The U.S. Department of Veteran’s Affairs has removed language from two Eye Comprehensive Standardized Episode of Care (SEOC) guidelines about community providers that previously ensured veterans would receive complex and surgical care only from ophthalmologists. The previous wording stated that “only ophthalmologists can perform invasive procedures, including injections, lasers and eye surgery.” The new language, which was revised to reflect some states’ expanded scope of practice laws for ODs, says that these services can now be provided by “an ophthalmologist or optometrist based on the state licensure of the provider.”¹

Alaska (2017), Arkansas (2019), Wyoming and Mississippi (2021), and Virginia and Colorado (2022) have added advanced procedures to their optometric scope of practice. Some of the permitted procedures are injections, excision and removal of non-cancerous lid lesions and chalazion, YAG capsulotomy and greater prescribing authority.

The VA has partnered with ophthalmology to provide care to patients and train ophthalmology residents for more than 75 years, but with these changes, many members of the ophthalmic community are upset and concerned for patient safety. As the VA is the largest integrated health system in the country, its policy changes have widespread effects.² Department chairs at academic medical centers with VA affiliations have sent more than 10 letters already.  

“We’re concerned that this revision, which is happening without the full involvement of ophthalmology, runs the risk of an expansion of scope that’s not in our veterans’ best interests,” says American Academy of Ophthalmology CEO and former chair of ophthalmology at the UCSF Stephen D. McLeod, MD. “The scope of practice of optometrists who work within the VA hasn’t changed at this point, but it could and that is a major concern.” 

Dr. McLeod says that at present, the policy guidance for care within VA health facilities limits complex care and surgical procedures to ophthalmology, but a language change to the VA’s community care referral guideline allows VA providers to refer out surgical cases to community-based optometrists who aren’t VA employees. “This revision of the community care guideline language was advanced through the VA without input from the ophthalmologists within the VA, who are primarily responsible for the surgical care of these patients,” he says.

At this point in time, the referring VA provider would only have the option to refer out a case in one of the few states that have passed a law allowing optometrists to perform laser and other surgical procedures. “If the VA has declared that it’s willing to consider this for its patients who are seeking care outside the VA, we’re concerned that they won’t appropriately consider the implications for patients within the VA,” Dr. McLeod says. 

The degree of skills training that VA ophthalmologists have is a “world of a difference” from the exposure skills training that an optometrist delivering the same care on the outside of the VA has, Dr. McLeod points out. “There are about 23 optometry schools in the U.S. and only a few of those schools are located in the handful of states that permit OD laser surgery. There just isn’t the opportunity to learn or be exposed to the procedures. Furthermore, the criteria to become certified to perform these procedures is minimal—sometimes requiring only a didactic component or a single case.

“When you compare that with the extraordinarily structured and deliberate training that’s part of medical surgical training for ophthalmology residents, there’s really no comparison whatsoever,” he continues. “We could end up with scenarios where if you’re in the VA, you receive treatment from an ophthalmologist with a wealth of experience and rigorous training, but if you go out to the community you could be treated by someone whose first procedure is going to be on a veteran. It just defies logic.”

This change in language is also dangerous, he says, because many patients aren’t aware of the “profound distinction in the rigor of training between ophthalmologists and optometrists.” 

The Academy is actively reaching out to medical centers and legislators to inform them of the VA’s changes and the risk to veterans’ eye care.^3,4 “We hope that the VA will be willing to listen to those who have expertise in this area as they make what may seem like an administrative decision but is really a decision of patient safety and quality of care,” Dr. McLeod says. “We’ve received universal support from ophthalmologists who are also veterans. We view this as an issue of health equity for our veterans. We want to ensure that veterans will have access to the same quality of care regardless of which states they find themselves in.”

Proponents of the language change have framed this as a victory for veteran’s access to care, citing a case in which the VA reportedly suggested a patient be referred to an ophthalmologist 60 miles away for an epilation.¹ According to a story on the AOA’s website, the VA stated to Mississippi Congressman Trent Kelly that “providing quality care in a timely manner is of utmost importance. Utilizing community care providers to their full extent is part of the process.” 

Dr. McLeod says that expansion of scope for ODs is frequently advanced as an access-to-care issue. “Firstly, when you look at geographic locations and geospatial maps, there’s significant overlap where optometrists and ophthalmologists reside,” he says. “Generally speaking, it’s not as if optometrists are living where ophthalmologists are not. Secondly, there’s absolutely no evidence from the VA right now that when patients are sent out of the VA for optometric care there’s been any inability to find an appropriately trained ophthalmologist for that care.

“The other thing I find disturbing is that, even if there were an access-to-care issue, that the way to solve that problem would be to dispatch our veterans to providers with a substantially lower level of training and experience than they’d receive within the VA,” Dr. McLeod says.

In addition to these recent changes to the SEOC guidelines, the VA is currently developing its new national standards of practice for ODs and 50 other health-care positions within its system. The Federal Supremacy Project, as it’s called, aims to develop “a standardized set of services that all health-care professionals in a given occupation can perform regardless of what is permitted by a state license, certification or registration.”⁵ 

The VA states on their website that these national standards “are designed to increase veterans’ access to safe and effective health care, thereby improving health outcomes for our nation’s veterans.”⁵ Dr. McLeod says the Academy is working to ensure it “has a voice in informing these standards.” 

In response to a request for comment by Review, the VA replied: “… At this time, VA is still reviewing optometry rules across the United States and has not made any decisions about how we will proceed. When we decide on what we believe may be the best Standard for our Veterans, we will seek input from the public, the States, and our own employees through a transparent online process. More information about that process can be found on our website at https://www.va.gov/standardsofpractice/. We will not move forward with a final OD National Standard of Practice until we have had the benefit of these consultations, and therefore it is premature to make any official statements or predictions about the specific content of the national standard of practice at this time.”

The national standards for optometry are expected to be released in early 2023.

^{1. Veterans notch win as VA rescinds restrictive language governing community ODs. AOA.com. November 3. https://www.aoa.org/news/advocacy/federal-advocacy/veterans-notch-win-as-va-rescinds-restrictive-language-governing-community-ods?sso=y. Accessed Nov 15, 2022.} 

^{2. Williams RD. VA Federal Supremacy Project and scope of practice. July 2022. https://www.aao.org/eyenet/article/va-federal-supremacy-project-and-scope-of-practice. Accessed Nov 15, 2022.}

^{3. VA drops eye surgery safety language for care vets receive in the community. AAO.org. September 28, 2022. https://www.aao.org/eye-on-advocacy-article/va-veterans-community-care-centers-sugery-language. Accessed Nov 15, 2022.} 

^{4. Academic center chairs speak up to protect quality veteran eye care. AAO.org. Oct 27, 2022. https://www.aao.org/eye-on-advocacy-article/chairs-speak-up-protect-quality-veterans-eye-care. Accessed Nov 15, 2022.}

^{5. VA National Standards of Practice FAQ. Va.gov. https://www.va.gov/standardsofpractice/faq.asp. Accessed Nov 15, 2022.}