, for each procedure, the minimum requirement for certification includes five cases completed to the satisfaction of a board-approved proctor. Of course, competence is achieved by more than a minimum number of completed cases, and it is encouraging that the bill includes language about minimum education and training, live patient experience and outcomes reporting.

However, the hurdles for practicing optometrists to achieve competence in this new skill will be profound, as it may take many partial cases before one can safely complete five in a row. Given the complicated logistics of assembling qualified proctors, aspiring optometrists and dozens of consenting patients, there will be enormous pressure to have training devolve into a weekend course and a day of five proctored cases.

This is a very different standard from what eye surgeons at Dartmouth are accustomed to. The bill’s isolated training requirement does not — perhaps it cannot — assure a proper surgical training milieu. It does not accurately account for the realities and complexities of surgical training. Let’s be clear: Surgical proficiency develops through mentorship and repetition, building on experience with real patients and skills accumulated over time.

This is true for even the “simplest” procedures. This is not a matter that should be glossed over. Research demonstrates, for example, that SLT glaucoma laser procedures performed by an optometrist were less effective and required additional surgery twice as often as when an ophthalmologist performed the SLT (JAMA Ophthalmology, October 2016).

As program director of the Dartmouth ophthalmology residency, if I proposed a training plan for laser surgery similar to what the New Hampshire optometrists are proposing, our training program would risk losing accreditation. New Hampshire should insist that its citizens receive surgery from properly trained surgeons. Please ask your legislators to reject HB 349.

Donald M. Miller, M.D., is assistant professor of surgery (ophthalmology) and founding program director of the Dartmouth Ophthalmology Residency Program at Dartmouth-Hitchcock Medical Center  in Lebanon.