An underlying theme in this retinal vascular disease issue is the close interplay between retina and other providers. Collaborating with other physicians for pathology like uveitis and tumors is obvious, as is working with endocrine, internal medicine, and family practice for retinal vascular disease. But when we work with optometrists or physician assistants (PAs) and nurse practitioners, the scope of practice and supervisory roles are very different. If new treatments for geographic atrophy become approved, the number of injections we will perform will skyrocket. How will we handle the dramatic increase in demand for our services?

For PAs, the American Medical Association policy allows providing patient care services under the direction and supervision of a physician or group of physicians and opposes any legislation/regulation authorizing PAs to make independent medical decisions or establishing independent regulatory boards. Most states require physician supervision of PAs and limit the number of PAs that a physician can supervise. Also, 47 states define a PA’s scope of practice to be determined by supervising physicians. However, it is important to understand that in the PA curriculum, eye care and specifically ocular pathology is generally not covered.

In Ohio, a physician can supervise a maximum of 3 PAs. A certain number of PAs’ charts must be reviewed for cosignature, the PA’s scope of practice is decided by the supervising physician, and the state medical board oversees licensing of PAs. Thus, the rules of the state would allow a PA to perform intravitreal injections under supervision of a retina specialist. In a recent evaluation of Medicare data, 2 nurse practitioners and 3 PAs performed injections in the United States (0.016% of all intravitreal injections).¹ This clearly shows that the standard of care in the United States is injection by physicians. However, nurses have been performing intravitreal injections under direct supervision of a physician, creating improved efficiencies, good satisfaction, and similar safety.² With appropriate training and supervision, PAs could dramatically extend physicians’ reach.

In many specialties, it is routine to get follow-up and ongoing care by PAs. Patients enjoy access to their medical providers in the face of a reduced workforce. This is especially true in orthopedics, emergency medicine, and internal medicine.

By contrast, optometrists are state licensed to practice eye care and are regulated by the state board of optometry. In some states, optometrists can perform nonretinal laser procedures and nonretinal ophthalmic surgical procedures independently. To date, no state allows the performance of retinal procedures, including intravitreal injections, laser procedures, and surgery. Clearly, it is only a matter of time for a state optometry board to legislate the performance of these procedures to be added to the scope of optometry practice. Without training and supervision, this would be a mistake. RP

REFERENCES

1. Emerson G. Medicare 2012-2017 intravitreal injections: certification and credentials of providers. Presented at: 2020 ASRS Virtual Meeting.
2. Rasul A, Subhi Y, Sørensen TL, Munch IC. Non-physician delivered intravitreal injection service is feasible and safe - a systematic review. Dan Med J. 2016;63(5):A5229.