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The original documents are located in Box 1, folder "Aging - Optometry Study" of the
Spencer C. Johnson Files at the Gerald R. Ford Presidential Library.
Copyright Notice
The copyright law of the United States (Title 17, United States Code) governs the making of
photocopies or other reproductions of copyrighted material. Gerald R. Ford donated to the
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Library.
HEALTH
EDUCATION AMERICA :
DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE
PUBLIC HEALTH SERVICE
USA
HEALTH RESOURCES ADMINISTRATION
BETHESDA. MARYLAND 20014
BUREAU OF HEALTH MANPOWER
APR 27 1976
Dear Dr.
Enclosed is a copy of the Optometry Study which has been forwarded for
review in the Department. The report was approved by Dr. Kenneth M.
Endicott, Administrator of the Health Resources Administration, and
has been forwarded to the Assistant Secretary for Health.
I want to take this opportunity to thank you for your assistance and
input to the preparation of the report. As I indicated at the last
consultant session, it was indeed a pleasure to work with such a
knowledgeable and competent and, at the same time, congenial group.
It was a rewarding experience for me and for the rest of the staff.
We will keep you advised as to the progress of the clearance process.
Sincerely yours,
Daniel F. Whiteside
Daniel F. Whiteside, D.D.S.
Director
Enclosure
1 puby
FORD & GERALD LIBRARY
REPORT TO THE CONGRESS
REGARDING COVERAGE UNDER PART B OF MEDICARE
FOR CERTAIN SERVICES PROVIDED BY OPTOMETRISTS
As Required by Title I, Section 109, of the
Social Security Amendments of 1975 (P.L. 94-182)
April 1976
U.S. DEPARTMENT OF
HEALTH, EDUCATION, AND WELFARE
FORD & LIBRARY GERALD
PREFACE
This report has been prepared in accordance with Study
requirements mandated by Title I, Section 109, of the Social
Security Amendments of 1975. It provides findings and recom-
mendations, including supportive material, concerning the
appropriateness of altering current coverage provisions under
Part B of Medicare to include services related to. aphakic and
cataract conditions when provided by optometrists.
The report has three major segments. Conclusions and
recommendations provided by the Department of Health,
Education, and Welfare to Congress, as well as additional
considerations raised by expert consultants to the Study, are
provided in the beginning. Part I consists of three sections
which provide an overview to the Study framework, the current
status of Part B coverage and reimbursement of interest to
the Study, and principal findings and conclusions underlying
the recommendations. Part II, in turn, consists of five
sections which provide detailed supportive material developed
as part of the Study effort.
1
B.E.RD & LIBRARY GERALD
TABLE OF CONTENTS
Page
Preface
i
Contents
ii
Conclusions and Recommendations
iii
Additional Considerations by Study Consultants
vii
PART I
1
Section I-A - Study Background, Strategy and Methodology
2
Section I-B - Current Status of Medicare Coverage
12
Section I-C - Findings and Conclusions - Summary
18
PART II
35
Section II-A - Nature, Incidence and Prevalence of Cataract. 36
Section II-B - Optometric Practice
53
Section II-C - Optometric Education
92
Section II-D - Supply and Distribution Considerations
111
Section II-E - Cost Implications
126
ii
FORD is LIBRARY GERALD
CONCLUSIONS AND RECOMMENDATIONS
CONCLUSIONS
The following set of conclusions responds directly to the
Congressional charge concerning whether it is appropriate to alter
Part B coverage under Medicare for services related to aphakic and
cataract conditions when provided by optometrists. These conclu-
sions have been derived from factual information, analytic findings,
and professional judgements assembled in the study effort.
1. Qualifications of optometrists. Optometry is a profession
qualified to provide a broad range of services which are
effective in patient management, including the management
of aphakic and cataract patients. These services are
reasonable, non-experimental, safe, and generally acceptable
to the vision/eye care community and the public.
2. Services related to aphakic and cataract conditions. Many
of these services are the same as the specific diagnostic,
therapeutic, and consultative services currently covered
under Part B of Medicare when provided to pre- and post-
surgery cataract patients by ophthalmologists or other
doctors of medicine and osteopathy. (See Table 1, Part I,
Section I-B.)
iii
FORD & LIBRARY GERALD
3. Detection and diagnosis of disease.
Evidence presented
during this study supports the conclusion that optometrists
are qualified to provide services for the detection and
preliminary diagnosis of ocular disease and ocular mani-
festation of systemic disease. Referral, where indicated,
is made to ophthalmologists and other health care practi-
tioners for definitive diagnosis and medical or surgical
treatment.
4. Standards of Procedure. Clinical standards committees of
professional associations have identified effective instru-
mentation and procedures that are available to and utilized
by optometrists which are effective in the diagnosis/detection
of disease, notwithstanding limitation by certain State
jurisdictions regarding the use of topical drugs.
5. Quality Assurance. Quality assurance is attainable in the
provision by optometrists of reasonable, safe, non-
experimental, and acceptable services to the Medicare eligible
population. The development of criteria of care for diagnos-
tic, therapeutic, and consultative services provided by
optometrists, that are similar to those existing for certain
other health professional groups, does appear feasible in
both organized and independent health care settings. Such
criteria currently exist in a number of individual situations
or are in various stages of development.
iv
6. Access to services. Vision/eye care services for aphakic
and cataract patients, as well as for patients more
generally, can be made more accessible to the Medicare
eligible population by expanding present coverage to include
services when provided by optometrists. In general, optome-
trists are more widely distributed geographically and
practice in many smaller communities where other vision/eye
care practitioners are not available.
7. Equity. Financial equity can be extended to those Medicare
beneficiaries who currently obtain necessary and reasonable
health services from optometrists but who do not currently
receive the reimbursement to which they should be entitled.
8. Delivery patterns. It is reasonable to infer that an
extension of current Medicare coverage to include services
for aphakic patients when provided by optometrists would
not significantly alter existing provider delivery patterns
within the vision/eye care community. The impact upon such
delivery patterns of an extension of current Medicare coverage
to include services to optometrists for cataract patients,
while likely to be small, however, is less clear.
9. Costs. It is reasonable to infer, furthermore, that an
extension of current Medicare coverage to include services
related to aphakic and cataract conditions when provided by
optometrists would result in some added costs to the
>
GERALD
Medicare program. These added costs will be to the extent
of the Medicare enrollees currently served by optometrists
without reimbursement, as well as those patients not now
receiving care, who would do so as a result of an extension
of coverage. Estimates suggest, however, that such added
costs would not be significant in the context of overall
Medicare costs for vision/eye care services and service
benefits.
RECOMMENDATIONS
1. Based primarily on considerations of patient needs, qualifica-
tions of optometry to provide services effective in patient manage-
ment, and increased access of Medicare beneficiaries to vision/eye
care services, the Department recommends that coverage of services
under Part B of Medicare be extended to include services related to
aphakia when provided by optometrists, and that optometrists be
defined as "physicians" for the purpose of providing these covered
services which shall be reimbursable. This recommendation is
presented in direct response to the requirements of Section 109 of
the Social Secutity Amendments of 1975 (P.L. 94-182).
2. Based on the same considerations as indicated above, the
Department recommends that coverage of services under Part B of
Medicare be similarly extended to include services related to
cataract conditions when provided by optometrists. This recommenda-
tion is in response to the broader legislative intent interpreted
for the scope of this study.
vi
GERALD FORD LIBRARY
ADDITIONAL CONSIDERATIONS BY STUDY CONSULTANTS
During the course of the study effort, a number of issues and con-
cerns were identified by the expert consultants to the study which,
although important considerations, represented matters not directly
responsive to the specific legislative charge as interpreted. The
recommendations and comments below, made unanimously by the consul-
tants, provides an opportunity to bring these matters to the
attention of the Department and the Congress.
1. Refractive services for aphakic patients
Aphakic patients, specifically, should be considered as having
special needs given their disabled condition. Refractive services
for such patients represent non-routine and necessary services in
the provision of prosthetic devices, i.e., lenses.
Study advisors recommend that consideration be given to extending
coverage under Part B of Medicare to include refractive services for
aphakic patients when provided by either ophthalmologists or
optometrists.
2. Low vision services and aids
For those patients who have inoperable cataracts or have less
than optimal results from cataract surgery, that is, those who have
reduced visual acuity, low vision services and aids represent
essential components of reasonable and necessary health care services
for these patients.
vii
GERALD FORD (IBRAR)
Study advisors recommend that coverage under Part B of Medicare
be extended to include the provision of appropriate low vision
services and optical aids for the above-referenced patients, when
provided by either ophthalmologists or optometrists.
3. Prevention, health maintenance, and health education
In the interests of health care cost advantages, effects on
productivity, and the overall improvement of benefits that can be
afforded our population, the expert consultants recommend that a
more effective effort be made to improve preventive, health main-
tenance, and health education measures. While this is needed in
all areas of health services, the vision/eye care field offers a
particularly promising area for such approaches.
4. Other service provided by optometrists
Vision/eye care services currently covered by Part B of Medicare,
when provided by ophthalmologists or other physicians,
include eye conditions other than cataract and aphakia. Optometrists
can provide appropriate services for some of these conditions. It is
recommended that extension of coverage to include the services of
optometrists for such appropriate conditions is a desirable subject
for further consideration.
5. Administrative considerations
Also during the course of the study effort, expert advisors
raised several concerns pertinent to the administration of the
Medicare program. These issues, also applicable to other Medicare
viii
GERALD LIBRARY
services, include the following: (a) inconsistent application of
coverage and reimbursement policies by individual carriers, (b) the
problem of payment duplication for services and reimbursement for
similar diagnostic procedures when performed for specific individuals
by more than one provider; and (c) need of improvement in coding and
billing proceedures for vision/eye care services.
6. Cooperative working relationships between vision/eye care
professionals
It became clear during the course of this study that more
effective working relationships between optometry and ophthalmology
and other providers in the vision/eye care field would enhance
patient care and result in improved services to individual patients.
While improved interdisciplinary coordination applies to all the
health disciplines and specialties, it is a problem of particular
concern in the vision/eye care field. Such working relationships
could be significantly strengthened by
a. Development of joint educational programs at the undergraduate
and graduate levels, including rounds, clinics, conference,
and meetings and publications;
b. Establishment of interdisciplinary clinics with optometrists
and ophthalmologists working together;
C. Facilitation of referral of patients between the optometrist
and the ophthalmologist when in the best interest of the
patient;
ix
GERALD FORD LIBRARY
d. Joint development of quality standards for service and
materials by peer review mechanisms. By materials,
particular reference should be assigned to varying quality
of lenses and frames and the need for furnishing laboratory
invoices of material costs for reimbursement.
e. Joint development of appropriate revision to State licensure
laws to permit use of diagnostic drugs (mydrictics and local
anesthetics) by optometrists.
While such joint endeavors are evident in various areas of the couttry,
they need to be broadened and routinized.
X
GERALD FORD LIBRABY
1
PART I
The three overview sections presented in this
first part of the report provide the reader
with a general summary of the entire study
effort. The first major section presents an
account of the study background, strategy, and
methodology. The second major section provides
the reader with a synopsis of existing Medicare
provisions pertinent to the study query. The
concluding major section, in turn, presents
key findings and conclusions that have resulted
from this study effort.
QERALD FORD LIBRABY
2
SECTION I-A
STUDY BACKGROUND, STRATEGY, AND METHODOLOGY
The Department of Health, Education, and Welfare currently pro-
vides, through a variety of mechanisms, financial assistance for
the provision and receipt of health care services. As stated in
its Forward Plan for Health (June 1975): "The focus of provid-
ing access to medical services through Federal financing has
gradually shifted from limited activities for the control of com-
municable diseases among various Federal beneficiary groups, to
services for special age and population groups; to care related
to specific health needs; to comprehensive service delivery
systems; to insurance for the aged and disabled; to reimbursement
of services to the poor and medically indigent. In terms of ex-
penditures, Medicare and Medicaid represent by far the greatest
share of the Department's health financing activities."
Slightly over a decade ago, the Medicare program was promulgated
as part of the Social Security amendments of 1965, when Congress
enacted a dual program of health care to meet the growing problems
of providing services for the aged. In effect, this program was
intended to provide financing of health care services for benefi-
ciaries who tended to be in poorer health than many other popula-
tion groups and who often had inadequate financial resources to
purchase such services. As enacted, Title XVIII of the Social
Security Act consisted of provisions relating to hospital benefits
(Part A), financed by universal mandatory contributions, and a
voluntary supplementary medical benefits plan (Part B), available
to any person aged 65 or over, irrespective of Social Security
status.
At various times furing the past decade of Medicare experience,
interest has arisen in the appropriateness of altering provisions
as originally mandated by the 1965 legislation. Where Congress
has favored modifications, changes have been enacted through a
series of emendments to Title XVIII of the Social Security Act.
One areas of interest in recent years has been directed to the ap-
propriateness of selectively altering coverage under Part B of
Medicare to include certain health care services when provided by
nonphysician professional practitioners. Currently, for example,
the Department of Health, Education, and Welfare is engaged in
several efforts directly or peripherally related to this issue.
This particular document represents the output of one such effort.
FORD & GERALD LIBRARY
3
Legislative Charge
During the Senate floor debate on December 17, 1975, on H.R. 10284,
Amendments to the Medicare Law, the following amendment, which was
later enacted as Section 109 of P.L. 94-182, was proposed to re-
quire a study by the Secretary of DHEW, due four months after
enactment, regarding eligibility under Part B of Medicare for
certain vision/eye care services when provided by optometrists:
"Sec. 109. The Secretary of Health, Education, and
Welfare shall conduct a study of, and submit to the
Congress not later than four months after the date
of enactment of this section a report containing his
findings and recommendations with respect to, the
appropriateness of reimbursement under the insurance
program established by Part B of Title XVIII of the
Social Security Act for services performed by doctors
of optometry but not presently recognized for purposes
of reimbursement with respect to the provision of
prosthetic lenses for patients with aphakia."
The amendment is essentially the same as the one adopted by the
Senate two years earlier as part of H.R. 3153, the Social Security
Amendments of 1973, which did not become law. At that time, it
was suggested in the Senate report on the bill that an appropriate
study should be undertaken utilizing the expertise of both
optometrists and physicians who are not employed directly or in-
directly in governmental agencies, and that at least half of the
professionals consulted should be actively practicing optometrists.
Supporting his amendment to H.R. 10284 this past December, Senator
Robert Dole referred to the guidelines set forth in the 1973
Senate report and added:
"
I would further suggest now that the Secretary
might assign the designated task to his Assistant
Secretary of Health, and that his office in turn
utilize existing Health Manpower agencies so that
information could be supplied regarding the opto-
metric curriculum and the distribution of optometrists
generally. I would also hope that the panel formed
would include consumer representatives and than, in
the course of their investigation, consideration can
be given to services provided the entire cataract
patient--including precataract cases where appropriate."
GERALD FORD LIBRARY
4
Interpretation of Charge
Interpretation of the charge from Congress was based on the joint
context of the amendment itself and the Senate floor speech. In
order to meet the requirements intended for the study, consequently,
the following question was viewed as the principal query for exam-
ination: What services related to aphakic and cataract conditions
currently covered under Part B of Title XVIII when provided by a
physician, are appropriate for coverage when provided by an opto-
metrist? Implicit in this interpretation was the expectation that
any recommendations which might result from the study for alter-
ing Part B of the Medicare program would require legislative
change.
Two points should be noted in the context of this Departmental
interpretation. First, it was deemed appropriate to confine the
study inquiry to optometrists and optometric practice. Accord-
ingly, limited attention was directed within the study framework
to other providers of vision/eye care services. Second, although
the principal focus of the study would be to examine matters
germane to the specific legislative charge, it was also viewed
appropriate to keep the study framework sufficiently flexible to
accommodate consideration of related areas of interest (e.g.,
services presently excluded from Medicare coverage for any pro-
vider of vision/eye care services).
Departmental interpretation of the legislative intent regarding
substantive content of the study, as well as the use of non-
government expert advisors, is treated in the remainder of this
section.
Study Strategy
In addressing the appropriateness of introducing modifications to
existing provisions under Part B of Title XVIII, a balanced assess-
ment must examine considerations of population health care needs,
the quality of service delivery provided to the Medicare eligible
population, resource distribution and access concerns, and
respective cost implications. The intensity of any study inquiry
into such areas, however, must be tempered by the availability of
time, resources, and information of relevance. Given the time
constraints available for the conduct of this mandated study, the
Department adopted a closely-defined strategy to undertake this
effort.
Health Care Needs. As stated in Vision Research Program Planning,
a report developed under the auspices of the National Advisory Eye
Council and published this past year by the National Eye Institute,
the National Institutes of Health, "the great toll taken each year
FORD & LIBRARY GERALD
5
in the United States by eye diseases is.
not measured in terms
of mortality--few disorders originating in the eye cause death--
but rather in degrees of physical limitation and financial burden.
But such measurements are inadequate, for they do not convey the
hardship or mental anguish of having to function in a complex en-
vironment deprived of normal vision. Perhaps for these reasons,
Americans have indicated that they fear blindness more than any
other physical affliction with the single exception of cancer "
Although applicable to persons generally, this passage has parti-
cular relevance for any consideration of vision/eye care disorders
and their impact upon the elderly members of our society. Persons
sixty-five years of age and over continue to account for a dispro-
portionate share of vision/eye problems, a fact that often further
complicates the already complex life conditions faced by many
geriatric persons.
An assessment of the extent of overall vision/eye care needs of
the elderly is itself a difficult undertaking, similar to efforts
addressing broader health care needs and other population segments.
Judgments from professional providers or other experts close to the
subject yield approximations with wide variation for both overall
vision/eye care needs as well as needs more pertinent to aphakia
and cataract. For this brief study effort, it was believed
reasonable that the identification of relevant incidence and pre-
valence data, along with selected data on utilization, would pro-
vide an adequate information base to address this area.
Quality of Service Delivery. In an consideration of modifications
to the Medicare program, an assessment of the qualitative dimen-
sions of health care delivery is also relevant. It is principally
due to a concern for minimizing variability within the qualita-
tive aspects of health care delivery that de facto adoption of
State Practice Act provisions, which often exhibit extensive
variations from one jurisdiction to another, has not been routinely
accepted as an exclusive criteria for extending eligibility to
providers currently outside the provisions of the program. This
consideration has been particularly relevant in situations where
universal coverage experience has not existed.
Given this context, the question of relevance is not whether the
quality of health care delivery should be addressed, but rather
how should it best be addressed. The quality of health services
is admittedly an elusive concept, involving measures that are
often, at best, imprecise.
The strategy of this study, in view of this consideration, was to
direct attention to selected structure, process, and outcome variables.
FORD & LIBRARY 038470
6
As such, consideration was given to the appropriateness of equip-
ment and procedures utilized by optometrists for providing re-
quired services; the extent to which optometric education and
usual practice correspond to the skills and experience identi-
fied for the requisite services; and the existance of any
optometric practice standards that might exist or be in the
process of development. Bibliographic searches were undertaken
to uncover the availability of any controlled studies that have
been directed to assess the effectiveness of optometric practice.
Attention was also directed to an analysis of State Optometry
Practice Act, primarily to document the extent of uniformity or
variability among extant provisions, as well as to supplement
analyses of relevant structure or process variables (e.g., the
extent to which continuing education requirements are stipulated
in State Practice Acts).
Distribution, Access, and Cost. Although access to health care
can be conceptualized in several ways, such as in terms of finan-
cial, physical, and attitudinal barriers to obtaining services,
a thorough examination of this issue requires a relatively broad
view of resource availability and distribution. For example, a
consideration of physical access solely in terms of numbers of
available health care resources represents a limited input for
policy development concerning resource access. Measurement of
physical access is better undertaken in terms of the monetary
and non-monetary costs of obtaining requisite services, includ-
ing considerations of respective transportation, time, and search
costs incurred. Insuring physical access in monetary terms, con-
sequently, should raise the possibility of tradeoffs between
improved financial access and improved physical access.
Despite such broader considerations, including respective impli-
cations for health manpower education policy, time and data
availability constraints for this study effort suggested a more
narrow course for examination. Attention was focused, therefore,
on the geographic distribution of the Medicare eligible popula-
tion and the corresponding distributional patterns of opto-
metrists and ophthalmologists. The rationale was to conduct a
first-order level of analysis concerning potential impacts upon
availability of manpower (services) from any potential alterations
in existing coverage.
Changes in existing utilization patterns, potential alterations
in the patterns of service delivery by providers, as well as
possibilities for duplication of services all represent minimum
considerations for analytic endeavors attempting to assess the
cost implications of any shifts in prevailing coverage. Attention
to respective consequences for Medicare program costs and health
care costs generally represents an integral part of any inquiry
FORD & LIBRARY GERALD
7
concerning the appropriateness of potential modifications to exist-
ing Medicare provisions and policy. Given such considerations and
again within the time and data constraints for this effort, the
study intent was to provide a rough first-order magnitude of the
respective cost implications at issue, as well as to delineate
several key dimensions that might be relevant for any definitive
inquiry into this matter.
Study Methodology
Current and historical studies, as well as data collection efforts
already completed, were heavily relied upon for information uti-
lized in this study. This process was expedited by the use of
selected bibliographic searches, as no primary data collection
activities were undertaken for this effort.
In accordance with the legislative charge, furthermore, a panel of
nine expert consultants was convened. This group of individuals
assisted the study effort by reviewing material assembled by the
study staff; provided information sources and, where appropriate,
access to relevant material for the conduct of the study; and
served in a technical advisory capacity. Although the consultants
contributed substantially to the preparation of this report, in-
cluding its conclusions and recommendations, its overall contents,
apart from the statement on Additional Considerations at the begin-
ning of this report, are the responsibility of the Department.
The panel consisted of three active practicing optometrists, three
ophthalmologists, one optometric educator, and two public members.
(See the Attachment to this section for a listing of the names of
consultants.) During the course of the study, the panelists were
convened on three occasions, although informal dialogue between
individual consultants and respective study staff continued
throughout the study's duration.
The above discussion concerning "study strategy" briefly outlined
the analytic components of the study. Logistically, during their
first meeting, panelists were presented with a series of questions
that study staff intended to address as part of the analytic
endeavors. Dialogue between panelists and study staff during that
meeting, as well as inputs provided by selected organizational
components of the Department, served to finalize the study frame-
work. During the latter part of the effort, the expert consultants
reviewed findings suggested by study staff, and, at the request of
staff, provided their professional views concerning the range of
potential conclusins and recommendations which might reasonably
be related to these findings.
GERALD ? FORD
8
The Bureau of Health Manpower of the Health Resources Administra-
tion, PHS, which is directed by Daniel F. Whiteside, D.D.S., had
primary responsibility for the staff work. Expert assistance in
specific areas of the study was provided by the Office of Policy
Development and Planning, Office of the Assistant Secretary for
Health, PHS; Bureau of Quality Assurance, Health Services Admini-
stration, PHS; National Eye Institute, National Institutes of
Health, PHS; National Center for Health Statistics and National
Center for Health Services Research, Health Resources Administra-
tion, PHS; and the Bureau of Health Insurance and the Office of
Research Statistics, Social Security Administration. A listing
of study staff, as well as formal linkage persons in Departmental
organizations identified above is also provided in the Attachment.
In addition, a number of additional governmental and non-govern-
mental sources were contacted informally during the course of the
study. Where information was obtained from such sources and
utilized in this effort, appropriate references are provided in
the text of this report.
GERALD LIBRARY FORD
9
ATTACHMENT
LISTING OF EXPERT CONSULTANTS, STUDY STAFF, FORMAL AGENCY LIAISON
I. Expert Consultants
Ron G. Fair, O.D.
Practicing Optometrist
Brighton, Colorado
James P. Gills, M.D.
Practicing Ophthalmologist
New Port Richey, Florida
Robinson D. Harley, M.D.
Practicing Ophthalmologist
Philadelphia, Pennsylvania
Albert N. Lemoine, M.D.
Department of Ophthalmology
The University of Kansas School of Medicine
Kansas City, Kansas
Carroll M. Martus, O.D.
Practicing Optometrist
Marblehead, Massachusetts
Michael J. Obremsky, O.D.
Practicing Optometrist
Annandale, Virginia
Henry B. Peters, O.D.
Dean, School of Optometry
University of Alabama
Birmingham, Alabama
R. Roy Rusk
Director, Program
American Foundation of Overseas Blind, Inc.
New York, New York
William K. Selden, Litt.D.
Princeton, New Jersey
FORD & LIBRARY GERALD
10
II. Key Study Staff
Paul M. Schwab, M.A., M.P.H.
Office of the Administrator
Health Resources Administration
Thomas D. Hatch
Nathan Watzman, Ph.D.
Grace Madison, J.D.
David B. Hoover, M.P.H.
Division of Associated Health Professions
Bureau of Health Manpower, HRA
Stuart Bernstein, B.A.
Larry W. Lacy, M.A.
Manpower Analysis Branch
Office of the Director
Bureau of Health Manpower, HRA
III. Formal Agency Liaison
Samuel W. Kidder, Pharm.D., M.P.H.
Office of the Assistant Secretary for Health
Linda L. Cohen, M.D.
Bureau of Quality Assurance, Health Services Administration
Luigi Giacometti, Ph.D.
National Eye Institute, National Institutes of Health
Peter W. Ries, Ph.D.
National Center for Health Statistics, Health Resources Administration
Alvin Abrams, M.D.
National Center for Health Services Research
Health Resources Administration
Harold Fishman
Bureau of Health Insurance, Social Security Administration
James Caple
Office of Research Statistics, Social Security Administration
GERALD FORD LIBRARY
11
IV. Secretarial and Meeting Coordination Assistance
Shirley G. Miller
Roberta Light
Frances A. Gaetano
Division of Associated Health Professions
Bureau of Health Manpower, HRA
V. Library and Reference Services
Elizabeth Martinsen
Manpower Analysis Staff
Office of the Director
Bureau of Health Manpower, HRA
GERALD FORD
12
SECTION I-B
CURRENT STATUS OF MEDICARE COVERAGE-
In order to provide the basis for a review of the question of the
appropriateness of extending coverage under the insurance program
established under Part B of Title XVIII of the Social Security Act
of services to cataract patients provided by optometrists, but not
presently recognized for coverage, it is essential to understand
the current status of coverage. The purpose of this section is to
provide that understanding.
Part B of Title XVIII of the Social Security Act (Sec. 1831-1879)
entitled "Supplementary Medical Insurance Benefits," in contrast
to the hospital benefits program (Part A), is a voluntary program
for eligible individuals who elect (or in certain cases do not
decline) to enroll. It is financed from premium payments by
enrollees and from contributions from fxnds appropriated by the
Federal Government. Eligible enrollees include persons who have
attained the age of 65 years and (after 1973) certain persons under
age 65 who are disabled or suffer from chronic renal disease. As
the title implies, the program supplements the benefits provided
under the hospital benefits program by covering physician and
certain other practitioners' services, additional home health
visits, plus a number of other medical and health services not
covered by the Hospital Benefits program. There are, however,
limitations on the benefit entitlements in the form of deductibles
and coinsurance, as well as exclusions relating to specific services.
The implementation of the Social Security Act is vested, by statute,
with the Secretary of Health, Education, and Welfare. Operational
responsibility for the Medicare program is carried out by the
Social Security Administration.
Coverage is defined by the statute and by regulations promulgated
pursuant to the statute by the Department of Health, Education, and
Welfare. It is also important to recognize the importance of
"legislative history" to both the formal regulatory process and
implementation of the program. Thus, where more than one inter-
pretation may be made from the statutory language itself, various
congressional documents, particularly reports issued by Congres-
sional committees, are utilized to determine congressional intent.
Also, one cannot underestimate the importance of the staff of the
Department of Health, Education, and Welfare, particularly the
Social Security Administration which has responsibility for
implementing the program within the law and regulations in a
consistent manner.
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The program is administered on a day to day basis through contracts
negotiated between the Federal Government and health insurance
carriers whereby the carriers reimburse from the trust fund estab-
lished from premium payments of enrolled beneficiaries and Federal
contributions. The Federal Government may also enter into agreements
with States for coverage of eligible individuals who are concurrently
receiving payments under public assistance programs provided through
the Social Security Act.
It is the responsibility of the carriers (or State agencies) to
interpret policies regarding benefits and limitations in accepting
or rejecting bills submitted for reimbursement and to determine that
charges made for covered services are reasonable and necessary. To
assist carriers in this process, the Social Security Administration
issues Health Insurance Manuals (HIM's). There are active contracts
with more than 70 carriers and one State agency agreement for
implementation of Part B.
As of July 1, 1973, 23.5 million aged and disabled persons were
insured under Medicare. Of these, 22.5 million were enrolled under
Part B, with 22.2 million covered under both Part A and Part B,
and 244, 000 under Part B only. Part B enrollees included 20.9
million persons over age 65 and 1.6 million under age 65
Basic Services Covered by the Supplementary Medical Insurance Program
The Social Security Act (Sec. 1832) divides the scope of benefits
covered by Part B into three basic elements: (1) "home health
services, " (2) "medical and other health services, " and (3) "out-
patient physical therapy services. 113/ In general, reimbursement to,
or on behalf of, enrolled beneficiaries is made for such services
subject to the Definition of Services, Institutions, etc.; and the
Exclusions from Coverage outlined in Part C of Title XVIII (Sec. 1861
and 1862).
Medical and Other Health Services are defined (Sec. 1861 (s)) to
include:
(1) physicians' services
(2) services and supplies furnished as an incident
to a physician's professional services
(3) diagnostic X-ray laboratory and other diagnostic tests
(4) X-ray, radium and radioactive isotope therapy
(5) surgical dressings, and splints, casts and other
defices used for reduction of fractures and dislocations
(6) rental or purchase of durable medical equipment
(7) ambúlance service
(8) prosthetic devices
(9) leg, arm, back, and neck braces
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The Act (Sec. 1861 (q) and (r)) further, defines "physicians'
services" and "physician."
The term "physicians' services" means "professional services
performed by physicians, including surgery, consultation, and home,
office, and institutional calls " (except those services
provided by interns and residents, which are outlined separately.)
"The term 'physician,' when used in connection with the performance
of any function or action, means (1) a doctor of medicine or
osteopathy legally authorized to practice medicine and surgery by
the State in which he performs such fxnction or action
"
Dentists, podiatrists, optometrists and chiropractors are also
defined as "physicians" for certain specific and limited purposes
within the Act.
Section 1862 sets forth exclusions from coverage under the Act,
prohibiting payment, notwithstanding any other provisions of
Titles A or B, for any expenses incurred for certain items and
services. A list of thirteen exclusions is specified. Of
pertinence to this study are items or services
- "which are not reasonable and necessary for the
diagnosis or treatment of illness or injury or
to improve the functioning of a malformed body
member;'
- "where such expenses are for routine physical
check-ups, eyeglasses or eye examinations for
the purpose of prescribing, fitting, or changing
eyeglasses, procedures performed (during the
course of any eye examination) to determine the
refractive state of the eyes, hearing aids or
examinations therefor, or immunizations."
Current Coverage for Services Provided to Persons with Cataracts
In general, diagnosis and treatment of cataract conditions are
services to which beneficiaries enrolled under Part B are entitled.
However, there are certain limitations to this coverage, both as to
specific services for which reimbursement may be made as well as to
the nature of the practitioner who provides the service. Exclusions
relating to the services for which expenses are not covered are as
follows:-
1. Routine physical checkups. Thus, for example, the
diagnosis of cataracts, if made during the course of
a routine physical examination, would not be covered.
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2. Provision of eyeglasses or contact lenses, except
both temporary and permanent post surgical lenses
which, after the natural lens of the eye has been
removed, are considered to be prosthetic devices.
3. Eye examinations for the purpose of prescribing,
fitting, or changing eyeglasses or contact lenses
for refractive error only.
4. Procedures performed in the course of any eye
examination to determine the refractive state of
the eye.
Limitations to the nature of the practitionér who provides covered
services to a cataract patient are principally related to the
definition of "physician" for purposes of the Act.
As noted above, in addition to doctors of medicine and osteopathy,
the Act defines other practitioners, including optometrists, as
"physicians" for specific purposes within the program. In the case
of optometrists, this definition is limited to "establishing the
necessity for prosthetic lenses. 115/ Regulations clarify this by
defining an optometrist as a "physician" " only for the purpose
of attesting to the necessity of prosthetic lenses. "6/
Regulations further state that "The prescription or order of a
doctor of optometry will be accepted as evidence of the medical
need for prosthetic lenses. However, optometric examinations for
any purpose are not covered. 1171
Inclusion of the above definition relating to doctors of optometry
was made by amendment to the Social Security Act in 1972. Prior to
that time, while prosthetic lenses were reimbursable when provided
by an optometrist, it was necessary for the patient to have a
prescription from a physician. The intent of the amendment was to
eliminate the necessity for an aphakic patient to obtain a physician's
order for prosthetic lenses by recognizing the ability of an
optometrist to determine a beneficiary's need for such lenses.
The reports of both the Senate and House Committees made it clear,
however, that the purpose of the amendment was solely for the
purpose of establishing or attesting to the medical need for
prosthetic lenses, and did not provide for coverage of services
performed by optometrists other than those previously covered
8/
In summary, current Part B coverage for cataract patients includes,
when provided by any doctor of medicine or osteopathy, (1) eye
examinations, except that part of the examination related to
refraction, if the examination is carried out in relation to a
specific patient complaint; (2) surgical and related professional
services carried out in connection with removal of the lens; and
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(3) services in connection with the provision of both temporary and
permanent prosthetic lenses, including fitting and providing the
lenses themselves. The only services for which optometrists may be
reimbursed are dispensing services in connection with the actual
fitting and provision of prosthetic lenses. Table 1 delineates
the status of Part B reimbursement for services within the scope
of practice of both physicians and optometrists.
TABLE 1
Part B Reimbursement Status of Services to Cataract and Aphakic
Patients which are Provided by both Physicians and Optometrists
Eligible for Part B
Reimbursement Under
Service*
Certain Conditions
MD/DO** OD
Personal and Family Health History,
Symptoms and Vision Requirements
X
Visual acuity - distance and near, with
and without correction
External examination (eye and adjacent structures)
Direct and indirect ophthalmoscopy
Biomicroscopy
Tonometry
Central and peripheral visual fields
Ophthalmometry/Keratometry
Refraction - objective and subjective,
distance and near
Ocular motility and binocular function
Visual perception, color vision, Stereopsis, motor
X
Evaluation for contact lenses
Evaluation for low vision aids
Evaluation for vision training therapy
Ophthalmic prosthesis and services
X
*
Services listed include only those within the scope of practice
of both physicians and optometrists. All of the listed services
would not necessarily be provided by either provider to every
cataract or aphakic patient during the course of each examination.
Most of these services, when provided by physicians, are typically
provided only by those specializing in Ophthalmology. However,
any doctor of medicine or osteopathy is authorized to carry out
any of the services listed and could be reimbursed for any covered
services provided.
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Footnotes and Bibliography
1/ Basic information included in this section is derived from the
"Social Security Act and Related Laws (including Amendments
through January 2, 1976), " Committee on Finance, United States
Senate, February 1, 1976; Federal Regulations No. 5, 39 F.R.
28624 (Aug. 9, 1974); and "Health Insurance Manuals" (HIM's)
issued by the Social Security Administration as instructions
to carriers. A useful supplementary compilation of the various
pertinent documents is "1974 Social Security and Medicare
Explained -- Including Medicaid --," Commerce Clearing House,
Inc., Chicago, Ill., 1974.
2/ U. S. Department of Health, Education, and Welfare, Social
Security Administration "Medicare 1973," DHEW Publication No.
(SSA) 76-11705, U. S. GPO, Washington, D.C., 1975, P. 1.
3/ Since home health services and outpatient physical therapy
services are not pertinent to this study, they will not be
discussed further.
4/ See Social Security Act, Part B, Section 1862 (a) (7); Regulations
No. 5, Subpart C, paragraph 405.310; Medicare Carriers Manual,
HIM 14-3 paragraphs 2320, 4125, 5217. See also Social Security
Act, Part B, Sec. 1861 (s) (8).
5/ Social Security Act, Title XVIII, Part B, Sec. 1861 (r).
6/ Regulations No. 5, paragraph 405.232 (a) (4).
7/ Regulations No. 5, paragraph 405.232 (c).
8/ See United States Senate Report of the Committee on Finance to
accompany H.R. 1, Senate Report No. 92-1230, September 26, 1972,
pp. 43-44; and U. S. House of Representatives Report of the
Committee on Ways and Means on H.R. 1, House Report No. 92-231,
May 26, 1971, PP. 117-118.
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SECTION I-C
FINDINGS AND CONCLUSIONS -- SUMMARY
This section provides a summary of the key study findings and con-
clusions which underlie recommendations presented in the beginning
of this report. The points highlighted below have been documented
on the basis of
statistical or factual information, or pro-
fessional judgements concerning what would represent reasonable
and likely inferences given professional experience. Detailed
inputs to the study, which were used in the preparation of this
section, are provided in Part II of the report.
Vision/Eye Care Needs of the Elderly
Geriatric patients are likely to suffer from multiple symptoms and
various interrelated disabilities, with underlying pathology that
is complex and that requires a range of diagnostic, therapeutic,
and domiciliary care services. Their health conditions are often
further complicated by social, psychological, and economic insta-
bility, requiring various health consultative services as well.
The elderly population accounts for a disproportionate share of
vision/eye problems, including cataract and aphakia, and requires
vision/eye care services provided in a professional, compassionate
manner. Lack of mobility, as well as dependency and depression,
represent but a few examples of life conditions experienced by
geriatric patients. Vision problems, furthermore, may precipitate
other problems, such as consequences of accidents and injuries
attributable to visual difficulties.
Cataract, as a structural definition, refers to any opacity of the
crystalline lens. Since such opacities result in most instances
from the normal physiological process of aging, it is therefore
not unusual for large numbers of the elderly to have varied degree
of cataract in technical terms. Although respective stages in the
progression of cataract can be generally classified, there does
not currently exist a means for objectively and consistently deter-
mining these stages. Consequently, general agreement does not
exist in the provider community concerning appropriate functional
definitions for cataract.
During the course of this study, the panel of expert consultants
did agree upon a functional definition of cataract for diagnostic
purposes:
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A clinically significant cataract is any opacity of the lens* that
reduces visual acuity and may be functionally disabling or dis-
ruptive of the normal life style, more particularly for near or
distant vision (e.g., reading or driving). This definition served
as a framework for addressing requisite patient services and pro-
vider qualifications. Given the lack of concensus within the pro-
vider community on functional definitions, as well as considerations
relevant for administering Medicare, this definition was not
necessarily formulated as a disease-specific criteria for Medicare
regulation-drafting purposes.
Statistical profiles on cataracts, despite definitional variations,
remain informative in addressing the general magnitude of this
eye disorder. Approximately three-fourths of an estimated inci-
dence of 912,000 new cases of cataract per year, for example, is
accounted for by the elderly. Among eye disorders, furthermore,
the relationship between cataract and blindness is particularly
significant.
Although senile (senescent) cataract accounts for approximately
ninety percent of the documented cases, it should also be noted
that most cataract of this type has no demonstrable etiology.
Approximately one out of every ten persons with senescent cataract
has overt diabetes millitis. Typical diabetic cataract usually
develops in patients with severe, prolonged poorly-controlled
diabetes. These patients are most commonly seen in later years
of life, although they may be seen early in their youth.
At the present time, surgery is the only method for treating cat-
aract. There is no medical treatment available that will dissolve
the opacity or prevent its development and progression. It is
estimated that in 1972 somewhat over 300,000 surgical operations
were performed for cataract extraction, with the largest propor-
tion occuring among the elderly. Most aphakic patients, that is,
thsoe who do not have their natural lens(es), have lost their
natural lens(es) as a result of surgery performed for cataract.
Approximately five percent of cataract extractions have signifi-
cant complications and most of these complications occur during
or soon after cataract surgery. Within this group, some common
complications consist of vitreous loss, intraocular hemorrhage,
cystoid maculopathy, a shallow anterior chamber, postoperative
intraocular infection, Elschnig pearls, glaucoma, and retinal
detachment.
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Refractive services are particularly important for the aphakic
patient. Optical correction of aphakia usually begins within a
day or two after surgery utilizing temporary eye glass correction.
A final permanent prescription is not given until two to three
months and sometimes longer after the extraction. Rarely are con-
tact lenses prescribed before six weeks following surgery. However,
there are several varieties of soft, hydrophilic contact lenses
now available which are prescribed early in the post-operative
period. These are prosthetic devices used to replace an excised
body organ.
Patient rehabilitation is initiated prior to surgery and is con-
tinued afterwards, beginning when final physiological changes sub-
sequent to surgery have taken place. With most patients, stabil-
ity tends to occur within six to eight weeks after surgery; in
some instances, however, the final fitting of prosthetic lenses
cannot be undertaken until six months or more have elapsed. For
certain patients, rehabilitation in the use of prosthetic devices
is necessary to assist the patient with spatial orientation and
mobility.
Since aphakic patients tend to be older, difficulties may result
in adapting to contact lenses. For example, physical disabilities
such as tremor and arthritis may require a lengthy period of
supervised use of contact lenses or preclude their use entirely.
In these patients, the structure of the eye lids may be soft and
flaccid, which may cause difficulties in contact lens removal or
may cause the lens to ride low with its center below the center of
vision. Other circumstances, such as abnormally large pupils or
cornea scarring resulting from surgery may complicate the adapta-
tion process as well.
For certain aphakic patients, the use of prosthetic devices such
as spectacles and contact lenses, or the implantation of a plastic
lens within the eye following cataract surgery after removal of
the natural lens, does not provide optimal vision for their life-
style and occupational requirements. The Study consultants recom-
mended that such patients be considered for low vision aids, such
as special microscopic reading glasses and telescopic spectacles.
Such devices have been very effective, when properly applied, in
providing the best possible vision function for certain lifestyle
activities, a requirement that is most important to the physical
and mental well-being of these patients.
Access To Vision/Eye Care Services
The management of cataract and aphakic patients requires a range
of diagnostic, consultative, and therapeutic services, apart from
surgery specifically. As outlined earlier, many of these services
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related to the eye are eligible for coverage under current Medi-
care provisions. For the most part, in addition, doctors of
medicine and osteopathy, when legally authorized to practice med-
icine and surgery by States in which they practice, are the practi-
tioners recognized by Medicare to render and be reimbursed for
these services.
It is virtually self-evident that currently covered vision/eye
care services related to aphakic and cataract conditions can be
made more accessible to the Medicare eligible population by expand-
ing the present coverage for services to include services provided
by optometrists. As a minimum, greater financial equity can be
extended to those Medicare beneficiaries who currently obtain
necessary and reasonable health services from optometrists without
Medicare reimbursement.
This conclusion is principally supported by analyzing comparatively
the distributional patterns of optometric and ophthalmologic man-
power. It should be noted that ophthalmologists are not the only
physician group rendering vision/eye care services and included
under Medicare provisions. Among physician providers, however, it
is reasonable to infer that ophthalmologists provide the bulk of
overall vision/eye care services.
In 1973, there were approximately two active optometrists for
every one active ophthalmologist in the United States. Respective
active supply estimates numbered 19,300 and 10,500. On a compara-
tive basis, the supply of optometrists was more evenly distributed
across the country. The study effort, utilizing data assembled
from American Medical Association records, the 1972-73 optometry
inventory conducted by the American Optometric Association and
supported by the Bureau of Health Manpower, and statistics collected
by the National Center for Health Statistics, DHEW, identified
specific findings relevant for examining overall supply and dis-
tributional patterns between the two provider groups.
Despite the national two-to-one relationship, most States exceeded
or approximated this ratio, as a number of large, heavily populated
areas statistically influenced the overall figure. Active ophthal-
mologists exceeded the number of active optometrists in only two
areas of the nation, Maryland and the District of Columbia. In
seven States, in contrast, there were greater than three times as
many optometrists than ophthalmologists.
The overall national relationship largely reflects distributional
experiences in the nation's metropolitan areas. For example, in
1973, there were approximately 1.7 optometrists for every ophthal-
mologist in metropolitan areas, in contrast to a ratio of 4.2 in
non-metropolitan areas. A total of 5,300 active optometrists were
located in non-metropolitan areas, or slightly more than one-fourth
GERALD LIBRARY FORD
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of the overall active optometric supply; this compared with 1,200
active ophthalmologists, or somewhat more than one-tenth the supply
of this provider group. In terms of persons sixty-five years of
age and older, there were 55 ophthalmologists and 99 optometrists
per 100,000 persons in metropolitan areas, in contrast to ratios
of 19 and 79, respectively, in non-metropolitan areas.
It should be noted that such metropolitan and non-metropolitan
differences vary by size of the respective areas and by regional
setting. For example, available data indicate that there are
somewhat higher ratios of both ophthalmologists and optometrists
to the Medicare eligible population in areas of 500,000 population
or more than in smaller metropolitan areas. In non-metropolitan
areas of the North Central States, for example, there are between
six and seven optometrists for every ophthalmologist, in contrast
to four and five-to-one relationships evidenced in the South, and
three-to-one relationships in the remaining non-metropolitan areas
of the nation.
One-third of all counties in the nation had the services of ophthal-
mologists in 1968 (latest data available), compared with two-
thirds of the countries for optometrists in 1973. Here, also,
more specific variations can be noted concerning metropolitan and
non-metropolitan counties. Overall, in comparing 1968 ophthal-
mologist data with 1973 optometrist data by county, 1,251 or 40
percent of the counties had one or more optometrists and no ophthal-
mologists; 33 or 1 percent had one or more ophthalmologists and
no optometrists; 1009 or 32 percent had both optometrists and
ophthalmologists; and 851 or 27 percent had neither provider group
represented.
Based upon existing trends, little change in the proportion of
either ophthalmologists or optometrists practicing in non-metro-
politan areas can be projected. The proportion of recent graduates
from schools of optometry, aged 30 and younger, practicing in non-
metropolitan areas is about the same or slightly lower for nine out
of ten established optometry schools as compared to the proportion
of total graduates practicing in these areas. In comparing 1968
to 1972 data, a lower proportion of ophthalmologists were practic-
ing in non-metropolitan areas in 1968, only 13 percent were
practicing in such areas in 1972.
In terms of overall supply, the Bureau of Health Manpower projects
the overall number of active ophthalmologists in the United States
to rise to 13,300 in 1980 and to 18,400 by 1990; this compares with
projected levels of 22,000 and 28,200 for optometrists in the same
time intervals. The proportion of ophthalmologists as a percent of
total professional vision care manpower it projected to grow from
35 percent in 1973 to 38 percent in 1980 and 39 percent in 1990.
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Available data preclude such projections on a detailed geographic
basis. (Note: These estimates should be interpreted cautiously,
and should be undertaken in the context of written documentation
available from the Bureau of Health Manpower.
Available documentation, in sum indicates that there are a number
of areas in the country, particularly in non-metropolitan settings,
where population groups are only served by optometrists. An exam-
ination of basic measures of productivity further suggests that
such optometrists may be seeing fewer patients on the average than
optometrists not practicing in these areas. This observation
results from an examination of data on average vision analyses
performed by optometrists and the utilization of auxiliaries by
optometrists. While non-metropolitan optometrists showed a some-
what greater proportionate utilization of auxiliaries than did
optometrists in metropolitan areas, optometrists in metropolitan
areas utilizing auxiliaries had a somewhat greater average number
of vision analyses than did optometrists in non-metropolitan areas
utilizing auxiliaries.
The above discussion has focused on access considerations pertinent
to Medicare beneficiaries in need of vision/eye care services, in-
cluding cataract and aphakic patients specifically. Attention
needs to be focused at this point, however, on the optometry pro-
fession itself, including its respective scope of practice, as
well as its qualifications for providing reasonable and necessary
services as required by law.
Optometric Practice
The Institute of Medicine of the Natinal Academy of Sciences, in
describing primary health professions who are direct providers of
patient care, defined optometry as follows: "The Doctor of Optometry
(O.D.) is a health professional who performs eye examinations to
determine the presence of visual, muscular, or neurological abnorm-
alities, and prescribes lenses, other optical aids, or therapy,
such as eye exercises to enable maximum vision. Optometrists are
trained to recognize disease conditions of the eye and ocular mani-
festations of other diseases, and to refer patients with these
conditions to the appropriate health professional."
This definition, as well as available documentation on the utili-
zation of optometric services, points to the optometrist's role
as a provider of primary health care services. In this role, the
optometrist functions as a principle point of contact within the
health care system for persons having visual complaints, including
certain numbers who have symptoms or conditions that require re-
ferral to other health practitioners.
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The scope of practice for optometry, similar to that for other
health care providers, is difficult to define precisely. Here also,
information is available from a number of sources to develop valid
concepts of a profession's role and function. Such sources in-
clude State laws, judgements of courts concerning the responsibi-
lities of practitioners, the usual and customary practices of the
profession, and the objectives, content, and standards of educa-
tion and training for the profession.
An examination of a variety of such sources in the study effort
suggests persuasively that optometry is a profession qualified to
provide a broad range of services which are effective in patient
management, including the management of aphakic and cataract
patients. (See discussion in Part II of this report for detail on
sources cited and information examined.) It is reasonable to infer
that such services correspond to many specific diagnostic, thera-
peutic, and consultative services currently reimbursable under the
Part B provisions of Medicare when provided to pre- and post-
cataract surgery patients by ophthalmologists or other doctors of
medicine.
Expert advisors to the study detailed more specifically the broad
range of services provided by optometry. These include personal
and family health history (symptoms and vision requirements);
visual acuity, distance and near (with and without correction);
external examination; direct and indirect ophthalmoscopy; biomicro-
scopy; gonioscopy; tonometry; central and peripheral visual fields;
macular integrity, fixation; ophthalmometry/keratometry; refraction,
objective and subjective, distance and near; ocular motility and
binocular function; visual perception, color vision, stereopsis,
motor; evaluation for contact lenses; evaluation for low vision
aids; evaluation for vision training therapy; and the provision of
ophthalmic prosthesis and services.
It was the further opinion of the study consultants that such
services comprise appropriate therapeutic modalities in eye care
including: prescription of lenses (spectacles or contact lenses),
vision training, rehabilitative services, including the teaching
of patients to use prescription devices properly, and post-surgical
monitoring of referred patients. Furthermore, the professional
judgement of the provider as to which therapy or combination of
therapies above should be used, is dictated by the presence or
absence of related ocular disease and complications of systemic
disease, as well as the occupation and life style of the patient.
In terms of practice setting, most optometrists are solo practitioners
and, therefore, serve in independent settings. Partnerships or
group practice arrangements account for approximately one-eighth of
GERALD FORD LIBRARY
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the optometric manpower supply. In independent settings, speci-
fically, similar to situations evident for many other health pro-
vider groups, it is difficult to determine the extent to which
individual practitioners provide the detailed range of services
articulated for the profession overall.
Advisors to the study effort indicated that, in their collective
professional judgement, most of these services would be provided
by optometrists. Variations in services provided by practitioners
generally would likely reflect differences in professional judge-
ment and the circumstances specifically characterizing the patient
presented. Given the variations in cases presented to vision/eye
care providers, it would be difficult to rigidly identify "cataract-
specific" vision/eye care services; such services, for example,
might often vary depending upon the type of cataract. In addition,
the nature of such services would also likely differ if the patient
were pre- or post-surgical.
Some documentation on this issue is available from the survey of
optometric practice, which was funded by the Bureau of Health
Manpower, DHEW, in 1968. The survey indicated that, as of that
year, most optometrists who were educated in the preceding twenty-
five years did report providing a broad range of services. The
extent to which the above-referenced services are provided by opto-
metrists is more easily documented, however, in organized health
care settings.
In settings such as the armed forces, health maintenance organiza-
tions, and, to a lesser extent, the Veteran's Administration faci-
lities, optometrists are used extensively for initial vision exam-
ination purposes, and, therefore, serve largely in the role of
primary care providers. In larger military medical facilities,
for example, optometry is a section of the department of ophthal-
mology, while in smaller installations the optometrists generally
work under the supervision of the director of hospital clinics,
but without close professional supervision. Overall, ophthalmolo-
gists in military installations do not provide services without
the assistance of optometrists. In this setting, furthermore, the
practice of triaging has been implemented successfully, where ophthal-
mologists, optometrists, and medical corpsmen are utilized together.
The Veteran's Administration, in contrast, has relied much more
heavily upon ophthalmology than optometry. The lower rate of opto-
metric utilization results in part from the establishment of non-
competitive civil service salary rates for optometrists, and, in
part, by only limited affiliation of VA hospitals with optometry
schools. A multidisciplinary committee within the VA has recom-
mended that training affiliations be established or strengthened
with the nation's optometry schools. The Opthalmological Advisory
GERALD FORD LIBRARY
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Committee of the VA, furthermore, has endorsed and fully imple-
mented the concept of expanding the present emphasis on eye health
care to the more comprehensive concept of vision care via inter-
disciplinary team delivery.
On a parallel note, optometric services have been included in a
number of reimbursement systems, including various Medicaid pro-
grams. Of relevance to the study query, conditions of participa-
tion in a number of State programs itemize explicitly the content
of a visual examination which is covered for reimbursement to opto-
metrists. Although perhaps circumstantial, there does exist a
clear correspondence between these service listings for participa-
tion and the detailed range of services identified above.
Quality Indicators and Controls
Similar to considerations pertinent to defining the scope of prac-
tice for health professions, the precise delineation of the practi-
tioners' area of professional competence is equally difficult to
set forth. Here also, a variety of sources must be examined and
consulted to provide reasonable and highly probable inferences.
This is particularly the case given the limited availability of
any carefully undertaken, controlled investigations that have been
directed to assess the effectiveness of services provided by in-
dividual practitioner groups.
As indicated earlier, a principal conclusion from the study review
is that optometry is a profession qualified to provide a broad
range of services which are effective in patient management, in-
cluding the management of aphakic and cataract patients. It is
reasonable to infer from information examined in the study, further-
more, that such services are reasonable, non-experimental, safe, and
generally acceptable to the vision/eye care community and the public.
Evidence presented, in addition, supports the conclusion that opto-
metrists are qualified to detect and make preliminary diagnosis of
ocular disease and ocular manifestation of systemic disease.
Material provided in Part II of this report presents the detailed
supportive findings which underlie these conclusions. The following
discussion, in turn, highlights several points of particular rele-
vance to this issue.
Optometric Education
Optometrists are primary providers of health care and as such are
responsible for determining whether the problem of the patient is
within his scope of treatment or whether the patient should be re-
ferred to another health provider. Optometric education includes
specific curriculum and clinical training related to the detection
and diagnosis of ocular disease and ocular manifestation of systemic
disease. Schools include on their faculty and in their clinical
DERALD FORD LIBRAR,
27
programs physicians, and particularly ophthalmologists, in the
training of optometric students. Particular attention is paid to
the detection and diagnosis of cataract, the complications follow-
ing cataract surgery and the procedures for the management and pro-
per followup of aphakic patients. On the basis of this educational
and clinical experience, the optometric student demonstrates a
mastery of the skills and knowledge necessary for the diagnosis
and management of the cataract and aphakic patient--for both gradu-
ation and licensure.
Although each of the individual schools and colleges of optometry
has developed its own philosophy and objectives for optometric
education, certain principles are stated by all of the institutions.
Chief among these are the provision of a high-quality educational
program intended to prepare each graduate to conduct a practice
which is competent, service oriented and ethical; and the stimu-
lation of any research which will further existing knowledge in
the visual sciences, usually through the medium of graduate programs.
While certain curricular components may be particularly relevant
concerning care for the cataract and aphakic patient specifically,
the basic curricular elements of schools of optometry are targeted
to overall evaluation and anlyses of patients, followed by a selec-
tion of treatment based on all of the disorders present, the needs
and characteristics of the patient, the prognosis, and the possible
interrelated effects of the proposed treatment procedures.
The basic curricular elements of optometry schools include the
following: biological science knowledge base; physiological optics
knowledge base; pathology knowledge and skills base; optics know-
ledge and skills base; professional orientation knowledge and skills
base; clinical patient care knowledge and skills base; and patient
care experience. Each of these generic areas are subdivided into
more specific areas for study and, where appropriate, to clinical
experience.
Clinics maintained by the schools provide students with supervised
clinical experience with a variety of patients, including cataract
and aphakic cases. The clinical experience for the optometry stu-
dent now commences in the second year and expands until, in the
fourth year, the optometric student devotes at least half-time to
work under supervision in a clinic setting. In the clinical area,
experience is gained in such areas as contact lenses, low vision,
children's vision and vision therapy, in addition to basic visual
analysis and the prescription of lenses.
BERALD FORD NEBRARY
28
Some areas of the optometric curriculum, as noted above, have more
information on or are directed more toward the care of the patient
with cataract or aphakia. In particular, these include considera-
tions of geriatric, low vision, pathology, optic, and visual per-
formance matters.
Similar to developments in education for all health professional
groups, the educational process and structure for optometry has
been strengthened overtime. The accreditation process of optometry
schools, for example, was informally iniated with the establish-
ment of the International Association of Boards of Examiners in
Optometry (IAB) in 1922. At this time, all optometric schools are
accredited by the regional college accrediting associations.
Prior to 1968, uniform requirements as to length of training were
not mandated for all schools of optometry. The requirement of
four years of training in an optometry school was made mandatory
by the Council on Optometric Education of the American Optometric
Association for all schools for the entering class of 1968. The
length of study currently in accredited schools of optometry is
four years following pre-optometry college studies.
In addition to the basic four-year curriculum in optometry schools,
a number of institutions offer advanced degrees as well. By the
1974-75 academic year, a total of sixty-six students were enrolled
in graduate programs. Recent trends suggest that this figure is
likely to increase further.
The strengthening of the overall educational process and structure
for optometry students has been particularly bolstered by efforts
undertaken by the Association of Schools and Colleges of Optometry
(ASCO).
In 1941, this Association was formally established with the goal
of "aid in the advancement of optometry by giving attention to the
problems of the education of optometrists, and by formulating and
supporting desirable educational standards and policies." The
Association, representing all U.S. schools and two programs in
Canada, was incorporated in 1972 and established a staffed national
office in 1974 which publishes a monthly newsletter and quarterly
publication.
This Association currently maintains standing Councils in three
major educational areas: Academic Affairs, Student Affairs, and
Institutional Affairs. Beginning in 1973, the Council on Academic
Affairs began development of a major statement concerning curri-
cular standards for optometry schools. Guidelines for optometric
residency programs and post-graduate pharmacology training have
been developed as well.
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29
State Practice Acts and Licensure. The regulation and control of
professional services to the public is a function of individual
State jurisdictions. For many health professions, including opto-
metry, State Practice Acts define (with varying degrees of preci-
sion) permissible and impermissible acts of individuals who are
licensed by the State to practice the profession.
To qualify for licensure, an applicant must be a graduate of an
approved school with a program leading to a Doctor of Optometry
Degree. All States require applicants to pass a written examina-
tion as a condition precedent to licensure. A National Board
Examination is currently accepted in lieu of the State written
examination in eighteen States.
In 1951, the National Board of Examiners in Optometry was established
to resolve the problem of varying content and quality of the State
board examinations for graduating optometrists. The National
Board Examination, which emerged from this initial concern and
subsequent efforts, is currently administered over a two-day period
and involves examination in the broadly ranging areas of visual
science; ocular pathology; theory and practice of optometry; theo-
retical optics; ophthalmic optics; ocular anatomy; social, legal,
ethical, economic, and professional aspects of optometry; and
ocular pharmacology.
Continuing Education. Similar to many other health professional
groups, the training of optometrists does not cease upon graduation.
Most States require that optometrists, as well as other health pro-
fessionals which are licensed, continually upgrade their skills.
For the few States without formal requirements, a number of State
optometric associations have instituted a system of continuing
education requirements for membership purposes. Currently, forty-
three states require continuing education for license renewal by
optometrists.
Continuing optometric education courses are offered by over 100
agencies, including the 51 State associations affiliated with the
American Optometric Association. It is estimated by the Associa-
tion that between 17,000 and 18,000 licensed optometrists have and
will continue to participate in continuing education courses.
Currently, the Council of Academic Affairs of ASCO is developing a
proposal to study the feasibility of conducting an organized and
structured national program of continuing education for practicing
optometrists, using existing schools and colleges as a base for
such training. This development is consistent with overall
FORD & LIBRARY GERALD
30
endeavors of the profession continually to upgrade and make uni-
form its respective educational programs. (Detailed documentation
on the existing content and overall nature of continuing education
offerings is provided in Part II of this report. )
Other State Developments. Apart from the above discussion, other
indicators of professional competence can be suggested. For example,
optometrists are increasingly being included in various health
care programs. A 1975 Kansas statute allows nonprofit corporations
to be created specifically to provide group optometric care pro-
grams. In 1974, California included optometrists in prepaid health
plans. In 1975, Rhode Island included services by optometrists in
its State catastrophic health insurance program. In 1974, Maryland
included services of optometrists in group health insurance policies.
And, in 1973, Colorado added optometry to services which certain
corporations may make available to health benefit subscribers. The
fact that optometric services have been included for reimburse-
ment purposes in many State Medicaid programs has been noted earlier.
Optometrists appear to be infrequently subject to malpractice suits,
in part reflected by the existing insurance premium for optometrists
(i.e., $280.00 per year). Suits have been brought, however, and
study staff examined cases available to shed further light on the
question of professional competence. A number of courts have em-
phasized that diagnostic services, specifically, are within the
realm of the optometrists' professional competence. In approxi-
mately ten decisions examined, all cases emphasized this role in-
dicating that optometric competence included the ability to dis-
cover, detect. and/or recognize eye disease.
Among recent developments in State Practice Acts, several statutes
have revised the definition or scope of practice of optometrists,
raising reasonable inferences concerning professional competence.
In 1974, Wisconsin construed the meaning of "physicians" to include
optometrists in all accident and sickness policies. New York, in
1974, included optometrists with other professionals who receive
legal immunity for service on utilization review committees.
California law now indicates that in determining whether an indivi-
dual is blind, the patient may be examined either by a physician
skilled in diseases of the eye or by an optometrist.
Referral Patterns and Provider Relationships. Studies of referral
practices of private practitioners would, if adequately conducted,
likely provide valuable insight into the extent to which optometrists,
as well as certain other health care providers, are able to detect
dispositions. Although studies have been undertaken in this area,
marked variations tend to exist in comprehensiveness, quality, and
overall objectivity. (The reader is ferred to Part II for detailed
discussion on studies examined during this study effort.)
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Ethical standards within the optometric profession speak directly
to the responsibilities of optometrists to refer patients to other
providers of vision/eye care services where appropriate. Ten of
the States expressly require by statute or regulation that an opto-
metrist refer patients in need of other professional care to the
appropriate practitioner.
Referral rates from optometrists to physicians typically may be
higher in organized settings than in the independent setting. A
number of studies examined during the course of this study indi-
cated that between two and three percent of patients examined by
optometrists in independent settings require referral to a physi-
cian; within the military setting, in contrast, referral rates
ranged between three and seven percent of the patients seen. A
1968 study of vision care within the Kaiser-Permanente prepaid
care plan in the Los Angeles area, however, indicated that 2.75
percent of the patients seeing an optometrist were referred to
ophthalmologists.
The collective judgement of the study advisors was that working
relationships between providers in the vision/eye care arens are
quite good and constructive. Although documentation on relation-
ships between respective practitioner groups are generally lacking,
study staff were able to uncover a recent effort that specifically
surveyed physicians about their relationships with optometry. This
particular effort was quite supportive of the viewpoint expressed
by study advisors.
Tonometry, A Case in Point. The provision of vision/eye care
services raises controversial issues within the provider community
concerning what services and procedures shouls be undertaken, re-
spective levels of effectiveness of such services and procedures,
and what types of specific manpower group should be engaged in
these functions. For example, tonometry is a relatively simple
process used for the determination of intraocular pressure and the
detection/diagnosis of glaucoma. In some clinic and group practice
settings, tonometry is only undertaken by ophthalmologists; in a
number of others, by any doctor of medicine. In other instances,
optometrists do tonometry, and in what appears to be an increasing
number of cases, technicians are being trained to undertake this
procedure.
The Department of Medicine and Surgery of Harvard Medical School,
in a 1974 study, found justification for glaucoma screening by
technicians in medical and ophthalmology clinics for all patients
GERALD FORD LIBRARY
32
40 years or more of age. Elsewhere, however, professional judge-
ments have been documented that, at least for patients with vision
complaints, tonometry should be a routine part of the optometric
examination for younger patients and for all adults.
Such disagreement within the provider community extends beyond
tonometry and glaucoma to other services and respective abnormali-
ties of the eye. Although this area lacks adeauate documentation
to resolve controversy, a number of inferences can reasonably be
drawn for relevance to this study effort.
First, the detection of cataract and/or aphakia is essentially an
uncomplicated process. Optometrists, as well as ophthalmologists,
are qualified to carry out requisite diagnostic services. Second,
many of the functions and procedures in dispute are being under-
taken currently by optometrists. The primary care role outlined
earlier for optometrists in organized settings, for example,
speaks to the capabilities of the profession to effectively under-
take such functions.
Although legal constraints exist in most State jurisdictions con-
cerning the use of topical drugs by optometrists, this issue re-
lates more to potential limiting factors in optometric capabili-
ties rather than to questions of professional competence. Despite
such constraints, suitable instrumentation and procedures afford-
ing quality performance are identified by the clinical standards
committees of professional associations and are available for
diagnostic purposes.
Overall, agreement exists within the provider community that the
broad range of services identified earlier in this report does
represent reasonable and necessary vision/eye care services, and
constitutes safe and non-experimental practice. The evidence
available to attest to the professional competence of optometry is
persuasive for one to conclude that the quality of such services
is not compromised when provided by optometry.
Quality Control
The development of standards of care for diagnostic, therapeutic,
and consultative services provided by vision/eye care practitioners
generally, and including optometrists specifically, does appear
feasible in both organized and independent health care settings.
Such standards do currently exist in a number of individual situa-
tions or are in various stages of development. As such, quality
assurance is attainable in the provision of reasonable, safe,
non-experimental, and acceptable services by optometrists to the
Medicare eligible population.
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Criteria and methodologies for performing review of the quality of
optometric practice under the aegis of Professional Standards
Review Organizations (PSRO) are just beginning to be developed.
The concepts of peer review utilizing explicit criteria basic to
the PSRO program are applicable to review of optometry practice in
the ambulatory care settings, even though PSRO emphasis is currently
on the review of inpatient care services. The optometry profession
recognizes its obligation for leadership in the development and on-
going refinement of quality measurements.
Cost Considerations
Widespread interest exists in seeking ways to make the health care
delivery system more effective and efficient. Apart from consider-
ations of patient needs, provider qualifications, and access con-
cerns, attention in the study was also directed to the potential
cost implications of an alteration in Medicare coverage. It is
reasonable to infer that an extension of current Medicare cover-
age to include services related to aphakic and cataract conditions
when provided by optometrists would result in some added costs to
the Medicare program. Rough calculations suggest, however, that
such added costs (i.e., between two and five million dollars)
would not be significant in the context of overall Medicare costs
for vision/eye care services.
An uncertain cost effect results from any increase in cataract
surgery rates that might occur given the change assumed in the
analysis for reimbursement. Expert advisors to the study viewed
the likelihood of such increased rates as negligible. Nonethe-
less, it should be noted that, for every additional operation
that might occur for Medicare eligible patients, Medicare program
costs would rise by roughly $1,500.
It has been suggested, furthermore, that such an extension of
coverage might change the nature of optometric practice suffici-
ently to raise the cost of malpractice insurance for optometrists.
Study staff did not have an opportunity to examine this matter in
detail; although a number of factors suggest such an occurrence
to be highly unlikely. First, the elderly represent a small
fraction of optometric practice and cataract services represent a
still smaller proportion. Second, optometrists would obviously
not be performing surgery, the major source of malpractice claims.
Third, in areas where Medicaid has extended coverage and reimburse-
ment to optometric services, there is no evidence that malpractice
premiums have changed significantly.
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Broader Concerns and Review
The material assembled and examined in the study effort, as out-
lined above, is highly supportive of recommendations to extend
coverage for currently covered services under Part B of Medicare
to include diagnostic, consultative, and therapeutic services re-
lated to aphakic and cataract conditions when provided by optome-
trists. Considerations of particular relevance include patient
needs, qualifications of optometrists to render effective and
necessary services, and concerns in assuring equitable access to
requisite services by the Medicare eligible population.
Much of the information reviewed pertains to vision/eye care
services generally, rather than to services related to aphakic and
cataract patients specifically. In part, this situation reflects
the available level of specificity in existing documentation. To
some extent, however, such as is the case with cataract patients,
a number of vision/eye care services are not disease specific and
extend equally to circumstances where different eye disorders may
be presented.
In inference arises from this last observation that it may be ap-
propriate to consider a broader scope of inquiry regarding the
provision of vision/eye care services and Medicare coverage. This
study effort, however, did not provide an opportunity to consider
such a broader concern in any detail.
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PART II
Detailed staff contributions to this study
effort are provided in this second part of
the report. Specific sections include
discussions concerning cataract conditions
and aphakia; State law and optometric
practice; optometric education; access
considerations; and potential cost impli-
cations of altering current reimbursement ement
under Medicare Part B.
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SECTION II-A
NATURE, INCIDENCE AND PREVALENCE OF CATARACTS
Compiled by
Nathan Watzman, Ph.D. *
A cataract is an opacity of the crystalline lens of the eye. For
the purposes of this paper, a clinically significant cataract is
defined as an opacity of the lens that reduces visual acuity
(sharpness of vision) and may be functionally disabling or dis-
ruptive of the normal life style, more particularly for near or
distant vision, e.g. reading or driving. The most effective treat-
ment of cataract is the surgical extraction of the opaque lens.
This results in the condition of aphakia (the absence of the
crystalline lens).
The lens is one of the most unique tissues in the body. It is a
powerful refracting organ of the visual system, transparent and
without a blood supply.- It is also unique for another reason:
cells in other parts of the body are constantly being broken down
(catabolism) and rebuilt (anabolism). Yet in the lens there is no
apparent protein synthesis or cell machinery present to maintain
the protein. It is, therefore, interesting that protein synthesized
during the embryonic period remains the same for sixty or more
years throughtout the life of an individual and still the lens
remains transparent. 1/ As one progresses through life, however,
internal and external factors can impinge upon the lens to cause
in it's transparency. For example, normal physiological changes
in protein content of this structure will bring on changes in
transparency.
The refractive power of the lens depends upon its curvature (variable
in the young eye), its refractive index (a function of its compo-
sition), and its location. Cataracts usually affect vision by
altering the refractive index more than by change in size or
location of the lens and by the resultant opacity blocking the
passage of light to the retina.
Symptoms of Cataract
The visual symptoms of cataracts usually consist of a slowly pro-
gressive, painless decrease in visual acuity while some patients
*Acting Associate Director for Regional Programs, Division of
Associated Health Professions, Bureau of Health Manpower, Health
Resources Administration, DHEW.
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37
experience a rapid loss of acuity over a period of months, weeks
or even days. Visual function will vary according to the location
of the opacity in the lens. For example, if the opacity is diffuse,
the haze will be constant, both indoors and out, and may be some-
what worse in bright light. If the opacity is confined to the
front area of the lens, the individual will experience a "glare",
especially outdoors or in intense light (which brings the pupil
down over the opacity and cuts down the vision) This person may
function normally in a house or dim light, but be "blind" outdoors.
If the center or nucleus of the lens is opaque, there will be a
constant haze and the individual will feel like he is looking
through a "dirty window". The patient may be visually limited
(blur, glare, distortion) in the tasks of driving and reading to
the point that he/she is disabled in his/her every day life style
or handicapped in the performance of his/her occupation.
It should be noted that a characteristic common to elderly patients
with cataracts is the renewed ability to read news print without
glasses, in spite of a decrease in distance acuity. This so called
"second sight" is due to a slow progression of nuclear sclerosis
and acquired myopia (nearsightedness) 2/ related to swelling of the
lens, an early diagnostic sign of cataract usually preceding opacifi-
cation.
Reduced color vision in cataract patients is not common because
discrimination of color changes very gradually. However, a
"yellowing" of vision is frequently experienced because the shorter
wave lengths of the visual spectrum (violet and blue) are select-
ively absorbed and the longer yellow and red wave lengths are
transmitted.
It should be noted that cataract can be associated with nearsighted-
ness which is attributable to nuclear sclerosis or farsightedness
when the cortex is affected disproportionately. In either circum-
stance, areas of the lens with different refractive indexes can
cause a beam splitting effect which results in projection of two
images on the retina. Thus, there is monocular diplopia (double
vision) ; where present, it is usually related to early stages of
cataract.
It is important to emphasize that cataracts can cause almost the
full spectrum of loss of vision ranging from a very mild impair-
ment to a severe degree of impairment characterized by minimal
light perception and poor appreciation of the direction from which
light enters the eye. Cataracts alone, however, are not respon-
sible for total blindness , but, surely account for a substantial
proportion of legal blindness.
Formation of Cataracts
The formation of a cataract is a highly complicated physico-chemical
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38
process, whether it be a result of normal physiological aging,
external physical insult, or internal metabolic changes. Two major
elements appear to be implicated in the generation of lenticular
opacities, namely, the water content and nature of the protein
within the lens. Relative to the first element, one important
mechanism in maintaining the viability of the lens is the capacity
of the electrolyte pump to maintain a normal state of hydration
(water content). As long as a normal equilibrium between the
intraocular fluids outside the lens and the fluids within the lens
can be maintained in terms of sodium and potassium ion content,
the lens will remain normal. If on the other hand, an imbalance
occurs in the pump equilibrium system, causing the lens membrane
to leak, high levels of water-retentive sodium will move into the
lens from the intraocular fluids causing osmotic swelling which is
a common feature of many cataracts 3,4/ The other important
mechanism of cataract formation is related to the relative concen-
trations of soluble and insoluble protein within the lens. The
normal lens has a water content of approximately 65% and a protein
content of about 35%.3/ As the lens ages, there is a decrease in
water content, and more and more of the soluble protein becomes
insoluble. Increases in concentration of insoluble protein are
related to the development of cataracts 3/ Also associated with
and probably directly related to the changing character of lens
protein (increase in insoluble and decrease in soluble protein)
is a progressive hardening of the lens which usually becomes
clinically manifest after age 40.2/ Thus, some loss of transparency
of the lens with age is as inevitable as the wrinkling of the skin
and greying of the hair. For an excellent review of the more
recent biochemical studies on lens protein and enzymes, lens lipids,
water balance in the lens, etc., the reader is referred to an
article by Kirsch 3/ and a symposium entitled "The Human Lens In
Relation to Cataract" 5/
Classification of Cataracts
While the physico-chemical processes involved in the formation of
a cataract are fairly well delineated, the etiology or causes
initiating the aforementioned sequence of events leading to a
cataract are not clear. However, studies- 67 of the close asso-
ciation of cataracts with systemic, hereditary and metabolic
diseases as well as externally-induced chemical and physical agents,
provide a great deal of insight into the possible causes of cataracts.
One of the preferred classification of cataracts is based upon
the above considerations:
Note: For vision terminology, see "Current Optometric Information
and Terminology" 35/
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39
A. Primary
1. Senile (Senescent)
2. Congenital
B. Secondary
1. Metabolic
2. Endocrine
3. Inflammatory
4. Toxic-chemical agents
5. Traumatic-physical injury
The word senile (more appropriately senescent) is commonly used in
association with primary cataracts developing in older persons.
Ninety percent of all cataracts are of the senescent type which
no demonstrable etiology The only relevant history may be that
of a familial occurrence. Nevertheless, there may be some under-
lying factor which may aggravate the development of this type of
cataract. For example, approximately 10% of patients with
senescent cataracts have overt 27 diabetes mellitus. Other patients
have a history of glaucoma.
The mature senescent cataract is seen as a diffusely opaque lens
that is usually white from complete cortical opacification. A
yellow nucleus is often detectable and in some cases the entire lens
is brown or even black in color 2/
A large variety of congenital lens opacities exists buy may not
cause visual impairment Virus damage from maternal rubella is
common; many cases of rubella catarcts were diagnosed during the
American rubella epidemic of 1963-1964 3/ Congenital cataracts
are also a prominant feature of a number of multiple congenital
disease syndromes 3/ such as the oculo-cerebro-renal syndrome of
Lowe, Werner's syndrome (premature aging) and a host of others 2/
Cataracts have also been associated with inborn errors of meta-
bolism involving genetic enzyme deficiencies. Examples are:
diabetes mellitus and galactosemia as well as syndromes with iden-
tified chromosomal abnormalities such as mongolism and dwarfism. 2/
For a more complete discussion and insight into the etiology of
cataracts, including the congenital type, the reader is referred
to Harley 8/ and Table A Evidence seems to indicate that con-
genital (infantile) cataract is not a single disease but a part
of a disease affecting other systems and caused by different
factors
9/
Lens damage may be caused by metabolic disturbances such as
maternal or 7/ infantile bypocalcemia, galactosemia, and diabetes
mellitus.
Diabetes mellitus was the first metabolic disorder
dnown to be associated with cataract formation. This disease is
now one of the leading causes of blindness in the United States
40
TABLE A
A Practical Classification of Cataracts
I. Congenital (Present at Birth)
A. Genetic origin
1. Congenital cataracts without other abnormalities (autosomal dominant, autosomal
recessive, sporadic, rarely sex-linked); many morphologic varieties such as nuclear,
zonular, mature
2. Lens opacities without visual impairment such as Mittendorf dot, anterior polar
"cataracts," sutural "cataracts"
B. Maternal origin
1. Secondary to maternal infections, e.g., rubella, syphilis
2. Secondary to amniocentesis
II. Infantile or Juvenile Onset (Genetic Origin)
A. Inborn errors of metabolism, e.g., diabetes mellitus, galactosemia, hyperlysinemia,
homocystinuria, hepatolenticular degeneration (Wilson's disease), oculocerebrorenal
(Lowe's) syndrome
B. Syndromes with identified chromosomal abnormalities, e.3., trisomy of chromosome 21
(mongolism, Down's syndrome), monosomy of X chromosome (Turner's syndrome),
trisomy of chromosome 13 (Patau's syndrome)
C. Syndromes of unknown etiology, e.g., familial craniofacial dysostosis, heredofamilial
atrophic dermatoses (Rothmund's syndrome), muscular dystrophy,
idiopathic hypoparathyroidism
D. Various ocular syndromes, e.g., persistent hyperplastic primary vitreous, Rieger's
anomaly, aniridia, microphthalmia, retinitis pigmentosa
III. Late Onset (Senescent Type)
A. Without associated familial or acquired disease
B. With contributory factors such as diabetes mellitus, familial incidence, ocular trauma,
glaucoma, intraocular surgery, Paget's disease of bone
IV. Secondary
A. Directly related to acquired systemic disorders, e.g., tetany (hypocalcemia),
starvation, aortic arch syndrome
B. Related to acquired ocular disease
1. Inflammatory, neoplastic, e.g., heterochromic iridocyclitis, intraocular neoplasms
2. Physical trauma and physical agents, e.g., blunt injuries, perforating injuries,
radiation (atomic, infrared), electric shock (lightning)
C. Secondary to local or systemic chemical agents, e.g., steroid therapy, chlorpromazine,
ergot, dinitrophenol, thallium, intraocular deposition of iron (siderosis) or
copper (chalcosis)
41
and over 50% of the visual loss is due to abnormalities of the lens
or retina
10/
Typical diabetic cataracts usually develop in
patients with severe, prolonged, poorly controlled diabetes. They
may be seen as early as seven years of age but most commonly in the
advanced years.
Examples of endocrine diseases that are associated with cataracts
are hypothyroidism and hypoparathyroidism. 3/
Inflammatory diseases of the interior of the eye may lead to the
development of a lens opacity. Acute and chronic iridocyclitis
with synechia formation (adhesions of the iris to the anterior
capsule of the lens) may severly compromise the clarity of the lens.
Chronic uveitis and vitritis frequently leads to posterior capsular
opacity and may be referred to as cataracta complicata. At times,
the entire lens may become opaque in association with chronic uveitis.
The literature documents many agents that will provide chemical
insult upon the lens to produce a toxic cataract 10/
Corto-
costeroids administered systemically or topically, naphthalene,
paradichlorobenzol, ergot alkaloids, oral contraceptives, miotics,
and the tranquilizer, chlorpromazine are but a few of the many
examples.
The exposed eye ball is extremely valnerable to flying objects and
particles which may cause severe injury. High velocity particles
striking the head may injure the eye via transmission of kinetic
energy from the point of impact in the head or face to the eye. 10/
Penetrating injuries more commonly enter the eye through the cornea
than through the sclera. Violation of the lens capsule by a flying
chip of steel penetrating the eye will admit fluid into the lens,
disrupt metabolism and result in cataract. Rupture of the eye
ball may also follow injury by an explosive blast which causes an
enormous increase in the atmospheric pressure. Traumatic cataract
is encountered more frequently in military men, particularly during
war, as well as men engaged in hazardous industrial occupations.
Blows to the eye while participating in active sports--boxing,
golf, tennis, and skiing may also produce cataracts. Thus, traumatic
cataracts may be caused by three types of physical insult: blunt
injuries with or without rupture of the lens capsule, explosive
blasts, and penetrating injuries of the globe.
Detection Procedures
The objective means of clinically determining the existence of a
cataract involves the use of the ophthalmoscope, retinoscope, and
slit-lamp biomicroscope 11/ The objective sign of cataract is,
of course, the presence of opacities in the lens. While an
advanced cataract is readily detected with simple instrumentation,
a more accurate assessment of early opacities is made by transmitted
GERALD FORD LIBRARY
42
light when opacities, obstructing the light reflected from the
fundus (back of the eye) appear black in the pupillary reflex.
Accurate information can also be obtained by direct observation,
using local illumination of the ophthalmoscope or biomicroscope
slit-lamp. The objective clinical examination is, therefore,
most satisfactorily started by observing the fundue reflex with
the ophthalmoscope or retinoscope, at first, at a distance 117 of
about one third of a meter and then with a +20 D lens.
Dobree
12/ recommends use of the ophthalmoscope with a +10 D to
+8 D lens to obtain accurate information as to position, form
and nature of lens changes. For the best view of the interior of
the eye, such an examination should be done with a widely dilated
pupil. One can also assess the integrity of the retina at the
same time. The use of an indirect ophthalmoscope is particularly
useful in studing the periphery of the retina. Examination with
the slit-lamp, however, provides information of even more value,
since it permits a detailed microscopic view of the lens by direct
or transmitted light and by indirect lateral illumination by
which fine changes and vacuoles can be detected. By its means,
not only can an accurate knowledge of the type and form of any
opacity be gained but it reveals the density of any opacity.
Pathological changes can be accurately localized topographically
in the cortex as well as in the nucleus of the lens. Most
importantly, the optical significance of the opacity can also be
objectively evaluated.
Complications of Cataract Surgery
About 5% of cataract extractions have significant complications
during or soon after the operation but most can be managed satis-
factorily and good vision obtained 2/ Poor vision following
cataract extraction is usually the result of unrelated degenerative
changes such as macular disease, corneal dystrophy or glaucoma.
The macula is a small yellowish area of the retina containing the
fovea centralis, the region of most acute vision. 13/ In the
presence of cataract, it is not always possible to accurately
evaluate the functioning of the macular prior to surgery.
Some complications of cataract surgery are: vitreous loss, intra-
ocular hemorrhage, cystoid maculopathy, shallow anterior chamber,
intraocular infection (e.g. endophthalmitis), Elschnig pearls,
retinal detachment, glaucoma, corneal decompensation, would
rupture, posterior capsule opacification, uveitis, vascular occlusion,
hyphema, vitritis, optic atrophy, changes in astigmatism, and dis-
location of intraocular lenses. Only some of the more frequent
complications will be discussed.
Vitreous loss is the most undesirable of the common complications
occurring at the time of surgery. The vitreous humor is a gel-
like substance which bathes the lens and occupies a large portion
GERALD FORD LIBRARY
43
of the intraglobal space. If drawn into the anterior chamber of
the eye, it will transmit traction into the retina increasing the
possibility of retinal detachment. Just as important, vitreous
which migrates to the anterior chamber after cataract extraction
can come in contact with the posterior surface of the cornea and
damage the endothelial cells producing an intractable corneal
edema. Vitreous loss does occur in 2 to 4 percent of cases in
spite of all operative measures to avoid vitreous disturbances
at the time of surgery 2/
Intraocular hemorrhage, another complication, may arise from the
iris, the wound, but only rarely from the posterior segment of the
eye. The latter is of major significance because bleeding from
that area can cause an outflow of intraocular contents at the time
of cataract extraction. Hemorrhaging from the iris or wound is
usually self limiting and manageable. /
Cystoid maculopathy is a fairly common complication characterized
by onset of macular edema in the early weeks following cataract
extraction. This condition occurs with greater frequency follow-
ing vitreous loss, in blue-eyed individuals, and in patients with
post-operative inflammation of the anterior segment. Vision may
be reduced as low as 20/200. The condition is most readily diag-
nosed by fluoroscein angiography which reveals a typical stellate
appearance of leaking dye at the macula or by measurement of
elevation with the slit-lamp and Hruby or Goldmann lens. The
condition is usually considered self-limiting.
2/
A shallow anterior chamber usually results from wound leakage in
the early post-operative period. Permanent damage to the eye does
not result if management is appropriate and prompt. Less frequently,
shallowing of the anterior chamber is a result of spontaneous
hemorrhage of the choroid. This fluid accummulation leads to a
marked displacement of both choroid and retina and to detachment
of the ciliary body. Usually, however, the fluid is reabsorbed
and there are no lasting effects. Pupillary block glaucoma is
still another cause of a shallow anterior chamber following
cataract extraction. The pupil becomes occluded by formed vitreous
but the pressure can be relieved by a surgical procedure.
Post-operative intraocular infection occurs in approximately 1 or 2
patients per five thousand operations, usually within a day or two
post-operatively 2/ A diagnosis is suspected by the occurrence of
ocular pain, lid swelling, and increase redness of the globe. Slit-
lamp examination reveals inflammatory cells in both the anterior
chamber and the vitreous. Because prompt control of the infection
is mandatory, the aqueous should be aspirated and bacteriologically
cultured. Appropriate broad spectrum antibiotics should be pre-
scribed until culture reports and sensitivity studies are avail-
able.
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Elschnig Pearls appear as small translucent vacuoles arranged in
clusters following surgery. They are remnants of lens epithelium
which remain in the eye following incomplete extracapsular cataract
2/
surgery
The incidence of retinal detachment following surgery for acquired
cataracts is reported to be approximately 2% 14, The average
interval between cataract surgery and the development of the retinal
detachment has been reported as 33.3 years 15/ Routine examination
of the retina through a dilated pupil is highly desirable on an
annual basis for the remainder of the patient's life.
Glaucoma in the aphakic eye may have pre-existed, may develop
de novo as primary open angle glaucoma following uncomplicated
cataract extraction, or may result as a surgical complication. The
various causes of aphakic glaucoma and their treatment are summa-
rized by Francois 16/ The latter type of glaucoma mentioned above
is termed aphakic obstructive glaucoma and is usually due to the
blockage of the normal circulation of aqueous humor, resulting in
inflammation and angle obstruction. For the aphakic patient, the
refractive error, particularly astigmatism, may change signif-
cantly, post-operatively. Such changes will affect the visual
acuity of the patient and may require modification of his/her
prosthesis.
Incidence and Prevalence
The actual extent of the problem of cataract and aphakia in this
country is not clear from the data available. There is no known
report of the numbers of individuals who have cataracts and have
not sought professional services or who have had cataracts diag-
nosed and have not had surgery.
It is, however, clear from the data available, both published and
unpublished, that cataracts are a condition, most predominantly,
of the elderly and a result of the normal physiological aging
process. Congenital, metabolic, endocrine and toxic cataracts do
not occur with the frequency to be epidemiologically significant.
Senile (senescent) cataracts, on the other hand, account for
approximately 90% of all of the documented cases 2/
Data that is available on the incidence and prevalence of cataract
provides some general idea about the magnitude of the problem.
The National Ambulatory Medical Care Survey (1973) 17/ indicates
that 2,723,000 visits were made to physicians' office for cataract
(primary diagnosis) for the period May 1973 to April 1974. During
the same period of time, 4,400,000 visits were made in which
cataract was only one of the diagnoses 18 While there is no
documented data on the incidence and prevalence of aphakia, it is
FORD & LIBRARY GERALD
45
estimated that approximately 1,000,000 visits were made for aphakia
during the same period of time.
18
Data on cataracts from the Health Interview Survey (1971)
19/
indicates a prevalence of about three million persons which is
equivalent to 14.9 cases per 1,000 persons. It also reported that
approximately 2,764,000 individuals or 13.7 per 1,000 persons had
visual impairments resulting from cataract. This is equivalent
to about 1.5 cases of all ages per one hundred people in the
United States. The following table (Table B below) 18/
provides
the prevalence data by age grouping:
TABLE B
Prevalence of Cataract and Number of Cases Per 100 People
Age
No. of Cataracts
No. per 100 People
Under 17
17-44
197,000
0.3
45-64
565,000
1.4
65+
2,212,000
11.4
Unpublished data from the National Eye Institute
20/
indicate:
that there is estimated to be about 912,000 new cases of cataracts
per year, based upon first visits to physicians, exclusive of
referrals. About three fourths of these were first diagnosed at
ages 65 and over. The incidence for women is considerably higher
than for men. In addition, there were estimated to be approxi-
mately 332,000 cataract surgeries performed in 1972. The only
data (Table C below) available, indicating the number of cataract
surgeries by age grouping, 217 is that obtained from short-stay
hospitals in 1972.
TABLE C
Estimated number of cataract operations in short stay hospitals
by age. U.S. 1972
Age
Est. No. Cataract Operations*
10-29
3,000
30-39
3,000
40-49
9,000
50-59
30,000
60-69
64,000
70-79
90,000
80+
42,000
Total
241,000
* first listed diagnosis of cataract in combination with lens
extraction.
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Table D provides incidence and prevalence data for blindness by
age groupings. It is clear from all of the data shown above
that the extent of the problem of cataracts is greatly magnified
with advancing age and becomes a socio-economic health problem
of national significance.
TABLE D
PROJECTION OF CATARACT BLINDNESS IN L1975 BY AGE
Age
Newly blind from cataract
Blind from cataract
Group
rate/100,000
Minimum
rate/100,000 Minimum
Number
Number
(Incidence)
(Prevalence)
5
.9
143
1.9
302
5-19
.7
411
6.4
3758
20-44
.4
290
8.2
5951
45-64
3.5
1524
23.0
10015
65-74
4.9
680
52.6
7208
75-84
14.0
931
128.4
8539
85+
40.8
766
492.2
9239
-
Estimated Total
4745 or 4700
45,102 or 45,000
1/ Age specific rates/100,000 of all additions to registers, 14 MRA
states, average 1969 and 1970 in Kahn, H.A. and Moorhead, H.B:
Statistics on Blindness in the Model Reporting Area, 1969-1970.
DHEW Publication No. (NIH) 73-927, U.S. Government Printing
Office, 1973.
2/ Number resulted from applying the incidence or prevalence rate
to the July 1975 resident population in the United States.
Population estimates are from: Current Population Reports.
Population estimates and Projections, Bureau of the Census.
Series P-25 No. 614, November 1975.
3/ Age specific rates/100,000 of persons on register, 14 MRA States,
Dec. 31, 1970 in Kahn, H.A. and Moorhead, H.B: Statistics on
Blindness in the Model Reporting Area, 196901970. DHEW
Publication No. (NIH) 73-927, U.S. Government Printing Office,
1973.
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Aphakia
Aphakia is defined as the absence of the lens of the eye.
Removal of the lens renders it highly hyperopic (requiring a
strong convex lens) and without accommodation. One fourth of the
normal static power of 60 diopters is lost and the refractive
system is reduced only to the refractive power of the cornea.
Some degree of astigmatism is always present after cataract
extraction 22/
Optical Correction of Aphakia
One of the great causes of disappointment to a patient following
surgery is the unexpectedly poor vision without glasses and
distortion of vision with glasses which may occur after cataract
surgery. The spectacle lenses required for the compensation of
the removal of the eye lens are of high power. Such lenses create
substantial magnification and distortion which results in spacial
disorientation for the patient. Since the retinal image is
magnified, the patient feels that all his surroundings are crowded
on top of him. Spherical aberration in the spectacle lens causes
flat surfaces to appear curved; 23, peripherally, lines are dis-
torted, "blind" zones are present and there is a reduction in
panoramic vision. In addition, there may be colored fringes
around everything seen and if only one eye is being used, a serious
disturbance of depth perception will be present. During the early
post-operative period, the patient continuously finds himself
reaching short of objectives and stepping too high for stairs well
below his feet. As a result, care has to be taken in negotiating
curbs and in going up and down stairs. Fortunately, with adapt-
ation, these distortions become less noticeable, but in a few
cases, the difficulty persists for a year or longer. It is not
an easy period for the young and it may be a hazardous time for
the aged. For many patients, the post-operative period is
particularly challenging. It is thus imperative that, prior to
surgery, the patient fully understands the effects that cataract
extraction will have on his vision. 2/
Monocular aphakia occurs when a cataract operation is performed
on one eye only and in this case, either the operated or unoperated
eye may be used, but the two eyes can no longer function together
using eye glass correction for the aphakic eye. This situation
occurs because the retinal image as seen through an eye glass lens
in front of an aphakic eye is usually about 25% larger than the
image on the retina of the normal eye. The brain simply can not
fuse two such vastly different images together (double vision).
If a contact lens is used, however, the discrepancy in image size
between the operated eye and the normal eye is limited to
approximately 2 8% and therefore, single binocular vision is
possible.
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Correction of refractive errors in aphakic patients is usually
done by either eye glasses, contact lens or the new implanted
intraocular lens.
Generally speaking, optical correction of aphakia usually begins
within a day or two after surgery, utilizing temporary eye glass
correction. A final permanent prescription is not given until
two to three months and sometimes longer after the extraction
2/
Rarely are contact lenses prescribed before six weeks following
surgery. However, there are several varieties of soft, hydro-
philic contact lens now available which are prescribed early in
the post-operative period 2/
For the purpose of this paper, only spectacles and contact lenses
will be discussed since optometrists in their practice do not
utilize intraocular implants which involve a surgical skill.
Various lenses have been advocated to solve problems of aphakic
correction. Regardless of type, the severity of visual difficulties
has been reduced, to some extent, by improved lens grinding
techniques.
Spectacle lenses have inherent optical defects which are not
appreciated by individuals that wear glasses in the power range
of + or -3 diopters (vast majority of patients) 24/ The four
components of false orientation in aphakic spectacles are: false
depth, false projection, swim and distortion 24/ It should be
noted that modern light-weight, aspheric, plastic eyeglass lenses
are superior to the heavy glass lenses of the past.
While lenticular, aspheric spectacle lenses have been utilized in
the past, corneal contact lenses are being used more as improve-
ment occurs in contact lens material and fitting. Development of
lenticular cut types of corneal contact lens has greatly enhanced
fitting of aphakic patients because they rest on the eye ball,
form part of the optical system, and move with the eye; with
spectacles, however, the lens are situated in air at a distance
from the eye and are immoveable with relation to the eye globe 22/
The literature abounds with articles on the use of contact lenses
for aphakia 25-32/ In bilateral aphakia, one study33/ reported
success in 200 cases with continuous use of tiny, hard corneal
lenses.
In the case of monocular aphakia, where the other eye has good
vision, the treatment of choice is to place a contact lens on the
aphakic eye; this results in single, binocular vision and is
satisfactory for a majority of these patients.
Use of hydrophilic (soft) lenses 34/ in aphakic patients gave
excellent visual acuity and was more comfortable than hard lenses.
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In the case of monocular aphakia, where the other eye has good
vision, the treatment of choice is to place a contact lens on the
aphakic eye; this results in single, binocular vision and is satis-
factory for a majority of these patients.
Use of hydrophilic (soft) lenses 34/ in aphakic patients gave
excellent visual acuity and was more comfortable than hard lenses.
The main advantages of the soft lens over eyeglasses are the lack
of spectacle blur, increase in visual fields and simplicity of
fitting. Contact lenses also provide an almost normal field of
vision with negligible magnification of the retinal image as com-
pared to eye glasses. Some 80% of aphakic patients can learn to
wear contact lenses if properly instructed 2/ In the elderly
patient, however, decreased manual dexterity may hinder the use
of contact lenses unless professional assistance is available.
It should be noted here that no matter how well cataract extraction
is tolerated, the visual result is largely determined by the state
of the retina as well as such factors as senile macular degeneration
and diabetic retinopathy which will cause poor vision even after
an excellent cataract operation 21/ Therefore, a careful assess-
ment of the function of the macula and the peripheral retina is
important pre-operatively SO that the patient may be warned if
the visual outcome of the operation seems doubtful even with the
best optical correction available. Such assessment may be
difficult or impossible in advanced cataracts.
Where indicated, rehabilitation training of patients in the use
of his/her prosthetic devices and aiding the patient in spacial
orientation and mobility is extremely important. In addition,
some post-surgical aphakic patients do not experience optimal
vision for their living or occupational requirements through the
use of regular (spectacles, contact lenses, intraocular lens
implants) ophthalmic prosthesis. These patients should be
considered for low vision aids such as special microscopic reading
glasses, telescopic spectacles and other such devices. These
have been very effective, when properly applied, in providing
optimal vision function for certain life style activities, a
requirement which is most important to the physical and mental
well-being of these patients.
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BIBLIOGRAPHY
1. Zinn, E.M., and Mockel-Pohl, S., "The Lens and Zonules",
Int. Ophthalmol. Clin., 13(3): 143-155 (1973).
2. Paton, D., and Craig, J.A., "Cataracts, Development, Diagnosis,
Management", Clinical Symposia, Ciba Foundation Symposium,
26(3): 2-32 (1974).
3. Kirsch, R.E., "The Lens", Arch. Ophthalmol. 93: 384-314 (1975).
4. Kinoshita, J., "Mechanisms Initiating Cataract Formation",
Invest. Ophthalmol., 13(10): 713-724 (1974).
5. "Symposium on the Human Lens - In Relation to Cataract,
London, 1973", Ciba Foundation Symposium 19, Associated
Scientific Publishers, Amsterdam, P. 324 (1973).
6. Newell, F.W., and Ernest, J.T., "The Lens", Ophthalmology:
Principles and Concepts, The C.V. Mosby Co., St. Louis,
3rd Ed., pp. 313-327 (1974).
7. Whitwell, J. "Inherited Eye Disease", The Practitioner, 214:
621 (1975).
8. Harley, R.D., Ed., Pediatric Ophthalmology, .A.Saunders,
Philadelphia, pp. 375-378 (1975).
9. Merin, S. and Crawford, J.S., "The Etiology of Congenital
Cataract", Can. J. Ophthalmol., 61: 178-182 (1971).
10. Bellows, J.G., Ed., Cataract and Abnormalities of the Lens,
Grune and Stratton, Inc., N.Y., PP. 217-283, 285-297, 421-
491 (1975).
11. Duke-Elder, W. Stewart, Textbook of Ophthalmology, Vol. III,
The C.V. Mosby Co., St. Louis, PP 3115-3244 (1941).
12. Dobree, J., Modern Ophthalmology, Vol. IV, Butterworth, Inc.,
Washington, D.C., p. 624 (1964).
13. Best, C.H., and Taylor, N.B., The Living Body, Henry Holt
and Co., N.Y., 4th Ed., p. 579 (1958).
14. Scheie, H.G. Morse, P.H., Aminiari A., Incidence of Retinal
Detachment Following Cataract Extraction", Arch. Ophthalmo.,
89: 293-295 (1973).
15. Kanski, J.J., Elkington, A.R., and Daniel, R., "Retinal
Detachment After Congenital Cataract Surgery", Brit. J.
Ophthalmol., 58: 92-95 (1974).
GERALD FORD LIBRARY
51
16. Francois J., "Aphakic Glaucoma", Ann. Ophthalmol., 5:
429-442 (1974).
17. The national Ambulatory Medical Care Survey: 1973 Summary,
U.S. May 1973-April 1974, Series 13 - Number 21, DHEW
Publication No. HRA 76-1772.
18. National Center For Health Statistics (HRA), Unpublished Data.
19. Prevalence of Selected Impairments, U.S., 1971, Health Interview
Survey, Series 10 - Number 99, DHEW Publication No. HRA
75-1526.
20. National Eye Institute (NIH), Unpublished Data.
21. U.S. Hospital Discharge Survey - 1972, National Center For
Health Statistics (HRA), Unpublished Data.
22. Beasley, H., "The Visual Fields in Aphakia", Trans, Am.
Ophthalmol. Soc. 63: 363-416 (1965).
23. Foulds, W.S., "Cataract", The Practitioner, 197: 5-12 (1966).
24. Benton, Jr., C.D., and Welsh, R.C., Spectacles For Aphakia,
Charles C. Thomas, Springfield, pp. 5, 22-25 (1966).
25. Stone, J., "Optical Comparisons Between Haptic and Corneal
Lenses For Aphakia", Amer. J. Optom. and Arch. Amer. Acad.,
Optom., 45(8): 528-531 (1968).
26. Koetting, R.A., "Special Considerations in the Fitting of
Contact Lenses in Aphakia", Am. J. Optom. and Arch. Amer.
Acad. Optom., 41(4) : 248-259 (1964).
27. Kumar, D., Goel, B.S. Srivastava, M.S., "Contact Lenses in
Monocular Aphakia", Contacto, 12(3): 35-39 (1968).
28. Welsh, R.C., "Contact Lens For Aphakia", Amer. J. Optom. and
Arch. Amer. Acad. Optom., 48(11) : 949-952 (1971).
29. Polse, K.A., "Contact Lens Fitting in Aphakia", Amer. J. Optom.
and Arch. Amer. Acad. Optom., 46(3): 213 219 (1969).
30. Crossen, F.J., "Aphakia-Contact Lenses-Hard-Soft-None",
Contact Lens Med. Bull., 6: 11-14 (1973).
31. Clahr, L. "Continuous Wear of Soft Contact Lenses By Aphakic
Patients", Contact Lens Med. Bull., 6: 35-37 (1973).
FORD & LIBRARY GERALD
52
32. Stein, H., Scott, B., "Contact Lens After Cataract Surgery:
A Review of 200 Aphakic Patients Fitted With Soft Lenses",
Can. J. Ophthalmol., 9: 79-80 (1974).
33. Welsh, R.C., "Continuous Use of Tiny Hard Corneal Lenses For
Aphakia (200 cases)", Ann. Ophthalmol., 5: 1003-1004 (1973).
34. Shaw, E.L., and Gasset, A.R., "Experience in the Use of Soft
Contact Lenses For the Correction of Monocular and Binocular
Aphakia", Ann. Ophthalmol., 5: 937-943 (1973).
35. Milkie, G.M. and Miller, S.C., Eds., Current Optometric
Information and Terminology, 2nd. Ed., St. Louis, American
Optometric Association (1975).
FORD & LIBRARY GERALD
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SECTION II-B
OPTOMETRIC LAW AND PRACTICE
Compiled by Grace W. Madison, J.D.* and David B. Hoover, M.P.H.**
The scope of practice and area of competence of the health professions
are of increasing importance as we attempt to improve the organization
and operation of the health care system. While precise definition
is not possible, information is available from several sources from
which to develop valid concepts of a profession's role and function.
The sources are:
- State laws which authorize activities and responsibilities
of health workers.
- Board regulations which implement and enforce activities
and responsibilities of health workers.
- Decisions by the courts concerning the responsibilities
of practitioners.
- The usual and customary practices of the professions.
- The objectives, content, and standards of education and
training for the profession.
This section presents information about the legal bases for the
practice of optometry, and draws upon evidence of how optometrists
function in present day practice. All health professions including
optometry are in a state of professional growth--i.e., an expansion
or re-definition of their responsibilities and functions--in response
to new professional specialties, and the changing demands of society.
Typically, professional growth is first observed in certain practice
settings, usually those where clinical, academic, or economic
pressures encourage the most efficient and effective use of personnel.
Professional education will quickly reflect this growth and encourage
its spread throughout the rest of the professional community.
Eventually, changes in legislation and regulation will be made to
accommodate the new responsibilities and functions.
* Program Analysis Officer, Division of Associated Health Professions,
Bureau of Health Manpower, Health Resources Administration, DHEW.
**Associate Director for Planning and Evaluation, Division of Associated
Health Professions, Bureau of Health Manpower, Health Resources
Administration, DHEW.
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Therefore, in attempting to state what optometrists or other health
personnel can and should do, it is important to examine what they
are actually doing and what trends in professional growth can be
observed.
*
*
"The Doctor of Optometry (O.D.) is a health professional who performs
eye examinations to determine the presence of visual, muscular, or
neurological abnormalities, and prescribes lenses, other optical
aids, or therapy such as eye exercises to enable maximum vision.
Optometrists are trained to recognize diseased conditions of the
eye and ocular manifestations of other diseases, and to refer patients
with these conditions to the appropriate health professional.
/
"Optometry as a profession is concerned with the problems of human
vision. Optometrists examine the eyes and related structures to
determine the presence of any visual, muscular, neurological, or
other abnormality. They prescribe and adapt lenses or other optical
aids and may use visual training aids (orthoptics) when indicated to
preserve or restore maximum efficiency of vision. Most optometrists
fit and supply the eyeglasses they prescribe. They do not prescribe
drugs, make definitive diagnosis of or treat eye diseases, or perform
surgery. 112/
These definitions of optometry reflect the optometrists' role as a
provider of primary health care. In this role he functions as a
principal point of contact with the health system for individuals
who have visual problems, some of whom will have symptoms or
conditions which require referral to other health practitioners.
A more complete description of optometric functions has been
previously published by the Department 3/
The optometrist's role as a provider of primary care has been of
steadily increasing concern and importance. This trend has received
additional sitmulus in recent years from the larger role assumed by
optometrists in health care in military settings, and in institutional
care as typified by health maintenance organizations, where he may
evaluate all patients who present themselves with visual problems.
Also, most States have specific statutory provisions prohibiting
discrimination between ocular practitioners in public and private
insurance programs, thereby giving persons the freedom to select
the practitioner to perform vision care services.
All of the health professions have experienced, in the last half-
century, tremendous growth in the scope and depth of their discipline,
and optometry is no exception. Optometrists have displayed a high
degree of responsiveness to technological change, and have made
noteworthy efforts to adopt new techniques as part of their practice
and to improve the scientific content of their education
55
Optometric Practice Authorized By State Law and Board Regulations
The practice of optometry is governed by statute in every jurisdic-
tion. While no single definition of optometry is used in all state
laws, certain descriptive and limiting phrases recur in almost all
States defining this profession. Generally, an optometrist may be
defined by statute as one who, having met the requisite legal and
education requirements, is licensed to examine eyes and to correct
refractive errors through ocular exercises or by prescribing and
fitting corrective lenses, but not through the use of drugs or
surgery. The optometrist is also expected to recognize, but not
treat, disease of the eye. This definition has been broadened by
a few States in recent years to authorize the use of diagnostic drugs.
Another significant source of information is regulations of State
Boards of Optometry. State Boards are delegated the authority to
make rules and regulations governing the practice of optometry which
they deem necessary for the effective enforcement of State laws.
Court decisions stemming from malpractice suits constitute a reliable
body of information with legal significance for the determination of
the scope, responsibilities, and proficiencies of a profession.
However, in optometry, malpractice suits have been rare, and there
are few such decisions to which we may turn.
A systemic analysis of State optometric practice acts is difficult
because of variations in phrasing and coverage of the acts. The
variations arise from the nature of the existing legal code of which
the act is a part, or conditions giving rise to the need for the law,
or for a revision thereof, in a given State. Differences in
expression and the use of terminology among authors of laws also
result in variations which make authority and intent difficult to
compare.
In determining the scope of practice of optometrists, i.e., what
procedures or functions they may perform, several indicators may be
considered. In rare cases, a statute or regulation will define the
term "optometry" or "practice of optometry" so as to detail specifi-
cally what procedures fall within the scope of practice. More
frequently, the law or regulation defines its terms broadly,
discussing specifics elsewhere. Many States include in their laws
a schedule of the minimum procedures which must be performed on
every patient being examined by an optometrist. These schedules
are perhaps the most valuable tool available for determining how
expansive the scope of practice is in a given State. A less
valuable tool, but nonetheless an indicator, are the statutory or
regulatory provisions outlining the equipment which each optometrist
must have in his or her office. If the minimum equipment schedule
includes a refractor and an ophthalmoscope, it may be concluded that
an optometrist may or should perform internal ophthalmoscopic
examinations and refractions in that State.
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A first procedure undertaken by this study was to use these
indicators to compile a chart of functions or procedures specifically
authorized in the laws and regulations of each State. The authori-
zation may be either expressed or implied as explained above.
The results of this effort-the chart and a discussion of findings--
are provided in Attachment A of this chapter. Although, the chart
gives an indication of how optometry is viewed by State legislatures
and regulatory bodies, it can be relied upon only as a partial
indicator of what optometrists should or should not do. For example,
only 24 States specifically mention refraction or measurement of
refractive powers among the permitted or required functions of an
optometrist, but, by definition, refraction is an essential component
of optometric practice in every State. Thus, from analysis of
practice acts and related regulations, with few exceptions, the law
is unclear as to what services optometrists may perform.
Optometrists As Providers of Primary Care
Of particular relevance to this study, is the extent to which optome-
trists are permitted by law ot provide a portion of primary care.
Primary health care by first-contact health professionals involves
the detection of disease or abnormality and proper disposition of
the patient.
State laws were examined to determine the extent to which they hold
optometrists responsible for, or require them to be knowledgeable
about this primary care function. In recent years, several States
have amended the laws to redefine optometry, notably, Alabama,
Connecticut, Idaho, Pennsylvania and Tennessee. The new definition
reflects further recognition of optometrists as primary care providers
by expressly enabling practitioners to ascertain the presence of
disease or pathological conditions and to refer the patient to the
appropriate medical practitioner for further diagnosis.
Further mention of such a requirement or ability is made in
Attachment B.
Optometrists are seldom subjected to malpractice suits, the very
low rate of insurance ($280.00 per year) reflecting this fact. Suits
have been brought, however, and it is informative to note the extent
to which courts hold that optometrists are responsible for the care
of their patients.
An optometrist has the duty to refer a patient to a physician for
pathological conditions which he recognizes. Optometrists have been
found both liable and not liable for malpractice in the prescribing
and fitting of corrective lenses and for failing to refer, and
different standards of care are used by the courts.
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In a Maryland optometric malpractice case in 1971, the court equated
the duty of an optometrist to advise patients with that of a
physician. 6/ The Supreme Court of the State of Washington has
apparently held, in a 1974 ophthalmological malpractice case, that
standards of eye care will be fixed by the court if professional
standards are found wanting-- a case which has significant implications
for optometry. 7/
The question of the duty and ability of an optometrist to discover
pathology was explored in a New Jersey case in which the Superior
Court, Law Division, stated that -discovery of pathology is
included within the scope of the responsibility and the minimum
examination to be administered by an optometrist. " This and other
precedents were cited in an opinion of the Attorney General of the
State of New Jersey that authorizes optometrists to utilize local
anesthetics. The opinion is quoted at length in footnotes to this
chapter 8/
Another aspect of the redefinition of optometry has to do with the
use of topical drugs for diagnosis. Prior to 1971, optometry law,
almost without exception, used the phrase, "any means except drugs
to diagnosis ocular abnormalities, " in defining the manner in which
optometry may be practiced. Since that time, several States have
amended the law to permit the use of drugs and appear to have
broadened the scope of practice. These recent changes in State
law support the conclusion that the States view optometrists as
first-contact primary vision care personnel.
Eight States now permit the use of topical drugs for diagnostic
purposes and require an examination in pharmacology as it relates
to optometry. One State, West Virginia, also permits optometrists
to use drugs in the treatment of the eye. The language of the
statutes vary from a general statement as to the use of topical
drugs to a specific statement as to the precise drugs to be used.
Attachment B summarizes recent laws and regulations respecting the
use of drugs.
The Assurance of Quality in Optometric Practice
To this point, this chapter has explored the legal basis for the
private practice of optometry as it is set forth by the respective
States. Several general conclusions can be drawn:
- There is wide variation among States in the manner in
which optometry is defined.
- State laws and Board regulations are often inconsistent
in specifying functions of optometrists.
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- Statutes relating to the practice of optometry have
been construed both strictly and broadly by the courts
and attorneys general.
- The legal basis for optometric practice does not antici-
pate the professional growth of practitioners, but rather
(as is typical for other licensed health professions)
follows developments in education and practice.
- It is not the intention of State legislative and regulatory
bodies to restrict the practice of optometry to refraction
and the provision of lenses.
A further issue relevant to this study is the assurance of quality
in vision care. Quality in health manpower is difficult to define
or measure, but it may be said to consist of proficiency- the
knowledge and skill of the practitioner--and performance--th
extent to which that knowledge and skill is fully applied in the
care of patients.
In health professions, both proficiency and performance are of
increasing public concern. Proposals to require periodic
re-examination of practitioners reflect a concern that proficiency
is maintained. Professional Standards Review (PSRO) is an attempt
to examine performance-- to determine, for example, that economic
incentives are not overruling professional judgment in the handling
of cases.
In investigating the current quality of any health profession, we
must expect considerable frustration. Statistical evidence of the
quality of care which also shows the reasons for any deficiencies
is hard to come by. So many variables in addition to the proficiency
or performance of the practitioner influence the outcome of a case
or dictate the need for a certain procedure or treatment that little
can be inferred about the practitioners involved. Individual case
experiences allow no generalization to a profession as a whole,
and of course, they come to our attention through malpractice
suits, disciplinary actions, and news accounts of patient's
complaints. They are, therefore, almost uniformly negative in
tone and there is no corresponding body of anecodotal evidence in
general circulation that reflects positively on a health profession.
Nevertheless, there is information from which we can make, cautiously,
some general deductions about the quality of a health profession.
Principally we have:
- The content and duration of basic education for the
profession.
- The nature and extent of organized evaluation and control
of basic education (i.e., accreditation).
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- Requirements for licensure and/or other forms of
professional credentialing (such as certification by
a voluntary professional board or agency).
- Requirements for periodic re-licensure and/or
re-certification.
- Continuing education: its availability, content, and
the extent to which practitioners avail themselves of it.
- Ethical codes and standards of practice promulgated by
professional associations.
- The disciplinary procedures and actions within the
profession.
Education and accreditation are discussed elsewhere in this study,
as part of a review of optometric education. It is convenient to
look at licensure, re-licensure, and continuing education in
optometry simultaneously, since these are inter-related. (This
is unusual among health professions, most of which unlike optometry
are not required to meet any quality-related criteria in order to
retain licensure or certification).
Initial Licensure Requirements
To qualify for licensure as an optometrist, an applicant must be a
graduate of an approved school with a program leading to a Doctor of
Optometry degree. Four States require applicants to complete an
internship as a prerequisite to being examined for licensure. The
length of the internship varies: three months in Alabama, six
months in Delaware and Rhode Island and one year in Oregon. North
Carolina does not require an internship but does require the
applicant to have completed a two week practice orientation.
Most States also specify some courses or subjects that must have
been included in basic optometric education or (more usually) that
must be covered in a licensing examination. The course which appears
most frequently in State statutes and regulations is ocular anatomy.
Thirty States examine candidates on this subject and/or require the
course for licensure. Twenty-three States require a course in or
an exam on ocular pathology. Twenty-three States require practical
optometry. Ocular physiology appears as a requirement in the laws
or regulations of 20 States, while theoretical optics appears in 19,
physiology in 18, and general anatomy in 15.
Thirteen States require course work or exams on pathology and on
visual training and orthoptics. A course in contact lenses is
required by 11 States, while optics is prescribed in ten.
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A number of subjects appear in less than ten of the State's
requirements. Refraction and geometric optics appear in nine
times each. Eight States require course work in psychology.
Physics and hygiene appear six times each, as does prescription
and fitting. Pharmacology is tested in five jurisdictions as
is clinical optometry. Optical laboratory and clinical work,
mathematics, and psychological optics each appear in four
State's examination requirements. Physical optics, ocular
myology, and ocular neurology are examined on in three States
each. Tonometry, mechanical optics, and case analysis are
required course work in two States.
Attachment C shows in tabular form the subject matter to be
mastered for licensure in each State.
All States require applicants to pass a written examination as
a condition precedent to licensure. There is a National Board
Examination in Optometry which is used at the discretion of the
State Boards and in 18 States is expressly accepted in lieu of
the State written examination. Sixteen States also require
applicants to pass an oral examination. In five other States,
an oral examination is optional. Twenty-eight States require
practical examinations and in two others, practical exams may be
required at the Board's discretion. Requirements of States for
initial licensure are presented in tabular form as Attachment D
to this chapter.
Continuing Education and The Renewal of Licensure
Optometry has taken formal steps to assure that practitioners are
required to continually upgrade their diagnostic and treatment
skills. Beginning with Iowa in 1938, forty-three States have
adopted, either by Board rule or statutory law, some form of
continuing education requirement for license renewal. Of the
remaining States without formal requirement, several State
optometric associations have instituted a system of continuing
education requirements for membership purposes
Content of continuing education courses also varies widely as do
the institutions and entities providing such services. 10/,11/,12/
The Southern Council of Optometrists recently provided 102 clock
hours of education to some 1200-1300 registered participants. A
separate listing which itemizes course offerings related to manage-
ment of the patient with cataract or aphakia is appended. 13/ The
list supplied by the Division of Education and Manpower, American
Optometric Association, samples courses offered over the last five
years.
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Continuing optometric education courses are offered by over 100
agencies. This includes the 51 State associations affiliated with
the American Optometric Association, the twelve U.S. schools and
colleges, national organizations such as the American Academy of
Optometry, American Optometric Foundation, and the Armed Forces
Optometric Society, and the seven regional councils of optometrists
(Central States, North Central States, Northeast States, Mountain
States, Southwestern States, and Southern). Several other organiza-
tions offer courses either individually or in conjunction with State
and regional annual meetings, e.g., the College of Optometrists in
Vision Development, The Vision Institute of America, The National
Optometric Association, and the Optometric Extension Program.
Some State Boards are also providing coursework related to changes
in optometry statutes and rules.
The presentation of continuing education can be described in two
general categories: that which is primarily clinical and laboratory
work (offered by schools and colleges) and the lecture form. The
latter frequently incorporate sophisticated learning aids, including
print in all forms, including motion pictures, film strips, photo-
graphs and models, recordings, and the like. Practitioners involved
in continuing optometric education include at a minimum, all licensed
optometrists in the States that require it for license renewal. It
is estimated that some 17-18,000 of the reported 21,000 licensed
Doctors of Optometry are currently obtaining continuing education.
Additional sources for maintaining knowledge of advances in optometry
are the various professional journals available to practicing
optometrists. These include the Journal of the American Optometric
Association (which contains a feature on continuing education self
assessment), the American Journal of Optometry, as well as many
publications from related professions and sciences. Most State
associations have periodicals for distribution to members which
contain case histories and new technique information.
The nature of the requirements for continuing education that forty-
three States impose varies considerably. Most States specify that
credit may be given for optometric or other scientific education,
lectures, symposiums or courses approved by the board, post-graduate
study at a school of optometry, or a course given by the optometric
association.
There is no uniform amount of time required. Requirements range
from eight to 25 hours. The requirement is generally a prerequisite
to license renewal and consequently must be fulfilled within the
renewal period. Attachment E summarizes the license renewal
provisions for continuing education in the various States.
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In common with other major health professions, optometry has codified
ethical standards and mechanisms for disciplining members of State
associations independent from any actions of regulatory boards. Of
particular interest here is the position of optometry on referral to
other sources of health care. The fifth precept of the Code of Ethics
adopted by the House of Delegates of the American Optometric Associa-
tion, at Detroit, Michigan, June 28, 1944, states that "It Shall Be
The Ideal, the Resolve, and the Duty of the Members of the American
Optometric Association TO ADVISE the patient whenever consultation
with an optometric colleague or reference for other professional
care seems advisable. "
Information on disciplinary actions of professional organizations
might indicate the extent to which the promulgated professional
standards are actually enforced. However, this information is not
made available (to do so would raise serious questions of the respect
of privacy and due process), and special efforts would be required
to undertake any assessment of the effectiveness of this method of
ensuring professional quality.
Optometry In Organized Health Care Settings
The capabilities of optometry are most easily examined in organized
settings such as military establishments and health maintenance
organizations. Here, in contrast to private practice, their
responsibilities and functions are more clearly defined and their
accomplishments and professional relationships with medicine are
more apt to be a matter of record.
Most optometrists are in private practice and data on the nature of
their practice and the efficiency of the provision of vision care is
lacking. Any amount of anecdotal evidence--single case histories or
the procedures and experience of single optometrists or ophthalmolo-
gists--is available to support the contention that optometrists
function effectively as primary care personnel, but from this one
can draw no firm conclusions about how the "average" optometrist,
or the majority, do in fact function.
However, utilization of the optometrist in an organized health care
setting does offer insight into how the private practitioner can
function. Organized settings include the armed forces, the Veteran's
Administration, and health maintenance organizations.
The armed forces employ 302 ophthalmologists and 521 optometrists.
Proportionately more optometrists are employed in the Air Force
(176 vs. 58 ophthalmologists), and fewer in the Navy (127 optometrists
to 130 ophthalmologists). In larger medical installations, optometry
is a section of the department of ophthalmology, while in smaller
installations the optometrists will work in the department of surgery
or under the director of hospital clinics but without close professional
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supervision. In military installations, ophthalmologists do not
provide services without the assistance of optometrists. Referral
rates from optometrists to physicians range between three and seven
percent of the patients seen, a higher percentage than that found
in civilian clinics.
Position descriptions for optometrists in Federal service emphasize
the breadth of the discipline. 14/ The services recognize examinations
performed by civilian optometrists. For example, the U.S. Navy
recruiting manual, Section 4, "Physical Qualification, 11 C-1401
"general" contains the following statement: "Statements from optome-
trists will be accepted on all matters pertaining to eye examinations
except definitive diagnosis of disease. This does not preclude the
acceptance of a statement from an optometrist regarding certain
conditions of the eyes or a statement that there is no disease of
the eye. 15/
The military have successfully instituted optometric triaging using
medical corpsman supplemented by optometrists. 16/ In this setting,
optometrists successfully function as primary care personnel. The
Civilian Health and Medical Program of the Uniformed Services
(CHAMPUS) provides or reimburses for health services for armed
forces retirees, dependents and others. CHAMPUS authorizes payments
to optometrists:
- for eye examinations performed for the purpose of ruling
out pathology even though the examination may result in
the determination that no pathology exists.
- for spectacles or special lenses required in the surgical
or medical treatment of pathological conditions.
but does not reimburse for lenses needed solely for the purpose of
correcting refractive error.
In the provision of vision care the Veteran's Administration has
relied heavily upon ophthalmology and to a much lesser extent upon
optometry. It uses the full-time equivalent of 100 ophthalmologists
(including 188 residents, 85 staff, and 90 consulting or attending
ophthalmologists) but only 8 full-time, 13 part-time and less than
40 attending or consulting optometrists. 17/ This low rate of
utilization of optometrists is partially explained by non-competitive
civil service salary rates established for them, and partially by
the lack of affiliation of VA hospitals and clinics with optometry
schools. An exception is the VA Hospital in Birmingham, Alabama,
which is affiliated with the School of Optometry, University of
Alabama. The VA, however, has recently established a Vision
Impairment Committee (with representation from Ophthalmology,
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Optometry and Blind Rehabilitation) which has recommended that
training affiliations be established or strengthened with schools
of or colleges of optometry. The VA's Ophthalmological Advisory
Committee has endorsed the concept of expanding the present emphasis
on eye health care to the more comprehensive conncept of vision care
via interdisciplinary team delivery 18/
Health maintenance organizations provide a setting in which optometry
has well-defined relationships with the other health professions.
Group Health Association of Washington provides primary care for
about 50,000 people, utilizing 55 full-time and 75 part-time
physicians supported by 400 ancillary personnel. 19/ Vision care
in Group Health Association is provided by two full-time ophthalmolo-
gists and 5 full-time and 2 half-time optometrists under the super-
vision of the Chief of Ophthalmology, a physician. Optometrists
evaluate all patients with visual problems, refer them to ophthalmolo-
gists as necessary, do refractions, determine visual fields, and fit
contact lenses. Ophthalmologists rarely refract and then only in
connection with pathology. Experience here and in other health
maintenance organizations shows that extensive utilization of the
optometrist's capabilities is compatible with high quality health
care.
Optometrists are effectively utilized in providing vision care
services under various Medicaid programs. The Medical Assistance
Program of New York City (Medicaid) for example, utilized optometrists
at the onset. It defined comprehensive public funded health care as
meaning a vigorous participation of all relevant professional
disciplines: medicine, dentistry, pharmacy, optometry, podiatry,
clinical psychology, etc. 20/ Under this program, the patient is
free to choose the practitioners, and the majority of vision services
are provided by optometrists. New York City Medicaid reimburses
optometrists for all aspects of optometric practice.
Insurance coverage per se cannot be considered as a decisive factor
in the utilization of eye care services. In a New York City survey
done seven years after the introduction of the Medicaid program,
individuals with insurance coverage had significantly lower
utilization rates than those without 21/ Ninety-four percent of a
sample of adults had had an "eye examination" sometime during their
life; of these, twenty percent were not able to state what type of
practitioner provided their last examination, "reflecting the wide-
spread confusion among consumers about eye care disciplines and
practitioners. 11 Of the individuals who could distinguish between
practitioners, 59% had last utilized optometrists, and 41%
ophthalmologists. An apparent majority of this urban population,
therefore, obtained vision care from optometrists, a finding con-
sistent with other surveys. This survey also showed that utilization
of optometrists as opposed to ophthalmologists is apparently unrelated
to race and slightly related to socio-economic rank (with the highest
rank more often utilizing the physician).
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This survey found substantially less utilization of optometrists
in the population over age 60 than among younger age groups. A
greater proportion of the older population is, no doubt, seeking
care from ophthalmologists. Two reasons for this are apparent:
the older population suffers to a greater extent from eye disease
requiring medical diagnosis and treatment, and present medicare
reimbursement policies lead patients requiring optometrist's services,
which are not reimbursable, to ophthalmologists, whose service is
reimbursable in part. This and other surveys point out that a
majority of the population chooses to rely or must rely upon
optometrists for primary vision care. 25/
From experience in structured multidisciplinary health care settings
it is clear that optometrists can function as primary health care
providers, with efficient relationships with medicine. Data from
private practice suggest that many or most in that setting are
equally effective, but that a proportion of private practitioners
need better working relationships with medicine than they have been
able to establish.
Other Information Bearing on Optometric Practice
It is accepted that optometrists are well-grounded in physical and
physiological optics and competent to refract and provide prosthetic
lenses. Such documentation of optometric care as exists deals only
with these aspects of practice and shows a high quality of service. 26/
Some insight into their effectiveness in providing other components
of patient care can be gained by examining practices of referral of
patients to physicians.
A considerable body of optometric literature has to do with referrals
to physicians--criteria for referral, procedures to detect systemic
disease, information that should be provided the physician, etc.
Optometric educators, administrators of vision care departments in
institutions or group practices, and leading practitioners are clearly
concerned with improving vision care by establishing more efficient
and effective working relationships with medicine in the detection
of abnormalities 27 For example, the Black Hills District Optometric
Society has, since the early 1960's, had periodic meetings which
include local ophthalmologists in order to devise and refine criteria
and procedures for referral of patients and to encourage good referral
practices 28/
Various studies indicate that between two and three percent of patients
examined by optometrists require referral to a physician. Reliable
data are not available to show how this rate varies by age of patient,
or the extent to which optometrists may over or under-refer. No
satisfactory study of referrals to and from optometrists in private
practice has been done; the best information comes from data collected
in group practices and clinics.
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A 1968 study of vision care within the Kaiser-Permamente prepaid
care plan in the Los Angeles area, for example, showed that 2.75
of the patients seeing an optometrist were referred to ophthalmolo-
gists. Patients suffering from neurological disorders (e.g.,
cerebral-vascular accidents, multiple sclerosis, suspected tumors)
are referred from physicians to optometrists for visual field testing
and examination of the fundus. The optometrist's findings are used
in arriving at a diagnosis.
A study of pathology detected, and of referrals in an inner-city
vision care clinic staffed by optometrists, optometry students, and
ophthalmologists showed a relatively high rate of detection by
optometrists and students of abnormalities requiring referral to
physicians
29
Glaucoma was the most prominant condition detected,
accounting for 21% of all referrals, with nuclear cataracts
accounting for a further 9%. Diabetic retinotopathy caused 6% of
the referrals. These represent only conditions for which there was
no previous record of diagnosis and treatment. The relatively poor
state of health and vision care of elderly innercity populations is
apparent from data this clinic, in which 17% of the patients in the
age group 51 to 60, and 27% of those in the group 61 to 70, required
referral to physicians. In 2.85% of the population of this clinic,
the detection of ocular abnormalities by optometrists or optometry
students led to the diagnosis of previously unrecognized and untreated
ocular or systemic disease.
From experiences in organized health care settings, it is apparent
that optometrists can be effective in the detection of abnormalities
of the vision system and in selection of patients who require medical
care. There is a definite trend toward utilizing technicians and
assistants of various types to carry out much of the initial
examination, subject to farther screening by the optometrists.
Studies of referral practices of private practitioners would, if
adequately done, provide valuable insight into the extent to which
optometrists are able to detect abnormalities of the visual system
and their disposition of such cases. Unfortunately, no reliable data
are available. A mail survey in 1960 of a sample of optometrists
revealed only that the overall referral rate to physicians was 2.19%
of cases, with 54% of these referrals being to ophthalmologists 30/
No information was obtained with which to judge whether this rate
is adequate, excessive, or inadequate.
Relationships between optometrists and physicians have considerable
bearing on the mode of practice of the optometrist. Most optometrists
have a working relationship with one or more ophthalmologists. Of
the information available about the ability and proper role of the
optometrist as seen by the physician, little has been collected in
any rigorous manner from a defined sample of respondents, and in no
case is it available in sufficient detail to allow more than the
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grossest speculation about the origin and nature of the opinions of
optometry that a minority of physicians hold. It seems likely,
however, that any negative opinions are based upon experience with
a few individual optometrists, most probably older practitioners who
were trained to and do restrict their practice to little more than
refraction and dispensing. Hafner's data 31 and findings from the
National Center for Health Statistics 1968 Survey of Optometry
Practice support this contention. The latter survey in particular
showed that many optometrists educated before 1940 (now constituting
about 13% of active optometrists) may not attempt to function as
primary care personnel and may not make a thorough attempt to detect
systemic disease which may have ocular manifestations.
A survey of California physicians concerning their relationships
with optometry was published in 1974 32/ General practitioners,
internists, and neurologists were surveyed and 372 usable replies
were obtained. 61% of the general practitioners had had patients
referred to them by optometrists while 55% of the neurologists and
39% of the internists had had such referrals. All but a few of
these physicians were of the opinion that the referrals were
properly handled and served the patient's best interests. Approxi-
mately the same proportion of physicians in this study who had
patients referred to them by optometrists referred their patients
to optometrists, and almost all reported that these referrals were
handled in a satisfactory manner. Of the responding physicians,
70% reported that it is in the patient's best interest for optome-
trists to check for ocular pathology and ocular signs of systemic
disease. These findings confirm an impression that on the individual
level, the majority of physicians and optometrists in practice enjoy
a fruitful and on the whole harmonious relationship, permitting a
high quality of patient care.
Earlier, reference was made to the National Center for Health
Statistics Survey of Optometric Practice conducted in 1968. The
survey was repeated in 1973, but only the 1968 study asked respondents
to check off the types of procedures performed in their office.
(Data from the 1973 survey is only now being produced, and has not
been published except as a series of reports by State).
The 1968 survey listed 14 services or procedures for the responding
optometrist to report as being done in his practice. The data
suggested that some optometrists do not perform an examination
that is sufficiently complete to serve as an adequate screen for
pathology. However, additional analyses were obtained and methods
of collection of the data were reviewed. After discussion, the
advisors and staff to this study were of the opinion that this data
cannot be taken as a reliable indication of the state of optometric
practice then or now 33
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There are numbers of other minor studies of optometric practice
which either do not address the proficiency or performance of
optometrists or are deficient to the point that they provide no
basis for generalization.
In view of this lack of definitive data, any comments about the
capabilities, or lack thereof, of all optometrists to provide
adequate vision care including primary care must be recognized as
having an unsteady base. It can be assumed that in optometry, as
in other health professions, there are individuals whose skill and
procedures do not conform with the standards set by the professions.
It cannot be said, however, that in this respect optometry is in a
worse position than any other health discipline.
The situation is not helped by disagreements about what constitutes
optical screening or an optometric examination, or disagreements
about what types of manpower should be entrusted with various
responsibilities and procedures. As we have seen, laws and regu-
lations vary widely when addressing these subjects. This is a
reflection of a general disorganization in the provision of vision
care.
To a notable degree in this field there are unresolved issues about
what procedures should be carried out and what types of manpower
should be employed. For example, tonometry, a relatively simple
process for the determination of intraocular pressure and the
detection of glaucoma is an important component of vision care.
Considerable ingenuity has been expended in devising sophisticated
devices to determine intraocular pressure. However, in some medical
clinics and group practices tonometry is reserved to ophthalmologists,
in others it is done by any physician. In some other instances,
optometrists do tonometry while in an increasing number of cases,
technicians are being trained for this. It seems that considerations
other than cost effectiveness are determining the utilization of
manpower in glaucoma screening. There is also some disagreement
about when tonometry should be done. The Department of Medicine
and Surgery of Harvard Medical School in 1974 study found justifi-
cation for glaucoma screening (by technicians) in medical and
ophthalmology clinics for all patients 40 years or more of age
34/
Elsewhere, however, we have opinions recorded that, at least for
patients with vision complaints, tonometry should be a routine
part of the optometric examination for younger patients.
Optometric Therapy
Therapy provided for patients who have cataract/aphakia relates to
the prescribing of pre- and post-surgical care that rehabilitates
the patient to the best possible visual acuity while providing clear
single binocular vision (fusion).
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Discussions with expert consultants to the study indicated that
such therapy may include referral and consultation relating to
secondary disease processes that are encountered by the optometrist
subsequent to the surgery (see Part II, Section A, Complications
of Cataract Surgery).
It was further concluded that the prescribing of lens therapy by
spectacles or contact lenses, vision training and rehabilitative
services, including the teaching of patients to use new prescription
devices properly, are part of the therapy prescribed. It was felt
by the consultants also that the post-surgical monitoring by the
optometrist of referred patients, especially in remote areas where
ophthalmologists are not available, constitutes an appropriate
form of therapeutic care. The optometrist may examine the post-
surgical patient on several visits to determine the rate of his/her
progress toward complete recovery.
Contact lens therapy is especially appropriate in the following
conditions: monocular aphakia, corneal disease, corneal injuries,
scarred corneas, irregular astigmatism, aniseikonia and kerataconus.
Both hard and soft lenses serve specific therapeutic purposes when
prescribed for rehabilitative care.
The complications of general systemic disease play an important
role in the method of treatment the optometrist may prescribe.
For example, arthritis may inhibit the patient from safely and
efficiently handling contact lenses, thus, requiring that alterna-
tive methods of correction be considered and selected. The total
life style as well as occupation of the patient must be considered
in the rehabilitation process.
Another example of where the optometrist adapts the therapeutic
lens prescription to the patient's individual needs occurs during
the progressive visual changes that frequently occur in diabetes.
Rapid development and changes in less than three months, associated
with the diabetic type of cataract, may require frequent prescription
changes to maintain adequate corrected visual acuity and permit the
patient to perform daily functions. The complications of diabetic
retinopathy may further compound the need for frequent examinations
and prescription changes. The patient may also require frequent
consultation between optometrists and ophthalmologists where medical
and surgical treatment is indicated. Prescription changes of a
major nature may be necessary during the dynamic phase of the
cataract/retinal complications associated with diabetes.
Other diseases, requiring similar prostheses, as well as frequent
examinations and lens changes, are associated with hypertensive
retinopathy, senile macular degeneration and arteriosclerosis, all
of which may require the prescribing of specific lens modifications
GERALD FORD LIBRARY
70
because of the effects that the disease process has on the
performance of the eye and vision. These and similar disease
processes are best managed, according to the study consultants,
by optometrists working together in a complimentary relationship
with general physicians and ophthalmologists to enhance the
patient's life style.
Trends in Optometric Practice
The regulation of the practice of optometry has undergone a number
of changes since 1973. The most frequent change has been the
increase in continuing education requirements. Thirteen States
introduced continuing education as a prerequisite to license
renewal. In addition, Nevada, in 1975 (Ch. 659), strengthened
its requirement by giving its Board the power to suspend the
licenses of optometrists who fail to fulfill the continuing
education requirement. The suspension automatically becomes a
revocation if the requirement is not fulfilled within one year of
the suspension.
The second major change has been in the relationship of optometrists
to programs for delivering health services. Optometrists are
increasingly being included in various health care programs. A
1975 Kansas statute (H. 2554) allows nonprofit corporations to be
created specifically to provide group optometric care programs.
California (Ch. 1141 (Laws 1974)) has included optometrists in
prepaid health plans. Rhode Island, in 1975 (Ch. 288), included
services by optometrists in the State's catastrophic health insur-
ance programs. Maryland (Ch. 482 (Laws 1974)) has included
services of optometrists in group health insurance policies. And
finally, Colorado, in 1973 (H.B. 1106), added optometry to services
which certain corporations may make available to health benefit
subscribers.
Some statutes have revised the definition or scope of practice of
optometrists. Wisconsin (Ch. 275 (Laws 1974)) construed the meaning
of "physicians" to include optometrists in all accident and sickness
policies. New York (Ch. 74 (Law 1974)) included optometrists with
other medical professionals who received legal immunity for service
on utilization review committees. California states that in
determining whether an individual is blind, the patient may be
examined either by a physician skilled in diseases of the eye or
by an optometrist.
Especially in organized health care settings more attention is being
paid to quality assessment in health care, including vision care.
The difficulties of making judgments about quality of care, and
especially of practitioner proficiency and performance, have been
mentioned. Nevertheless optometry for the most part deals with
readily visualized or measurable conditions, and is more amenable
FORD
GERALD
LIBRARY
71
to the comparison of practice to standards than are many health
professions. Some progress is being made in this, and organized
optometry is generally cooperative in these efforts.
Peer review is an approach which may be used to measure and assure
the quality of medical and optometric practice. Optometrists have
a role in the review responsibilities of the Professional Standards
Review Organizations (PSROs). Although the current emphasis on
review of inpatient care or services leaves little opportunity for
review of optometric services under the aegis of PSRO at this time,
the concepts are applicable to the ambulatory care setting.
Furthermore, guidelines and possible protocols now exist.
Standards of vision care as they relate to peer review and guide-
lines for peer review have been developed by many organizations.
The American Optometric Association Peer Review Committee Standards
were adopted in 1972 and supplementary guidelines for peer review
were produced by AOA's Community Health Division's Committee on
Clinical Standards in 1973. The National Center for Health Services
Research and Development has developed a protocol for the cataract
patient which is applicable both to hospital admissions and to
outpatients 35/
The New York State Optometric Association has developed standards
for the New York State Regional Health Department Audit and Review
which involve site visits to practitioner's offices, clinic visits,
records review, and examination of utilization rates. The accepta-
bility of the examination findings is assessed 36/
In May of 1975, the American Medical Association drafted "Model
Screening Criteria to Assist Professional Standards Review Organi-
zations. Standards for hospital admission of patients with cataract,
corneal disease, glaucoma, retinal detachment and strabimus were
developed by the American Academy of Optomology and Otolaryngology
and the American Association of Ophthalmology. Although optometrists
do not admit patients to hospitals, the concepts involved in these
standards are applicable to review of optometric practice and in
general have been endorsed by the American Optometric Association
37/
Also, in 1975 the National Academy of Sciences published the "First
Interprofessional Standard for Visual Field Testing," in which both
ophthalmologists and optometrists participated 38/
The California Optometric Care Foundation, a statewide non-profit
corporation, has developed an optometric care review program outlined
(in an unpublished document of the Foundation) in September 1975.
Their review of optometric services is concentrated in two areas,
diagnosis and treatment, and materials prescribed. This review
would monitor optometric practice principally through statistical
profiles of the types of services received by patients in various
age groups, of ICDA codes, and similar data.
BERALD FORD LIBRARY
72
Thus, it is apparent that within particular defined limits of
practice, standards and review mechanisms can be developed for
vision care as a means of quality control. It is encouraging to
note that much of the development of these mechanisms is being
initiated within or with the cooperation of the optometric
professions itself. 39/
FORD is LIBRARY GERALD
73
Footnotes and Bibliography
1. Costs of Education in The Health Professions.
Report of a
Study. The Institute of Medicine, National Academy of Sciences.
Washington, D.C., 1974.
2. Health Resources Statistics, 1974. National Center for Health
Statistics, U.S. Department of Health Education, and Welfare.
Rockville, Maryland, 1974.
3. The Health Careers Guidebook published jointly by the Department
of Health, Education, and Welfare and the Department of Labor
describes optometry as follows:
An optometrist, Doctor of Optometry (O.D.), is educated
and trained to examine eyes to detect vision problems.
He may prescribe eyeglasses or contact lenses as needed,
or he may recommend other optical treatment to preserve
or to improve eyesight. If evidence of eye disease or
injury is observed, he refers the patient to an opthal-
mologist for diagnosis or treatment. In addition, an
optometrist may render service in any or all of the
following areas:
Contact Lenses: Recent years have seen greatly increased
use of contact lenses. Much of the research and develop-
ment has been done by optometrists. Some optometrists
now devote their entire attention to prescribing and
fitting contact lens. To others it has become an ever
increasing part of their general practice.
Children's Vision: Optometry is playing a leading role in
discovering and solving children's vision problems, espe-
cially in the development and use of vision training and in
orthoptics. Many optometrists specialize in children's
vision; others serve as consultants to schools and school
systems.
Aids for the Partially Sighted: Many of the effective aids
for the partially sighted have been developed by optome-
trists. Through their research, telescopic and microscopic
lens systems have been improved to benefit many in the older
age group; these aids have also helped thousands of children
with seriously impaired vision.
Vision Training: Vision training has long been recognized as
an effective method of correcting some types of crossed eyes.
It is also useful as a way to sharpen visual perception and
to improve vision for reading. Some optometrists devote a
large part of their time to this specialty; others include it
as one of several services.
FORD & GERALD LIBRARY
74
4. Roberts, Bertram L., "Communication Between Optometrists. "
J. American Optometric Association. V. 42, No. 1, January 1971.
5. An example of change in the scope and depth of optometry
occurred in the 1940's when it became apparent that in the
control of blindness due to glaucoma, early detection and treat-
ment was essential. Optometric education was modified to
emphasis this and to stress the importance of a case history,
physical findings, and the measurement of intraocular tension.
Optometrists have been quick to use the latest technical advances
in tonometry.
6. Tempchin V. Sampson, 277 A. 2nd 67.
The court, in its opinion, equated the duty of an optometrist to
that of a physician and stated the general rule to be: "The liabi-
lity of an optometrist to a patient is to be tested by standards
analogous to those used to test physicians and surgeons--whether
or not he did fail to exercise the amount of care, skill and dili-
gence as [an optometrist] which is exercised generally in the
community in which he was practicing by [other practitioners]
in the same field".
7. Helling V. Carey, 519 P.2d 981.
8. In New Jersey, the question raised was whether an optometrist may
be permitted to utilize a local anesthetic in performing a normal
tonometric examination during the course of examining the eyes for
the purpose of prescribing lenses. The Attorney General's opinion
stated: "It is clear that the New Jersey Supreme Court has indi-
cated that optometrists have the right to recognize pathology.
Since glaucoma is a pathological condition an optometrist has the
right, during the course of an examination for determining whether
or not such pathological impairment exists. However, while the
optometrist has the training to diagnose the pathology to medical
doctors because the Code of Ethics of New Jersey Optometric
Association, Section 1, prohibits optometrists from the care or
treatment of injuries, growths or diseases of the eye. Formal
Opinion 1961, No. 8, Attorney General David D. Furman. "
9. Washington Optometric Association, Continuing Education Guidelines.
Washington State Optometric Association, 1974.
10. 53rd Annual Southern Education Congress of Optometry, Atlanta,
Georgia, 1976.
11. Ellerbrock Memorial Continuing Education Courses, American Academy
of Optometry, Columbus, Ohio, 1975.
12. University of Alabama in Birmingham, School of Optometry descriptive
brochures of courses in ocular manifestations of hypertension,
diabetes, and blindness prevention, 1973-75.
FORD & LIBRARY GERALD
75
13. Continuing Education Courses Directed Toward Care of the Ahakic
Patient. Compiled by Division of Education and Manpower,
American Optometric Association, 1976.
14. The United States Army's MOS Code 3340, "Optometry Officer",
lists the duties of the optometrist:
"Conducts examinations of eyes and, when appro-
priate, prescribes corrective treatment without
the use of medicine or surgery. Determines by
means of ophthalmic instruments and optometric
procedures, vision abnormalities which may be
corrected or improved by contact or ophthalmic
lenses, prisms or other ophthalmic devices; pre-
scribes corrective lenses; refers patients for
medical treatment or surgery when ocular manifes-
tation of disease is detected; develops and
monitors eye and vision protection programs; super-
vises optician technicians in fabricating and
dispensing spectacles, manages optical service unit
or lens laboratory; instructs and supervises subor-
dinate personnel in optical and optometric procedures;
engages in vision research; provides optometric
consultant services; records optometric data on
approved forms and records."
15. Chapman, W. Judd, O.D. "Optometry's Role in the Dection of
Pathology". Military Med. 136:904, 1971.
16. Johnson, David E., O.D., M.P.H. "Optometric Triage in Military
Screening. Optometry Weekly. 62 (36), September 9, 1971.
17. Myers, Kenneth J., O.D. "Veterans' Administration: We Train
Health Professionals." J.Opt. Ed., V. 1 No. 2, Spring 1975.
18. Ibid.
19. Segadelli, Louis J. "Group Health Association - A Working HMO."
Opt. Weekly. 65(5): 133-135. January 31, 1974.
20. Alexander, Raymond, M.B.A., M.S., Bellin, Lowell, M.D., M.P.H.,
Kavaler, Florence, M.D., M.P.H., and Rosenthal, Jesse, M.S., O.D.
"The Participation of Optometrists in New York City's Medicaid
Program. " Pub. Health Reports, V. 84 No. 11, November 1969.
21. Haffner, Alden N., O.D., Ph.D., Jolley, Jerry L., O.D., M.P.H.,
and Soroka, Mort, M.P.A. "The Utilization of Optometric
Services." J. Am. Opt. Assn., v.49 No. 10, October 1974.
22. The National Center for Health Statistics, Optometric Manpower:
Characteristics of Optometric Practice, United States - 1968.
DHEW Pub. No. (HRA) 74-1808, 1974.
FORD is LIBRARY GERALD
76
23. Coate, Douglas C., Studies in the Economics of the Profession
of Optometry. Unpublished doctoral dissertation, City
University of New York, 1974.
24. Dorn, W., Mou, T., and Peters, H., A Proposed Regional Plan for
the Expansion of Optometric Education in the South. Southern
Regional Education Board, Atlanta, Georgia, 1974.
25. Haffner, Alden N., O.D., Ph.D., A National Study of Assisting
Manpower in Optometry. Report of Department of Labor Contract
No. 81-34-70-11, 1971. DOL, Washington, D.C.
26. Alexander, Belling, et.al. (op.cit.)
27. Robert, Bertram L. (op.cit).
28. Wick, Ralph E., O.D., D.O.S., F.A.A.O. "Interprofessional
Relations-A Case Report.' J. Am. Opt. Assn. V. 39, No. 11,
November 1961.
29. Hirsch, Jerome A., O.D., The Incidence of Pathology in an Inner
City Population. An unpublished study from the Pennsylvania
College of Optometry, 1976.
30. Kintner, Galen F., O.D. "Optometry's Role in Health Maintenance-
A Study of Referrals." Am. J. Pub. Health, V. 51, No. 11,
November 1961.
31. Haffner, Alden N. and Jolley, Jerry L. (op. cit.).
32. Silva, Gregory M., O.D., and Smith, Gary, E.M., O.D. "A Survey
of California Physicians Concerning Their Relationships With
and Opinions of Optometry. 11 J. Am. Opt. Assn. V. 45, No. 40,
October 1974.
33. The National Center for Health Statistics. Optometric Manpower:
Characteristics of Optometric Practice. United States, 1968.
(op. cit.)
Table 3, p. 23 of this report shows that of 18,238
optometrists providing refraction, 16,928 provided
ophthalmoscopy, 13,780 examination of visual fields,
12,098 tonometry, and 5,907 biomicroscopy. The
proportions for solo practitioners only proved much
the same. Non-performance of diagnostic procedures
proved to be highly correlated with age, year of
graduation, State of practice, and school.
The reliability of this data is open to question since
the procedures were listed and the respondent was asked
to check if they were done but to make no mark if they
were not done. Therefore, incomplete response is treated.
as non-performance of the procedure. Furthermore,
FORD & LIBRARY GERALD
77
refraction headed the list and to many optometrists
(especially those relatively long out of school) the
term "refraction" covers all normal diagnostic proce-
dures. (A principal textbook of optometric practice
is titled simply "Refraction"). The use of the term
refraction in this larger sense is thought to be
associated with the school and year of graduation and
to some extent with the State of practice. After much
discussion, therefore, it was concluded that these
data cannot be taken at face value.
In addition, the data were collected in 1968. In the
intervening eight years two things have happened:
many of the older or part-time optometrists who reported
minimal diagnostic procedures have retired, and the
active optometric work force has upgraded practice
(although to an unknown extent) as standards have risen
in the profession, practitioners have been pressured to
meet the new standards, and continuing education has
been emphasized. It therefore becomes even more difficult
to draw conclusions respecting optometrists active in
1976 from this data.
34. Spector, Renold, M.D.; Lightfoote, Johnson B.; Cohen, Phin, M.D.;
and Claylack, Leo T. Jr., M.D. "Should Tonometry Be Done by
Technicians Instead of Physicians?" Arch. Intern. Med. V. 135,
September 1975.
35. American Optometric Association, Committee on Public Health and
Optometric Care. A.O.A. Guidelines on Vision Screening. J. Am.
Opt. Assn. V. 43, No. 8, August 1972.
36. New York State Optometric Association. NYSOA Proposed Standards
for New York State Regional Health Department Audit and Review
Standards. N.Y.S.O.A., July 1975.
37. American Medical Association. Draft Model Screening Criteria to
Assist P.S.R.O.s. A.M.A. (unpublished). May, 1975, with
unpublished comments of the American Optometric Association.
38. National Academy of Sciences. First Interprofessional Standard
for Visual Field Testing. Committee on Vision, Assembly of
Behavioral and Social Sciences, N.A.S., Washington, D.C., 1975.
39. California Optometric Care Foundation. An Outline of the
California Optometric Care Foundation's Optometrical Peer
Review Program. c.o.c.f. (unpublished), September 1975
LIBRARY GERALD R. FORD
78
ATTACHMENT A
SPECIFIC PROVISIONS FOR THE PRACTICE OF OPTOMETRY
AS FOUND IN STATE LAWS AND BOARD REGULATIONS
Based upon provisions of State optometric practice acts and
board regulations outlining the equipment which an optometrist
must have, a chart of functions/procedures has been compiled.
In most cases, only the functions expressly authorized in the
laws or regulations appear on the chart for a given State.
However, where specific functions were not detailed, an analysis
of the provision could often uncover implied functions. For
example, the Delaware licensing law authorizes optometrists to
"employ any objective or subjective means or methods for the
purpose of determining the refractive powers of the human eyes
and/or any visual, muscular or anatomical anomalies of the human
eyes and their appendages; or any ocular deficiency". On the
basis of this definition, the chart for Delaware was composed to
reflect the following procedures: external and internal examin-
ation, visual fields, visual acuity, refraction, and sensory
motor testing. The definition may in fact be broad enough to
encompass all of the functions on the chart. If a provision
empowers an optometrist to measure visual powers or visual range,
the chart will reflect visual acuity and visual fields. If the
provision defines "optometry" as the "measurement" or "diagnosis"
of the human eye, it may be inferred that the authority to examine
the eye is granted.
When both the express and implied functions are tabularized, the
following patterns appear. In each State, optometrists may or
must perform external and internal examinations of the eye.
Visual acuity testing is either part of the required minimum
examination of each patient or a function expressly or impliedly
permitted in the laws and regulations of 34 States. Visual fields
meaurement is required or permitted in 33 jurisdictions. Twenty-
seven States direct optometrists to keep patient histories for
varying periods of time.
Twenty-four States mention refraction or measurement of refractive
powers among the permitted or required functions of an optometrist.
The measurement of muscular anomolies or muscle balance falls
within the practice of optometrists in 22 jurisdictions.
Eighteen States define the functions of an optometrist to include
measurement of the amplitude of convergence and accommodation.
In eighteen jurisdictions, one of two situations occurred:
FORD & LIBRARY GERALD
79
either the retinoscope was required equipment or the optometrist
was expressly authorized to perform a retinoscopy.
Phoria and duction appeared 13 times among lists of conditions
for which each patient must be tested. In 13 States, either the
keratometer is required equipment or the measurement of corneal
or curves is expressly within the scope of. practice of an optom-
etrist. Color testing and steropsis appeared 8 times each on
the minimum requirements lists for patient examination.
"Subjective findings far and near" appears on six lists of
conditions which must be tested as part of a minimum patient
exam, while "trial case" appears on five lists. Only three States
include consultation with the patient, advice, or follow through
on lists of required procedures.
To date only 10 States expressly require, by statute or regulation,
that an optometrist refer patients in need of other professional
care to the appropriate professions. On this chart, the following
abbreviations were used to indicate the location of the referral
provision:
D
- Definition section
Disc.
- Disciplinary provision (Suspension and revocation)
M.E.
- Minimum Examination of Patients provision
Pol
- Statement of policy
Rec
- Records provision
FORD & LIBRARY GERALD
SPECIFIC PROVISIONS FOR THE PRACTICE OF OPTOMETRY, 1975
PATIENT HISTORY
EXTERNAL EXAM OF THE
INTERNAL OPTH. EXAM
SENSORY MOTOR/MUSCLE
EYE 1
BALANCE
VISUAL FIELDS
REFRACTION
VISUAL ACUITY
TONOMETRY
COLOR TESTING
SUBJECTIVE FINDINGS
NEUROLOGICAL ASSESS-
MENT
PHORIA AND DUCTION
TRIAL CASE
CONSULTATION. ADVICE
FOLLOW-THROUGH
CORNEAL CURVATURE
MEASUREMENTS
RETINOSCOPY
FUSION
STEREOPSIS
AMPLITUDE OF CONVER-
GENCE & ACCOMODATION
REFERRALS
a. SECTION
b. CITES
GERALD
FORD & LIBRARY
15
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80
SPECIFIC PROVISIONS FOR THE PRACTICE OF OPTOMETRY, 1975 (CONTINUED)
PATIENT HISTORY
EXTERNAL EXAM OF THE
INTERNAL OPTH. EXAM
SENSORY MOTOR/MUSCLE
EYE
BALANCE
VISUAL FIELDS
REFRACTION
VISUAL ACUITY
TONOMETRY
COLOR TESTING
SUBJECTIVE FINDINGS
NEUROLOGICAL ASSESS-
MENT
PHORIA AND DUCTION
TRIAL CASE
CONSULTATION, ADVICE,
FOLLOW-THROUGH
CORNEAL CURVATURE
MEASUREMENTS
RETINOSCOPY
FUSION
STEREOPSIS
AMPLITUDE OF CONVER-
GENCE & ACCOMODATION
REFERRALS
a. SECTION
D. CITES
North Dekota
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Chin
X
X
Chichenn
X
X
X
X
X
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Crecon
X
X
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X
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Rec/Reque 10-045
X
X
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X
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D
63 8231
Phode
X
X
X
X
X
X
X
X
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South Carolina
X"
it
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X
X
X
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Wisconsin
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District of
Columbia
X
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lVisual fields (confrontation) and visual fields central (after age 40).
?Including presbyonic findings if prescribed for.
3Performed on patients after age 40 unless contra-indicated.
4By implication/analysis.
GERALD
?
FORD
LIBRARY
81
82
ATTACHMENT B
LAWS AND REGULATIONS RESPECTING THE
USE OF DRUGS BY OPTOMETRISTS, 1976
Delaware optometrists may employ "topical ophthalmic drugs for
diagnostic purposes only." The drugs for such diagnosis will be
limited to: topical anesthetics, mydriatics, cycloplegics, and
myotics. Each new applicant for licensure in Delaware will be
examined on the subject of pharmacology as it relates to optometry.
Practicing optometrists must complete a refresher course in pharma-
cology as it relates to optometry before employing these drugs.
This course must be given by an institution recognized by the
National Commission on Accreditation or the Delaware State Board
of Examiners in Optometry.
Louisiana permits optometrists to use "topical ocular diagnostic
pharmaceutical agents." In the initial examination for licensure,
applicants will be tested on "general pharmacology and ocular
pharmacology as it applies to optometry with emphasis on the
topical use of diagnostic pharmaceutical agents to the eye."
Louisiana defines diagnostic pharmaceutical agent as "any chemical
in solution, suspension emulsion, or ointment base other than a
narcotic which when applied topically to the eye, results in physio-
logical changes which permit more efficient or otherwise facilitates
examination of the external eye or its adnexa or the evaluation of
vision or which is necessary to determine normal physiological
function as part of an examination regimen."
Prior to the employment of topical ocular diagnostic pharmaceutical
agents by a licensed optometrist, that licensed optometrist must
submit to the Louisiana State Board of Optometry Examiners satis-
factory evidence that the optometrist has successfully completed
courses, approved by the board, in pharmacology as they apply to
optometry, with particular emphasis on topical application of
diagnostic pharmaceutical agents to the eye.
Optometrists in Maine may use diagnostic drugs solely for "the
purpose of detecting any pathological condition or functional
abnormality to the eye." Prior to employing these drugs, practic-
ing optometrists must obtain a diagnostic drug license by complet-
ing "a course in general and ocular pharmacology as it applied to
optometry approved by the board." Furthermore, "each use of a
diagnostic drug shall be noted in writing and shall be made part
of the record of each examination and placed on file." Licensure
FORD & LIBRARY GERALD
83
examinations for all new applicants will include the "subject of
general and ocular pharmacology as it relates to optometry and
the use of topically applied diagnostic drugs.
Every individual desiring to commence the practice of optometry
in Oregon after January 1, 1976, or to use diagnostic drugs in
his practice shall have satisfactorily completed "a course in
pharmacology as it applies to optometry, by an institution accred-
ited by a regional or professional accreditation organization
which is recognized or approved by the National Commission on
Accrediting or the United States Commissioner of Education with a
particular emphasis on the topical application of diagnostic
agents to the eye for the purpose of examination of the human eye
and the analysis of ocular functions." The Oregon Board of
Examiners must designate those diagnostic pharmaceutical agents
which may be used in practice of optometry. Categories for
selecting such drugs shall be cycloplegics, mydriatics, topical
anesthetics, dyes such as fluorescein and, for emergency use only,
miotics.
In Pennsylvania, the Secretary of Health shall determine the
specific agents optometrists may use. The determination shall be
made from the following categories: cycloplegics, mydriatics,
topical anesthetics and miotics which are applied topically.
Licensed optometrists may employ these agents only after complet-
ing "a course in pharmacology as it applies to optometry, by an
institution accredited by a regional or professional accreditation
organization which is recognized or approved by the National
Commission on Accrediting or the United States Commissioner of
Education with particular emphasis on the topical application of
diagnostic pharmaceutical agents to the eye for the purpose of
examination of the human eye and the analysis of ocular functions."
The examination for licensure will include the subject of pharma-
cology as it applies to optometry.
In Rhode Island, only those presently licensed optometrists who
have "(i) satisfactorily completed a course in pharmacology, as
it applies to optometry, at an institution accredited by a
regional or professional accreditation organization which is
recognized by the National Commission on Accreditation, with
particular emphasis on drugs to the eye for the purpose of detect-
ing any diseased or pathological condition of the eye, approved
by the Board of Examiners in optometry and the chief of pharmacy
in the Department of Health, and (ii) have successfully completed
an examination given by the Board of Examiners in conjunction
with the Chief of Pharmacy of the Department of Health, shall be
permitted to apply drugs topically to the eye. Said Chief of
Pharmacy shall consult and advise the Board of Examiners in
optometry with respect to that portion of the examination dealing
FORD & LIBRARY GERALD
84
with pharmacology. The standard examination for licensure in
optometry shall also include pharmacology as it applies to
optometry with particular emphasis on the topical application of
diagnostic drugs.
In order to employ diagnostic drugs in their practice of optometry,
optometrists in Tennessee must demonstrate "professional competence
and transcript credit of at least six (6) quarter hours in a course
or courses in general and ocular pharmacology with particular
emphasis on diagnostic pharmaceutical agents applied topically to
the eye, from a college or university accredited by a regional or
professional accreditation organization which is recognized or
approved by the National Commission on Accrediting or the United
States Commissioner of Education. It specifies, further that
"the optometrists so qualified are authorized to utilize in con-
nection therewith diagnostic pharmaceutical agents (miotics,
mydriatics, cycloplegics and anesthetics), applied topically only."
West Virginia now defines optometry as "the examination of the
human eye, with or without the use of drugs prescribable for the
human eye, which drugs may be used for diagnostic or therapeutic
purposes for topical application to the anterior segment of the
human eye only and, by any method other than surgery, to diagnose,
treat or refer for consultation or treatment any abnormal condi-
tion of the human eye or its appendages."
Only two of these, Maine and Rhode Island, expressly state that
the diagnostic drug shall be used only for detecting any diseased
or functional abnormality of the eye. All laws prohibit the use
of ocular drugs or pharmaceutical agents in "treatment" of
disease.
The optometric practice acts of three States amended the definition
of optometry to extend the scope of vision care without the use of
drugs. Alabama enlarged the practice of optometry to "(a) ascer-
taining the status of the human visual system, including the
refractive and functional abilities thereof; or (b) ascertaining
the presence of ocular disease or ocular manifestations of
systemic disease and any other departure from the normal which
may require referral to other health care practitioners."
Idaho permits optometrists to "employ in the examination, diagnosis,
or treatment of another, any means for the measurement, improvement,
or development of any or all functions of human vision or the
assistance of the powers of range of human vision or the determin-
ation of the accommodative or refractive status of human vision or
the scope of its functions in general. 11
New Mexico enacted legislation in 1973 to define practice of
optometry to prohibit the use of drugs.
BERALD FORD
85
The State of Washington, in its definition of the practice of
optometry, permits the use of any "diagnostic instruments or
devices for the examination or analysis of the human vision
system." It is doubtful that these four provisions extend to
diagnostic pharmaceutical agents.
Other legislative authorities have addressed these changes in
definition. The Rhode Island State Supreme Court Decision upheld
the constitutionality of the Rhode Island amendment which was
passed in 1971. This decision of Marcy 27, 1974, remitted the
case to the Superior Court, where no further action was taken,
thus ending the matter. Optometrists in the State of Rhode
Island have utilized pharmaceutical agents for diagnostic purposes
since 1974.
A recent Louisiana Attorney General's opinion held that the new
law "does not illegally encroach upon the practice of medicine."
Also opinions of State Attorneys General in Florida, Indiana,
Nevada, and New Jersey state that there is no statutory prohibi-
tion in those States which preclude the utilization of pharmaceut-
ical agents for diagnostic purposes by optometrists.
FORD LIBRAR if GERALD
1
VIOI in
Colorado
California
Alaska )
Alabama
LIBRARY OROF BERALD
)
G
5
)
HV
a
G
11
',
X
X
X
X
X
:-
X
Geometric Optics
X
:-
X
X
X
X
X
X
X
X
X
X
X
:-:
X
X
Ocular Anatomy
X
:-:
X
X
X
X
:-
X
X
X
X
X
X
X
Ocular Pathology
X
X
X
X
:-
X
:
X
:-
:-:
X
X
Ocular Physiology
X
X
X
X
X
X
X
X
X
X
Theoretical Optics
X
X
X
X
X
X
X
X
X
X
X
X
X
Practical Optics.
X
X
X
X
X
,
X
X
X
X
X
X
X
X
X
X
Physiological Optics
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Theoretical Optometry
X
X
X
X
X
X
X
X
X
X
X
A
X
X
Practical Optometry
X
X
X
Hygiene
X
X
X
X
Psychology
Optical Laboratory
X
X
& Clinical Work
X
X
X
X
X
X
%
X
X
Visual Training/
Orthoptics
X
X
X
X
X
X
X
Contact Lenses
X
X
X
X
X
X
X
X
X
X
General Anatomy
X
X X X
X
X
X
X
X
X
X
X
X
X
Psysiology
X
X
X
X
X
X
Pathology
Mathematics (as
X
X
X
related to 0)
X
X
X
Physics
X
X
X
X
X
X
X
Optics
SUBJECT MATTER MASTERY REQUIRED FOR INITIAL STATE LICENSURE OF OPTOMETRISTS
X
X
Ocular Examination
X
X
X
X
X
Refraction
Case Analysis
X
X
Prescribing &
X
X
X
Fitting
Duplication
X
X
X
X
Clinical Optometry
X
X
X
X
X
Pharmacology
X
X
Physical Optics
X
X
Mechanical Optics
X
X
X
Psychological Optics
X
:-:
Tonometry
:<
Ocular Myology
98
X
Ocular Neurology
SUBJECT MATTER MASTERY REQUIRED FOR INITIAL STATE LICENSURE OF OPTOMETRISTS 4 (CONTINUED)
Geometrics Optics
Ocular Anatomy
Ocular Pathology
Ocular Physiology
Theoretical Optics
Practical Optics
Physiological Optics
Theoretical Optometry
Practical Optometry
Hygiene
Psychology
Optical Laboratory
& Clinical Work
Visual Training/
Orthoptics
Contact Lenses
General Anatomy
Psysiology
Pathology
Mathematics (as
related to 0)
Physics
Optics
Ocular Examination
Refraction
Case Analysis
Prescribing &
Fitting
Duplication
Clinical Optometry
Pharmacology
Physical Optics
Mechanical Optics
Psychological Optics
Tonometry
Dcular Myology
Ocular Neurology
North Dakota 5
Ohio:
X
X
!
X
X
X
X
X
X
Oklahoma
X
X
X
X
X
X
X
X
X
X
X
X X
Oregonl,2
X
X
X
Pennsylvania2
X
X
X
X
X
X
X
X
X
Phode Island
X
X
X
X
X
X
X
X
y
South Carolina
X
X
X
X
X
X
X
X
X
X
X
X
South Paketal
X
X
X
X
X
X
X
X
X
X
X
X
X
Tennesseet
X
X
X
:
X
X
X
X
X
X
X
Tennsit
X
X
X
X
X
X
Utahi
X
X
X
X
X
X
5
Virginia++
X
X
X
Washington
X
X
X
X
X
X
X
X
X
X
X
X X
XX
West Virginia
X
X
X
X
X
X
X
Wisconsin-
X
X
X
X
Wyoming
X
X
X
X
X
X
X
X
X
X
X
X
X
District of
X
X
X
X
X
X
X
X
X
X
Columbia
1 Plus those courses the Board may require.
2 Accepts National Board Exam.
Actual course requirements.
5 Except as specified, indicates subject/matter required to be covered in an examination
FORD s LUBRARY GLARD
Not specified
87
BERALD FORD LIBRARY
REQUIREMENTS FOR INITIAL STATE LICENSURE OF OPTOMETRISTS
Personal Qualifications
Education
Examination
Cood
Number of time
State
Age
Citizenship
Character
Other
Preliminary Professional Experience
Written Oral Practical Proficiency Candidate may
be reexamined
Alabama
21
X
X
H.S.
X
3 mos.
X
X
Alaska
21
X
H.S.
X
X
X
X
Arizona
X
H.S.
(1)
X
75%
Arkansas
21
X
X
x⁷
x⁷
California
18
X
H.S./60 hrs. 2800 hrs.
x5
X
75%
32
College
Colorado
21
X
X
X
X
X
X
75%
Connecticut
18
X
H.S.
4 yrs.
x5
X
Delaware
X
II.S./2 yrs.
4 yrs. 3
6 mos.
x5
X
X
75%
College
Florida
18
x4
X
4 yrs.
x11
Georgia
21
X
H.S./2 yrs.
3 yrs.
X
75%
College
Hawaii
18
X
H.S.
X
X
X
75%
Idaho
21
X
X
x5
X
X
Illinois
21
X
X
H.S./1 yr.
3 or 4 yrs.
x5
X
X
75-60%
8
32
Indiana
18
X
2 yrs. Coll.
4 yrs.
X
Iowa
H.S.
4 yrs.
x5
X
X
75-65%
8
2
Kansas
X
X
H.S.
4 yrs.
X
X
Kentucky
18
X
X
H.S.
5 yrs.
x5
X
12
75-60%
8
x2
Louisiana
X
X
H.S.
X
X
Maine
18
X
X
X
X
Maryland
18
X
H.S./2 yrs.
4 yrs.
X
X
X
College
Massachusetts
18
X
H.S.
3 yrs.
X
X
70%
x2
Michigan
18
X
H.S./2 yrs.
4 yrs.
X
75%
College
Minnesota
X
2 yrs. Coll.
X
x5
X
2⁶
ATTACHMENT D
Mississippi
21.
X
H.S.
X
x9
X
Missouri
21
X,
H.S./x¹³
x¹³
X
X
X
Montana
18
X
X
H.S.
4 yrs.
x5
X
X
75%
Nebraska
21
X
X
H.S./2 yrs.
3 yrs.
X
75-60%
College
Nevada
21
X
X
H.S./2yrs.
4 yrs.
X
X
75%
College
FORD & LIBRARY GERALD
REQUIREMENTS FOR INITIAL LICENSURE OF OPTOMETRISTS (CONTINUED)
Personal Qualifications
Education
Examination
Good
Number of time
State
Age
Citizenship
Character
Other
Preliminary
Professional
Experience
Written
Oral
Practical
Proficiency
Candidate may
be reexamined
New Hampshire
18
X
2 yrs. Coll.
4 yrs.
x3,5
X
X
New Jersey
21
X
X
Residency
H.S./2 yrs.
4 yrs.
College
x5
X
New Mexico
18
x4
X
H.S./College
X
X
x7
X
75%
New York
21
X
X
X
X
75-60%8
North Carolina
21
X
4 yrs.
X 10
x5
X
X
75-60%
North Dakota
18
X
H.S.
X
X
x⁷
Chio
21
X
X
2 yrs. Coll.
3 yrs.
X
75%
4
Oklahoma
21
X
H.S.
X
X
75%
12
Oregon
18
X
4 yrs.
1 yr.(I)
x5
Pennsylvania
21
X
X
X
75%
Rhode Island
21
X
H.S./2 yrs.
4 yrs.
6 mos.
X
X.
South Carolina
21
X
2 yrs. Coll
4 yrs.
X
X
X
South Dakota
18
X
H.S.
X
x5
X
70%
Tennessee
18
X
X
H.S.
4 yrs.
x12
x12
75%
Texas
21
X
X
H.S./2 yrs.
4 yrs.
X⁷
X7
x⁷
75-70%
Utah
21
X
H.S.
2000 hrs.
X
X
75-60%
8
Vermont
18
X
H.S./2 yrs.
4 yrs.
x5
X
X
College
Virginia
18
H.S.
X
x5
Washington
X
H.S.
X
Xs
West Virginia
18
X
H.S.
2000 hrs.
X
Wisconsin
18
X
H.S./2 yrs.
3 yrs.
xs
X
75-70%
8
x6
College
Wyoming
19
X
4 yrs.
X
75%
District of
Columbia
21
X
2 yrs. H.S.
5 yrs.
1. 2 alternate methods (a) 5 year course in optometry (b) 3 year optometry course with 60 hours of college work
2. Reexamined in failed area
3. 6 month internship required after written examination and before any practical examination or receiving certificate to practice
4. Or declared intent to become a citizen
5. National Board accepted for written examination
11. Exam required, form not specified
6. Further education may be required after failure
12. Either written or oral, not both
7. At boards discretion
13. Must graduate from an approved school of optometry. The school must
S. Minimum in any one subject
require for graduation a minimum of 5 terms of pre-optometric training
68
9. Applicant must pass a second exam after 1 year's practice
in not less than 5 years.
10. 2 week practice orientation
GERALD FORD FIBRARY
RENEWAL OF LICENSES AND CONTINUED EDUCATION FOR OPTOMETRISTS
Renewal
Continuing Education
State
Period
Required
Type
Duration
(yrs.)
Alabama
1
X
25 hours/yr.
Alaska
1
2
X
(3)
24 hours/2 yrs.
Arizona
1
Arkansas
1
X
(3)
2days/yr.
California
1
X
1
(2)
Colorado!
1
X
24 hours/yr.
Connecticut
1
X
8 hours/yr.
Delaware
1
X
(3)
12 hours/2 yrs.
Florida
1
X
(3)
24 hours/yr.
Georgia
1
X
(3)
10 hours/yr.
Hawaii
1
X
(3)
8 hours/yr.
Idaho
1
X
(3)
12 hours/yr.
Illinois
1
X
6
(5)
(5)
Indiana
1
X
(3)
12 hours/yr.
Iowa
1
X
(3)
12 hours/yr.
Kansas
1
X
(3)
2 days/yr.
Kentucky!
1
X
(3)
8 hours/yr.
Louisiana
1
X
(3)
12 hours/yr.
Maine
1
X
(3)
20 hours/yr.
Maryland
1
X
(3)
25 hours/yr.
Massachusetts
1
X
(4)
(4)
Michigan
1
X
(3)
12 hours/yr.
Minnesota
1
X4
(4)
12 hours/yr.
Mississippi
1
X
(4)
20 hours/yr.
Missouri
1
X
(3)
8 hours/yr.
Montana
1
X
(3)
12 hours/yr.
3 ATTORMENT
Nebraska
1
X
(3)
16 hours/yr.
Nevada
1
X
24 hours/yr.
New Hampshire
1
X
(3)
25 hours/yr.
New Jersey
1
X
(3)
50 hours/2 yrs.
New Mexico
1
X
(3)
2 days/yr.
New York.
2
06
North Carolina
1
X
(3)
10 hours/yr.
FORD i LIBRARY GERALD
RENEWAL OF LICENSES AND CONTINUED EDUCATION FOR OPTOMETRISTS
Renewal
Continuing Education
State
Period
Required
Type
Duration
(yrs.)
North Dakota
1
X
(3)
18 hours/3 yrs.
Ohio
1
X
(3)
12 hours/yr.
Oklahoma
1
X
(3)
2 days/yr.
Oregon
1
X
(3)
12 hours/2 yrs.
Pennsylvania
2
Rhode Island
1
South Carolina
1
X
(3)
6 hours/yr.
South Dakota
1
X
(3)
8 hours/yr.
Tennessee
1
X
(3)
18 hours/yr.
Texas
1
X
(3)
12 hours/yr.
Utah
1
Vermont
1
1
7
Virginia
X
(3)
Not to exceed 16 hours/yr.
Washington'
1
West Virginia
1
X
(3)
8 hours/yr.
Wisconsin
1
X
(3)
10 hours/yr.
Wyoming
1
X
(3)
25 hours/yr.
District of Columbia
1. Board regulations being developed.
2. Requires satisfactory proof that licensee has stayed abreast of present developments by means
of Continuing Education.
3. Optometric or other scientific education, lecture, symposium or course approved by board and
postgraduate study at school of optometry or course given by Optometric Association.
4.
Set by board
5. Determined by examining committee
6. Effective May 1977.
91
7. Effective August 1976.
92
SECTION II-C
OPTOMETRIC EDUCATION
Compiled by
David B. Hoover, M.P.H.*
The responsibilities and function of health professionals are to a
large extent defined by the basic occupational preparation for the
profession. The organization of health care is such that personnel
tend to be utilized to the limit of their capacities, especially in
institutional settings and subject to limits and sometimes vague
constraints in law. Typically, legal or other formal recognition
of a responsibility or function of a particular health occupation
follows its adoption by some practitioners and its incorporation
into educational objectives and philosophy.
An examination of how optometrists are educated therefore contributes
at least as much to understanding their functions and capabilities
as does analysis of the legal basis for practice or the data that
are available about practice itself.
There are thirteen schools of optometry in the United States. The
oldest was established in 1870, the youngest in 1975. Seven are
schools or colleges within public universities (or in one case
within a State college). Five are private and independent insti-
tutions, and one is a school within a private university. All meet
the accreditation standards of the council on education and pro-
fessional guidance of the American Optometric Association.
Admission to a school of optometry requires at least two years of
college study
The optometry professional curriculum itself is
four years long, leading to the degree of Doctor of Optometry (O.D.).
Seven schools also have graduate programs which grant a Master of
Science degree, and six have programs leading to a Ph.D. in
physiological optics. Enrollment in optometry schools ranges from
85 to 566, with an average of about 300; a class size is about
one-fourth of this. A list of schools and their enrollments is
found as attachment A to this section.
The Development of Optometric Education
Education for the health professions has evolved from informal
apprenticeship in on-the-job types of training to the present
*Associate Director for Program Planning and Evaluation, Division of
Associated Health Professions, Bureau of Health Manpower, Health
Resources Administration, Department of Health, Education, and Welfare.
FORD & LIBRARY GERALD
93
elaborate, formal, and controlled systems found in medicine,
dentistry, optometry, pharmacy, and other diciplines. Organized
optometric education dates from the nineteenth century, beginning
with schools in which students served a formal apprenticeship under
a successful practitioner. Specialized educational institutions
emerged rapidly as, in the latter half of the century, there were
many advances in optics and in the application of optical principles
to the correction of vision 2/ Ohio State University dates its
education in optometry from 1870, and the independent Illinois
College of Optometry from 1872.
A university program (now defunct) was established at Columbia
University in 1910, and full four-year programs leading to the O.D.
degree at Ohio and the University of California at Berkeley. These
early university courses were usually conceived of as a division
within the general study of Physics. In time, however, the emphasis
in optometry shifted toward the physiological aspects of vision and
the programs became distinct from physical optics
3/
As optometry began to be recognized as an appropriate subject for
university education, there was a corresponding movement within the
profession to standardize the qualifications for optometric schooling
and actual course offerings at the various colleges. The 1912
convention of the American Optometric Association adopted a resolution
concerning educational standards of qualification for practice. The
standardization and upgrading of education has continued to the present
day, stimulated by new knowledge of vision disorders, technological
advances in diagnosis, treatment, and rehabilitation, obvious unmet
needs for optometric services, and more stringent requirements for
licensure and educational program accreditation.
Development of the Accreditation Process
The International Association of Boards of Examiners in Optometry,
(IAB) was created in 1922. At a "Conference to Establish Optometric
Standards" held in St. Louis that same year, it was resolved that
the process of accreditation should include adoption of a uniform
syllabus by all the schools
4/
During 1925 and 1926 the accreditation process, which involved on-
site inspections by a committee of the IAB, was commenced.
Accrediting procedures were continually refined, with the AOA's
Council on Education and Professional Guidance eventually taking
over the function of the IAB in this area by 1941.*
*The Council is recognized by the Commissioner, U.S. Office of
Education, as the official accrediting agency for schools of
optometry.
FORD & LIBRARY GERALD
94
At a 1936 meeting of representatives from the AOA, IAB, American
Academy of Optometry and most of the schools and colleges, it was
first proposed that a four year curriculum be implemented by all
the educational institutions 5/ The Council on Education and
Professional Guidance produced in 1941 a manual of accrediting which
is now in its eighth (1975) edition.
The Association of Schools and Colleges of Optometry.
The Association of Schools and Colleges of Optometry was organized
in 1941, with the goal of "aid in the advancement of optometry by
giving attention to the problems of the education of optometrists,
and by formulating and supporting desirable educational standards
and policies. Today the Association represents the thirteen
schools and colleges of optometry in the United States and two
programs in Canada, with nearly 4,000 optometric students. The
Association incorporated in 1972 and established a staffed national
office in 1974, which publishes a monthly newsletter, the ASCO
EDUCATOR, and a quarterly JOURNAL OF OPTOMETRIC EDUCATION (JOE).
ASCO maintains standing Councils in three major educational areas;
Academic Affairs, Student Affairs, and Institutional Affairs. The
Council on Academic Affairs is currently working on a major policy
statement concerning curricular standards for optometry programs.
The effort began in 1973 and a preliminary curriculum model was
recently presented to the Board of Directors and published in the
Journal of Optometric Education. The same Council has developed
guidelines for optometric residency programs and post-graduate
pharmacology training. Currently, the Council is developing a
proposal to study the feasibility of conducting an organized and
structured national program of continuing education for practicing
optometrists, using the schools and colleges as a base.
The Council on Student Affairs has developed and produced the
Optometry College Admissions Test. The test is administered to
over 4,000 applicants yearly throughout the U.S. and Canada, and is
required as part of the admissions process at each member institution.
National Board Examinations
If there is large variation from State to State in the subject matter
in which a candidate is examined for licensure, and especially if
some of the subjects are no longer relevant to proficiency in
practice, educational programs for that occupation are faced with
a dilemma. Training the student to master all of the subjects on
which he may be examined becomes difficult or impossible as well
as undesirable. The examinations will not represent, collectively,
a suitable set of educational objectives. Optometry found itself in
this position in the 1940's, with the additional complication that
rapid advances in optometric knowledge were quickly making exam-
inations obsolete. A uniform national examination that could be
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adopted by States as a licensing examination seemed in order.
Both the IAB and ASCO constituted committee in 1950 to formulate
proposals for a National Examining Board of Optometry, and estab-
lished the National Board of Examiners in Optometry in 1951.
Currently the national examination is administered over a two day
period in April and involves approximately nineteen hours of
testing. It serves as the written examination for licensure in 18
States currently. Candidates are examined in the areas listed
below:
Visual Science
Ocular Pathology
Theory and Practice of Optometry
Theoretical Optics
Ophthalmic Optics
Ocular Anatomy
Social, Legal, Ethical, Economic and Professional
Aspects of Optometry
Ocular Pharmacology
During the 1950's, most of the schools adopted first a five and
then a six year program of studies, including four years of pro-
fessional instruction leading to a doctor of optometry degree.
"The move from a two year to a four year professional course over
the past 25 years has resulted in much more clinical experience
for the optometry student, now commencing in the second year and
expanding until, in the fourth year, he devotes at least half-time
to work under supervision in the clinic. He gains experience in
such areas as contact lenses, low vision, children's vision and
vision therapy, in addition to basic visual analysis and the pres-
cription of lenses
8/
The sixties had witnessed a sharp rise in the number of applicants
seeking admission to colleges of optometry. As a step toward
securing highly qualified candidates as potential optometrists,
ASCO explored the feasibility of instituting a national entrance
examination for all prospective optometry students. The first
Optometry College Admissions Test (OCAT) was administered in 1971,
and by 1972 the test was offered using approximately the same
format in existence today 9/
Educational Philosophy and Objectives
Although each of the individual schools and colleges has developed
its own philosophy and objectives for optometric education, certain
principles are stated by all of the institutions. Chief among these
are: providing a high quality educational program intended to
FORD & LIBRARY GERALD
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prepare each graduate to conduct a practice which is competent,
service oriented and ethical and; stimulating any research which
will further existing knowledge in the visual sciences, usually
through the medium of graduate programs.
In 1971 an eighteen month study was undertaken by the National
Commission on Accrediting which examined all aspects of optometric
education. Under the direction of Robert J. Havighurst, Professor
of Education and Human Development at the University of Chicago,
a report was prepared and subsequently published in 1973.
"Optometric Education, A Summary Report" dealt with current trends
and future goals of the professions under such topics as Manpower
Needs, The Scope of Optometry, and Financing Optometric Education.
The Commission recommended an ongoing review process in optometric
education, a recommendation which has received endorsement from
the optometric community.
Optometric education has reflected the expanding role of the
optometrist as a provider of primary health care. In the last
twenty-five years major modifications have taken place in the
educational process. They can be measured both in additions to
the curricula of the schools and in the continuing revision of
the NBEO.
Among the courses that evidence the direction of optometric edu-
cation are Pennsylvania College of Optometry's Environmental
Optometry" and Illinois Learning Disabilities of Children", which
carry the following descriptions:
Environmental Optometry
The student will be taught the application of standard
optometric techniques as well as new and innovative
procedures for the detection. and correction of visual
problems resulting from changes and alterations in
man's environment. Special problems of illumination;
seeing under condition of movement, especially high
speed transport; reactions of the eye to smog and
pollutants; problems of vision in the industrial set-
ting; and classroom design to assist vision in the
educational institution. This will serve to prepare
the future practitioner for the role of consultant on
such matters. A concurrent laboratory will give the
student exposure to experiences of working in these
areas in the college building as well as external
training centers (schools, factories, etc. )11/
Learning Disabilities of Children
This seminar provides students with the opportunity
of indepth discussions of issues in the complex field
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of children's learning disabilities. The multidis-
ciplinary approach is considered in an analysis of the
contributions of several professional disciplines to
the overall optometric evaluation of treatment of the
learning-disabled child. 12/
Advanced Degrees
Ohio State was the first of the optometry schools to offer a master's
degree and later a Ph.D. in physiological optics, beginning its
program in 1936. At the end of Work War II, the University of
California at Berkeley initiated its own graduate curriculum. A
few years after its founding, Indiana conferred advanced degrees,
while the College of Optometry at the University of Houston secured
approval for a Master's program in 1971 and admitted students for
Ph.D. study in 1975. The University of Alabama and the State
University of New York are the schools with the newest programs for
Graduate Study in Optometry. The schools which currently award the
M.S. and Ph.D. degrees are seeking to develop qualified persons to
be primarily employed in teaching and research in vision science.
The graduate degree in physiological optics is available not only
to O.D.s, but also to others with professional scientific back-
grounds. Also, a program at the Massachusetts College of Optometry
provides individuals who presently hold a Ph.D. degree with an
opportunity to receive their O.D. in only two years. In the
academic year 1974-75 sixty-six students were enrolled in graduate
programs.
Education For Care of the Cataract and Aphakic Patient
The proper care of the cataract and aphakic patient requires specific
knowledge, skills, and attitudes by the practicing optometrist, but
no anomaly can be evaluated and treated as a separate entity.
Further, patients with aphakia or cataract, whether congenital,
traumatic, or degenerative, are subject to a high probability that
other visual, ocular, or systemic anomalies will be present. The
proper optometric care of any patient whether they have cataract,
aphakia, or other anomaly requires a full evaluation and analysis
followed by a selection of treatment based on all of the anomalies
present, the needs and characteristics of the patient, the prognosis,
and the possible interrelated effects of the proposed treatment
procedures. To provide this full scope of care the optometrist
should not only be trained in the care of cataract and aphakic
problems, but just as importantly he must be educated and trained
to be concerned about all aspects of health care that may fall
within his purview, and specifically to detect and manage visual
and ocular problems and to enhance visual performance.
All optometry schools share certain basic curricular elements which
follow at least two years (and for the majority of students four years)
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of undergraduate studies, predominately in the biological sciences.
The basic elements include:
- A biological science component.
This includes gross and microscopic human anatomy,
general human physiology, biochemistry, and pharma-
cological principles, all presented with emphasis on
the visual system and related structures.
- Physiological optics.
Vision processes, visual stimuli, accommodation
mechanisms, neurophysiological mechanism, ocular
motility, binocular perception.
- Pathology
Essentials of bacteriology and virology, principles
of health and disease, tissue changes in pathology,
ocular diseases and abnomalities, ocular manifestations
of systemic disease.
- Optics
Light, lenses, optical systems, ophthalmic materials.
- Professional orientation (health practice)
Epidemiological procedures, the epidemiology of specific
disorders, health care organization, public health,
interpersonal relations, management of practice.
- Clinical skills
Patient history, refraction, visual performance
measurement, detection and diagnosis of visual anomalies
and visually-related learning and perceptual disturbances,
low vision rehabilitation, care of the aging patient,
contact lens fitting.
A more complete listing of this common subject matter is found in
attachment B to this Section. The catalogues of the schools provide
still more detail.
Some areas of the optometric curriculum have more information on or
are directed more toward the care of the patient with cataract or
aphakia than others, but elements of the whole curriculum are
involved in preparing the optometrist to care for such patients.
The understanding of the functioning and anomalies of the body as
well as the eye are involved. Elements of optics, pharmacology,
and visual perception, understanding of the aging process, health
care delivery systems and the problems of the partially-sighted, as
well as patient care skills and experience, are involved in providing
care for the patient with cataract or aphakia. The entire optometric
curriculum fosters the broad range of knowledge, skills and attitudes
necessary to provide the needed optometric care for patients with a
&
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developing cataract, a clinical cataract, and with the problems of
aphakia.
1. Geratric consideration: The patient with cataract or aphakia
is generally elderly, and consequently the care of such patients
necessitates an understanding of the physiological, psycho-
logical, and sociological changes associated with aging. The
decrease in mobility and activity, the increase in illness and
accidents, and the psycho-social problems of the elderly pose
special problems to those providing health care to such patients.
2. Low vision consideration: If the patient is a surgical high
risk patient and the cataractous lens is left in place, attempts
are made to improve the visual performance with the use of low
vision devices and/or modification of the visual environment.
In some patients (7% to 16%) who have the crystalline lens
removed, the corrected visual acuity is reduced, due to prior
problems or surgical complications. Low vision services may
be helpful to these patients, and therefore are often utilized
in the care of patients with cataract or aphakia. Optometry
specializesin low vision aids, and all students are taught to
understand their function and application and to recognize
situations in which they will be of benefit.
3. Pathology consideration: Patients with cataract or aphakia are
generally elderly and have a high incidence of systemic and
ocular pathological conditions with much use of therapeutic
drugs. The association of systemic disease and cataract
(diabetic cataract, thyroid cataract, tetany cataract) and of
ocular disease and cataract (irodocyclitis, intraocular tumor,
glaucoma) and the cataractogenic character of some drugs
(steriods, miotics, antimitotics) needs to be understood by the
practitioner for assistance in the early detection and care of
such patients, and these subjects have received emphasis in
the optometric curriculum and in supervised clinical experience.
An understanding of ocular pathology, its causes, symptoms and
detection, and treatment is provided students to enable them to
make early detection of and prompt referral for complications
of cataracts and cataract surgery such as secondary glaucoma,
corneal edema, retinal detachment, and the like. Effective
optometric practice in this area requires integration and
synthesis of many basic elements in the optometric curriculum,
through supervised clinical training.
4. Optical consideration: Optometrists must be skilled in the
fitting of contact lenses and ophthalmic lenses (spectacles) on
patients with aphakia, who present special problems. The pres-
cription of ophthalmic lenses induces several optical complications
such as ring scotoma, increased peripheral prismatic effects and
FORD & LIBRARY GERALD
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aberrations, increased magnification of the field, decreased
field, decreased field of view, thick lenses, convergence
problems, etc. If there is a unilateral aphakia there is the
additional problem of aniseikonia (a difference in image size
between the two eyes). The capability of the elderly patient
for the physical management of contact lenses must be a factor
in prescribing. Students call upon knowledge of basic optical
principles, physiologic optics, and optical anatomy, among
other subjects, to deal with these problems. An objective of
education and training is to have the practitioner skilled in
the fitting of contact lenses and ophthalmic lenses on patients
with aphakia, understanding the sources of the optical problems,
and able to select the most appropriate lens design.
5. Visual performance consideration: The ultimate aid of visual
rehabilitation is to maximize visually-dependent functions,
not merely to obtain a particular correction of refractive
error. Visual performance is dependent upon many factors other
than acuity. For providing service to elderly and, especially,
aphakic patients the optometry student is taught this broad
view of rehabilitation and the underlying concepts of health
and health services.
The use of vision to relate the patient to his environment is
directly related to the characteristics of the patient's
retinal images. When an elderly patient has had good clear
vision for several years, followed by a period of dim catar-
actous vision, and then suddenly following cataract surgery
has clear but magnified and somewhat distorted retinal images,
significant consequences can occur in his visual performance.
Older patients often have mobility problems, and the change in
their perception of space brought about by the magnification
and other optical problems of aphakic lenses can aggravate the
mobility problem and produce a significant obstacle to their
moving about effectively in their environment. Since falling
is the major cause of accidents in the elderly, and most of
them are aware of it, this changed perception of space can have
a profound impact on their activity. A visual rehabilitation
to the new visual system must occur before the patient can
return to somewhat near his pre-cataractous life style. Opto-
metry students obtain understanding of visual perception,
visual performance, lens design, and the problems of aging so
they will be equipped to design the best correction lens and
to assist the patient with the necessary rehabilitation.
Faculty
The nature of the faculty is recognized as a principal determinant
of educational experience in the health professions. In Schools of
Optometry the great majority of faculty are optometrists, as is to
be expected. Many of these advanced degrees are in optometry or other
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fields. At the University of Alabama, for example, among 33 faculty
20 hold higher degrees other than or in addition to the O.D.s
including 12 Ph.D.s (7 in physiological optics, two in neuro-
physiology, and one each in biomedical science, physics, and
experimental psychology). Three faculty hold degrees in public
health. At the Illinois College of Optometry, 21 faculty have
advanced degrees other than the O.D., including 10 Ph.D.s (psy-
chology, pharmacology, microbiology, and biochemistry), 2 M.D.s
(ophthalmology and anatomy), and 2 Ed.D.s.
At the Pennsylvania College of Optometry 30 faculty members hold
advanced degrees other than the O.D., including 18 Ph.D.s, 8
Master's degrees excluding the M. Opt., and 2 M.D.s. The Ph.D. in
physiological optics is becoming recognized as an appropriate point
of entry into optometric education, but the faculty of the schools
shows a diversification that is consonant with the broad range of
subject matter taught.
Optometrists are primary providers of health care and as such are
responsible for determining whether the problem of the patient is
within his scope of treatment or whether the patient should be
referred to another health provider. Optometric education includes
specific curriculum and clinical training related to the detection
and diagnosis of ocular disease and ocular manifestation of
systemic disease. All schools include on their faculty and in
their clinical programs physicians, and particularly ophthalmologists,
in the training of optometric students. Particular attention is
paid to the detection and diagnosis of cataract, the complications
following cataract surgery and the procedures for the selection of
therapy, management and proper followup of aphakic patients.
Optometry students in their clinical training rotate through
affiliated clinics in hospitals, nursing homes, and other community
health facilities. Here they examine patients with cataract and
aphakia, and detect and diagnose ocular diseases related to these
conditions as well as other ocular abnormalities.
On the basis of this educational and clinical experience the
optometric student must demonstrate a mastery of the skills and
knowledge necessary for the diagnosis and management of the cataract
and aphakic patient for both graduation and licensure.
The training provides the capability to diagnose complications of
cataract surgery such as shallow anterior chamber, secondary
glaucoma, cystoid maculopathy, intraocular infection, Elschnig
Pearls, etc.; and the appropriate use of techniques such as bio-
microscopy, gonisoscopy, tonometry, direct and indirect ophthal-
moscopy perimetry, etc., as well as the skilled use of standard
optometric techniques applicable to patients with cataract or
aphakia (Such knowledge and skills on the part of optometrists
are recognized by ophthalmologists in the regular referral patterns
between individual optometrists and ophthalmologists in the care of
cataract and aphakic patients.).
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Footnotes and Bibliography
1/ According to The Association of Schools and Colleges of Optometry,
53% of the 1975 entering class had baccalaureate degrees, and
an additional 6% had a higher degree. Of applicants to optometry
schools, 15% have also applied to medical schools and 14% to
dental schools, and 16% and 15% have taken the respective admis-
sions tests for these schools.
2/ Hofstetter, Henry W., Optometry: Professional, Economic and
Legal Aspects. St. Louis: The C.V. Mosby Company, 1948, P. 295.
3/ Gregg, James R., American Optometric Association: A History.
St. Louis: American Optometric Association, 1972, PP. 51-52.
4/ Hofstetter, Henry W., Optometry: Professional, Economic and
Legal Aspects, P. 298.
5/ National Academy of Sciences, Report of a Study: Costs of
Education in the Health Professions, Parts I and II, Washington:
Department of Health, Education, and Welfare, 1974.
6/ Carter, Darrell B. and Uglum, John R., "The History, Activities
and Present Status of the National Board of Examiners in
Optometry," Journal of the American Optometric Association.
37:2 (February, 1966) pp. 130-131.
71 National Board of Examiners in Optometry, Topical Outline, 1976
Revision. New York: NBEO, 1976.
8/ Havighurst, Robert J., Optometric Education: A Summary Report.
Washington: National Commission on Accrediting, 1973, P. 32.
9/ Optometry College Admission Test, Handbook. New York: The
Psychological Corporation, 1974, P. 1.
10/ Havighurst, Robert J. (Op. Cit.)
11/ Pennsylvania College of Optometry 1975/1976, Philadelphia:
Pennsylvania College of Optometry, 1975, PP. 50-51.
12/ Illinois College of Optometry Catalog 1973-1975, Chicago:
Illinois College of Optometry, 1973, P. 61.
GERALD FORD LIBRARY
Currently Active Professional Programs in Optometry
School or
Public/
Year
Degree (s)
Total
1
College Name
City
State
Indepen.
Estab.
Offered
Enrollment
ICO
Chicago
Illinois
Indepen.
18722
O.D.
532
IU
Bloomington
Indiana
Public
1951
O.D.,M.S.,Ph.D.
266
MCO
Boston
Mass.
Indepen.
18943
O.D.
285
PCO
Philadelphia
Penn.
Indepen.
1919
O.D.
533
PU
Private
1921
4
Forest Grove
Oregon
O.D.,M.S.
294
SCCO
Fullerton
Cal.
Indepen.
19045
O.D.
307
6
SCO
Memphis
Tenn.
Indepen.
1932
O.D.
566
SUNY
New York
NY
Public
1970
O.D.,M.S.,Ph.D.
85
TOSU
Columbus
Ohio
Public
18707
O.D.,M.S.,Ph.D.
218
UAB
Birmingham
Alabama
Public
1969
O.D.,M.S.,Ph.D.
98
UCB
Berkeley
Cal.
Public
19238
O.D.,M.S.,Ph.D.
231
UH
Houston
Texas
Public
19529
O.D.,M.S.,Ph.D.
264
10
Ferris State
Big Rapids
Michigan
Public
1975
O.D.
20
1
1974-75 Annual Survey of Optometric Institutions, Council on Optometric Education, American
Optometric Association.
2
Began as Northern Illinois College of Ophthalmology and Otology, later the Northern Illinois
College of Optometry.
3
Began as Klein School of Optics, adopted the name Massachusetts College of Optometry in 1909,
will change to New England College of Optometry in 1976.
4
Operated as North Pacific College until 1945, when its charter was transferred to Pacific University.
5 Founded in 1904 under the name Los Angeles College of Optometry, the present name was adopted in 1972.
6 Founded by J.J. Horton, changed to non-profit status in 1944.
7
First established as a division of the Physics Department, became a separate school in 1952.
8
Founded as a division of the Physics Department. In 1941 a separate school was established.
Attachment A
9
Originally a private school, the school became state supported in 1963.
10
Presently only the first year class is enrolled.
*
See attached page for full names.
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104
Attachment
ICO - Illinois College of Optometry
IU - Indiana University, School of Optometry
MCO - Massachusetts College of Optometry
PCO - Pennsylvania College of Optometry
PU - Pacific University, College of Optometry
SCCO - Southern California College of Optometry
SCO - Southern College of Optometry
SUNY - State University of New York, College of Optometry
TOSU - The Ohio State University, College of Optometry
UAB - University of Alabama in Birmingham, School of Optometry
UCB - University of California, Berkeley, School of Optometry
UH - University of Houston, College cf Optometry
Ferris State - Ferris State College, College of Optometry
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ATTACHMENT B
BASIC ELEMENTS OF THE CURRICULUM OF SCHOOLS OF OPTOMETRY
1. Biological science knowledge base.
a. Gross human anatomy and microscopic anatomy, with emphasis
on head, neck, and thorax.
b. Embryology, gross and microscopic anatomy of the human
nervous system - concentrating on the central nervous
system.
c. General human physiology, including the study of the funda-
mental organ systems and the mechanisms which regulate body
function. Emphasis is on the sensory, motor and cardio-
vascular systems.
d. Basic concepts of general and cellular biochemistry, with
study of nomenclature, structure, and reactions of organic
molecules. Emphasis is on the visual system - tears, intra-
ocular fluids, lens, retinal photochemistry, and actions of
drugs upon these.
e. Concepts of human genetics and genetic disorders, including
the frequency and distribution of genetic disease, inheri-
tance patterns, polygenic inheritance, chromosomal abber-
ration syndromes, multifactorial genetics, and principles
of genetic counseling.
f. Gross and microscopic anatomy of the lids, orbit, orbital
content, globe, muscles, nerves, and vessels, and embryology
of the eye.
g. Vegetative physiology of the eye, extraocular and intra-
ocular fluids, corneal and lens metabolism, ocular circula-
tion, retina and optic nerve metabolism.
h. General pharmacological principles, methods of administration,
various systemic drugs and their pharmacological action and
side effects with emphasis on those that affect the visual
system, such as cataractogenic and glaucoma producing drugs.
i. Pharmacology; uses, doses, contraindications, and adverse
effect of drugs producing miosis, mydriasis, cycloplegia,
accommodation, and ocular anesthesia. The pharmacology, use
contraindications, and adverse effect of drugs commonly used
in treating visual and ocular problems.
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2. Physiological optics knowledge base:
a. Introduction and orientation to physiological optics,
anatomical and physiological processes associated with
responses to light; vision and the processes of vision.
b. Measurement and specification of visual stimuli, light
sources, radiometry, photometry, colorimetry. The eye
as an image forming mechanism, the optical role of the
pupil, the retinal image and its evaluation. Nature,
classification, and etiology of ametropia. Physiological
mechanism and optical aspects of accommodation.
c. Monocular sensory mechanism of vision, photoreception and
retinocortical transmission, spatial and temporal inter-
action and resolution, adaptation, brightness discrimina-
tion, color vision and their possible neurophysiological
mechanisms.
d. Ocular motility. Intra- and extra-ocular muscle systems
with regard to their anatomy, physiology, pharmocology, and
neurology. Measurement, characteristics, and control of
ocular movements.
e. Binocular vision and space perception. Visual direction,
theory of correspondence, mapping of ninocular space.
Modifications of space perception. Binocular eye move-
ments, fusion, rivalry, ocular dominance, steropsis.
Neurophysiological mechanisms.
f. Perception and information processing. Theories of per-
ception. The perception of time, size, shape, distance,
motion. Perceptual and sensory deprivation, and percep-
tual adaptations.
3. Pathology knowledge and skills base:
a. The essentials of bacteriology, virology, and immunology
and the biological properties of micro-organisms, processes
of infection and chemotherapy. Flora of the anterior
segment of the eye and adnexa and the anatomical and
physiological features which favor or inhibit their activity.
b. Principles of health and disease. A survey of disease,
disease processes, and disease manifestations. A study
of tissue changes in inflammation, tumor formation, al-
lergies, disturbances of metabolism and circulation, and
injuries.
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c. The etiology, epidemiology, symptoms, signs, and course
sequelae of ocular disease and anomalies. Disease and
anomalies of lids, orbit, conjunctiva, cornea, sclera,
iris, ciliary body, lens, vitreous, retina, choroid, and
optic nerve.
d. Ocular manifestations of systemic disease and anomalies.
The etiology, epidemiology, symptoms, signs and course
sequelae of visual and ocular neurological anomalies, lid
and pupillary anomalies, paralytic strabismus, and visual
field problems.
e. The etiology, epidemiology, symptoms, signs and course
sequelae of the major and/or more common health problems
in the U.S.A.. Principles of emergency care.
4. Optics knowledge and skills base:
a. Light and light rays, the formation of images, reflection,
spherical mirrors, refraction, spherical refracting sur-
faces, thick lenses, thin lenses, cenrered systems, theory
of stops, fields of view.
b. Cylindrical lenses, prisms, aberrations, aspherical mirrors
and lenses, magnification, microscopes, telescopes.
Nature of light, interference, diffraction, polarization,
resolving power, dispersion, spectra, thin films. Princi-
ples of optical systems, optics of keratometer, lensometer,
radioscope, retinoscope, ophthalmoscope, slit-lamp, NCT
tonometer, tropscope, eikonometer, stereoscopes, fundus
camera.
C. History of ophthalmic materials; physical characteristics
of lenses, lens aberrations, lens design; ophthalmic
prisms, multifocal lenses, lens specifications; physical
characteristics of frames; lens and frame specification,
elements of a prescription, lens and frame inspection and
verification; fitting and dispensing concepts.
d. Special lenses and frames, protective eyewear, unique
designs, low-vision aids, aniseikonic lenses, fitting
and dispensing. Optics and design of contact lenses,
contact lens specification, fabrication, verification,
and modification of contact lenses.
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5. Professional orientation knowledge and skills base:
a. National, State and local development of the optometric
profession. Opportunities available in the eye care and
vision research fields.
b. A review of descriptive statistics, probability, sampling,
correlation, prediction, and their use in optometry and
vision research. The essentials of epidemiological study
procedures and their significance in health care. Epidemi-
ology of major systemic disorders and disorders of the
visual system.
c. Introduction to health care. Health care and sick care.
Health care systems. Health care professions, their
numbers and distribution. Role of optometry in health
care. What an optometrist is and what he does.
d. Principles of human interpersonal relationships. The
development of patient-doctor, technician-doctor, staff-
doctor, and community-doctor relationships. Emphasis
is
on preparing the student to understand and deal
with the many human interpersonal relationships necessary
in the practice of optometry.
e. History of public health, sociological aspects of health
care, the financing of health care, organizations of
health care. Methods of payment. Evaluating an optometric
practice.
f. Local, State, Federal organizations involved in health
care, comprehensive health planning and new trends in
health care delivery, health and patient-community educa-
tion, organization of health services.
g. The development and management of an optometric practice
from a patient and community service point of view--
office design, office routine, patient care administration,
personnel management, recall systems, developing patient
and interprofessional relationships through effective
communication.
h. The establishment, development, and management of an opto-
metric practice from a business point of view. Legal
development, governmental relationships, legislation and
the legislative process, licensing procedures, State
boards and laws, malpractice, professional ethics, taxes,
fee structures, insurance, and accounting methods.
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6. Clinical patient care knowledge and skills base:
a. Introductory clinical optometry, patient orientation,
essentials of case history, clinical testing of inter-
pupillary distance, versions, accommodation, and pupillary
reflexes.
b. Development of clinical skills necessary for patient care
in the areas of refraction, ocular motility, binocular
intergration, and visual performance.
c. Correlation, evaluation and analysis of optometric data.
The process of patient care-diagnosis, prognosis, therapy--
relating to the needs of the patient. Preview discussion
of optometric specialty areas.
d. Historical development of the contact lens and its use.
Basis theories and methods of fitting. Contraindications
for fitting. Fitting of hard and soft contact lenses and
their modification, post fitting care and problems, care
and treatment of contact lenses. Contact lens solutions.
e. Advanced contact lens fitting, theories and clinical
methods for meridional, prism segment, bifocal contact
lenses. Fitting keratoconus, astigmatic corneas, aphakic
eyes, and high refractive errors. Use and fitting of
haptic lenses, cosmetic shells, and prosthetic eyes.
f. The etiology, epidemiology, symptoms, signs, and course
sequelae of the obstacles of binocular vision sensory,
integrative, motor--and the detection, diagnosis, prog-
nosis, and orthoptic treatment of such anomalies. Clinical
care of aniseikonia.
g. The etiology, epidemiology, sysmptoms, signs, and course
sequelae of learning, perceptual--motor, and other vision
performance problems, and their detection, diagnosis,
prognosis, and therapy. Study of the psychology, unique
examination procedures, and care of pediatric patients
and their problems and needs.
h. The etiology, epidemiology, symptoms, signs and course
sequelae of low vision. Methods of testing, prognosis,
and selection of therapy, design of environmental and
optical aids, problems of rehabilitation. Agencies, laws,
public and social assistance for the partially sighted
and blind.
FORD & LIBRARY GERALD
110
i. The physiological, psychological, and sociological changes
with age. Disease and aging. Visual and ocular problems
of the elderly. Unique examination procedures and care
of the geriatric patients.
j. The principles of efficient illumination, vision require-
ments in homes, schools, business, industry, and vision
safety in the environment. Vision screening in schools,
industry, community, motor vehicle examinations. Visual
aspects of job analysis, the relationship between vision
and vocational and avocational efficiency. The roles of
patient care and human engineering in maximum visual
performance.
k. Presentation and discussion of interesting clinical patients.
Additional clinical testing techniques and concepts. Further
discussion of patient data analysis--the process of deter-
mining diagnosis, prognosis, and therapy. Further dis-
cussions in the optometric specialties. Recent informa-
tion that relates to the process of vision and the clini-
cal practice of optometry.
7. Patient care experience:
a. The clinical examination and care of patients in the
general optometry clinic, along with the design, fitting,
evaluation, and dispensing of opthalmic lenses and frames.
b. The clinical examination and care of special patient popu-
lations in hospitals, nursing homes, schools for blind,
visual screening, etc.
c. The clinical examination and care of patients in the opto-
metric specialty areas--contact lenses, low vision, ani-
seikonia, analysis, etc.
FORD & LIBRARY GERALD
111
SECTION II-D
SUPPLY AND DISTRIBUTION CONSIDERATIONS: ACCESS
Compiled by
Stuart Bernstein, B.A. *
In 1973, there were 10,496 active ophthalmologists and 19,265
active optometrists in the United States, a ratio of nearly one
to two.
Sources of Data
The data on ophthalmologists are from the records of the American
Medical Association 1/,2/,3/ The AMA defines ophthalmologists as
any physician in practice who declares ophthalmology as a primary
specialty. This includes ophthalmologists in private practice as
well as those active in clinics, hospitals or other institutions.
However, this self declaration implies neither board certification
in ophthalmology nor full time commitment to the practice of oph-
thalmology. Any physician reporting practicing ophthalmology as
a secondary or tertiary specialty is also, therefore, not included
in the number of ophthalmologists reported by AMA.
Data on active optometrists are from the 1972-73 inventory of
optometrists conducted by the American Optometric Association
through State Licensure Boards and with the cooperation of the
International Association of Boards of Examiners in Optometry 4/
The inventory supported by the Bureau of Health Manpower, HRA,
took place between October 1972 and December 1973, following the
licensure renewal cycle of the Boards.
Of the total number of active ophthalmologists, 9,568, or 91 per-
cent are classified by the AMA as non-Federal practitioners in
patient care activities. About 95 percent or 18,300 of the
active optometrists are comparably classified as being non-Federal
practitioners in patient care activities.
A count of Board Certified Ophthalmologists from the 1974-75
Directory of Medical Specialists indicated that 6,600 or about
three-fifths of all ophthalmologists are Board Certified. 6/
*Statistician, Manpower Analysis Branch, Office of the Director,
Bureau of Health Manpower, Health Resources Administration, DHEW.
FORD is LIBRARY 038470
112
Differences Between States
In terms of the medicare eligible population, age 65 and over,
there were 45 active non-Federal ophthalmologists and 90 active
optometrists per 100,000 resident population in 1973. Table 1
shows the number of active non-Federal opthalmologists and optom-
etrists in each State and geographic division as well as the ratio
to 100, resident population age 65 and over. Although the same
two States, California and New York, have the largest numbers of
both ophthalmologists and optometrists, careful examination of the
table will show that in the Nation, as a whole, there is no appar-
ent correlation between the ratios of ophthalmologists and optom-
etrists to the medicare eligible population in a given State.
This has been demonstrated by other studies as well. On a
regional basis, it can be said that in the Pacific States for both
ophthalmologists and optometrists the highest ratios of practi-
tioners to the over 65 population occur. Conversely, the lowest
ratios for both disciplines occur in the East South Central States:
The relationship between optometrists and ophthalmologists that
exists on a national basis (2 to 1) is exceeded or approximated
in most States. However, notable exceptions exist. Only in
Maryland and the District of Columbia does the number of active
ophthalmologists actually exceed the number of active optometrists.
Louisiana has only 20 percent more optometrists than ophthalmol-
ogists and New York, Florida and Utah have fewer than 50 percent
more optometrists than ophthalmologists. In seven States, (Maine,
Rhode Island, Indiana, Illinois, North Dakota, South Dakota, and
Nebraska) there were greater than three times as many optometrists
as ophthalmologists. It should be noted that, proportionately,
the distribution of all active ophthalmologists by State approxi-
mates the State Distribution of Board Certified Ophthalmologists.
Differences Between Metropolitan and Non-Metropolitan Areas
The major concern as related to access of the medicare eligible
population to the services of ophthalmologists and optometrists
is the gross difference in distribution of the two disciplines
within States, namely between metropolitan and non-metropolitan
areas.
Table 2 shows that in metropolitan areas of the United States,
there were approximately 1.7 optometrists for every ophthalmol-
ogists, while in non-metropolitan areas the ratio was two and
a half times as great, 4.2 optometrists for every ophthalmolo-
gist. In terms of persons 65 and over with medical insurance
coverage, 97 there were 55 ophthalmologists and 99 optometrists
per 100,000 persons in metropolitan areas while there were 19
ophthalmologists and 79 optometrists in non-metropolitan areas.
Clearly, the medicare eligible population in non-metropolitan
areas has greater access to the service of optometrists in that
approximately 27 percent of the optometrists and 13 percent of
FORD & LIBRARY GERALD
113
the ophthalmologists are in non-metropolitan areas potentially
serving 32 percent of the medicare eligible population. Within
metropolitan areas, available data indicate that there are a
somewhat higher ratio of both ophthalmologists and optometrists
to medicare eligible population in areas of 500,000 population
or more than in smaller metropolitan areas.
Only 6 of the 69 metropolitan areas of 500,000 or more population
had more active ophthalmologists than optometrists in 1973.
The largest of these metropolitan areas were Baltimore and New
Orleans. The Chicago metropolitan area had the greatest difference,
more than three times as many optometrists than ophthalmologists.
The distribution of ophthalmologists and optometrists between metro-
politan and non-metropolitan areas differs throughout the Geographic
Divisions of the United States (Table 3). In non-metropolitan
areas of the North Central States there are between six and seven
optometrists for every ophthalmologist. In non-metropolitan areas
of the South (South Atlantic, East South Central and West South
Central Divisions) there are between four and five optometrists
for every ophthalmologist. The remainder of the non-metropolitan
areas of the Nation has approximately three optometrists for every
ophthalmologist.
There is substantially less difference between the numbers of
optometrists and ophthalmologists in metropolitan areas of the
United States than non-metropolitan areas. Only in the New
England East North Central Divisions are there more than two
optometrists for every ophthalmologist. In the remainder of the
metropolitan areas of the Nation, there are approximately 1.6
optometrists for every ophthalmologist.
The highest ratio of ophthalmologists to 100,000 medicare eligible
population is in the metropolitan areas of the Mountain States;
the lowest ratio is in non-metropolitan areas of the West South
Central States. The highest ratio of optometrists to 100,000
medicare eligible population is in the metropolitan areas of the
Pacific States; the lowest ratio is in non-metropolitan areas of
the East South Central States.
Distribution Within Counties
The most recent data on the distribution of ophthalmologists within
counties of the United States is from the 1968 Survey of Ophthalmol-
ogists condicted by the National Center for Health Statistics.
10)
However, more recent data in a number of States indicate that there
has been little change in the number of counties with and without
the services of ophthalmologists since this time. In 1968, only
one-third of the counties in the United States had active ophthalmol-
ogists.
This is in sharp contrast to the fact that two-thirds
of the counties in the United States in 1973 had the services of
optometrists. The proportion of counties with and without the
FORD & LIBRARY GERALD
114
services of ophthalmologists and optometrists varies in the
different regions of the Nation.
In the Northeast (New England and Middle Atlantic States) in
contrast to the Nation as a whole, four-fifths of the counties had
active ophthalmologists in 1968. One-half of the counties in the
Pacific States had active ophthalmologists. In contrast, five of
the six remaining Divisions in the United States had fewer than
30 percent of the counties with active ophthalmologists in 1968.
To substantiate this, a study by the Southern Regional Education
Board showed that there were only 19 percent of the counties 117 of
the South with Board Certified Ophthalmologists in 1973.
Also, data used in a study by the Institute of Medicine, National
Academy of Sciences 127 showed that in the States of Georgia,
Michigan and Oregon there was little difference in the number
of counties with ophthalmologists in 1974 as compared to 1968.
Only four States ( Massachusetts, New Hampshire, Rhode Island
and New Jersey) had fewer counties without ophthalmologists than
without optometrists. Broken out by region, the following table
illustrates the proportion of counties without the services of
ophthalmologists in 1968 or without optometrists in 1973.
Counties Without
Counties Without
Ophthalmologists
Optometrists
United States
67%
32%
Northeast
19
13
South
73
38
North Central
69
26
West
65
37
It should be noted that in the non-metropolitan counties with the
smallest population, a far greater proportion of optometrists are
located than are ophthalmologists 57 Eleven percent of ophthalmolo-
gists are located in counties with total population of under 25,000
in contrast to 22 percent of optometrists in the same county size
group. Fewer than 1,000 ophthalmologists were located in such
counties in contrast to nearly 4,200 optometrists, a number more
than four times as great.
In comparing 1968 ophthalmologist data with 1973 optometrist data
by county, 1,251 or 40 percent of the counties have one or more
optometrists but no ophthalmologists, 33 or 1 percent have one or
more ophthalmologists but no optometrists, 1,009 or 32 percent of
the counties have both optometrists and ophthalmologists and 851
or 27 percent have neither optometrists nor ophthalmologists.
FORD & LIBRARY GERALD
115
On a regional basis, the break-out follows:
All
Optometrists Ophthalmologists
Counties
Only
Only
Both Neither
Northeast
100%
16%
1%
80%
3%
South
100%
39%
2%
26%
33%
North Central
100%
48%
1%
30%
21%
West
100%
32%
1%
34%
33%
Future Supply and Other Considerations
Between 1968 and 1973, active non-Federal ophthalmologists in
patient care grew from 8,300 to 9,600, an annual growth rate of
2.8 percent compounded. At the same time, active optometrists
grew from 18,400 to 19,300, an annual growth rate of 0.9 percent
compounded. The Bureau of Health Manpower projects the number of
active ophthalmologists in the United States to grow from 13,300
in 1980 to 18,400 in 1990. 5/ The number of active optometrists
are projected to grow to 22,000 in 1980 and 28,200 in 1990.
The proportion of ophthalmologists as a percent of total professional
vision care manpower is projected to grow from 137 35 percent in 1973
to 38 percent in 1980 and 39 percent in 1990.
The number of active ophthalmologists per 100,000 population age
65 and over is projected to grow from 49 in 1973 to 54 in 1980
and 64 in 1990. The number of active optometrists per 100,000 pop-
ulation age 65 and over is projected to be about level at 90 between
1973 and 1980 and grow to 97 in 1990.
The greatest growth in the number of active ophthalmologists over
the period from 1968 to 1973 was in the South. However, during
the same period the greatest growth in ophthalmology residencies as
reported by AMA was in the West. 14/ No data exists relating place
of ophthalmology residency to place of eventual practice. However,
a study published by AMA indicated that for interns and residents
who were 1960 graduates of medical schools, 51.7 percent were
practicing in the same State in 1975 as the final year of graduate
training
15,
The same study showed that 42.7 percent were practicing
in the same State in 1975 as where they graduated from Medical
School in 1960. However, no conclusions can be drawn as to whether
ophthalmologists in practice followed a similar pattern.
Optometrists experienced a much smaller growth than did ophthalmol-
ogists between 1968 and 1973. 16/ However, it is notable that the
South and West experienced a far greater growth in optometrists in
this time interval than did the Northeast and North Central States.
More than four out of five optometrists under age 45 practicing
in States where Schools of Optometry are located are graduates
from the school (s) within their State. Little difference in this
statistic exists between metropolitan and non-metropolitan areas.
FORD & LIBRARY GERALD
116
In States with long-standing Schools of Optometry, the relationship
is even more marked. The proportion of all active optometrists
who are graduates from schools within their State of practice are
more than 92 percent in Illinois, 86 percent in Pennsylvania, 81
percent in California and 77 percent in Massachusetts.
It should be noted that in two States where there has been a
substantial growth in the over 65 population, Florida and Arizona,
also show substantial growth in the numbers of both ophthalmolo-
gists and optometrists between 1968 and 1973. In neither of these
States is located a School of Optometry.
In regard to the relationship between location of school and State
of Practice, it is notable that in Illinois which has the greatest
concentration of optometrists also has the most prolific School of
Optometry. (Illinois College of Optometry and its predecessors,
the Northern Illinois College of Optometry and Chicago Monroe
College of Optometry), accounting for nearly one-third of all active
optometrists in the United States.
The American Medical Association in its "Directory of Approved
Residencies" reports that only 2.3 percent of the approved resi-
dencies offered in ophthalmology in 1975-76 were located in non-
metropolitan areas. Little change in this statistic is evident
over the last decade as three percent of the approved residencies
in 1964 and two percent of the approved residencies in ophthalmol-
ogy in 1969 were located in non-metropolitan areas. There have
been no studies relating metropolitan status of residency location
to metropolitan status of practice location for ophthalmologists.
However, several studies support the thesis that hometown size and
specialty choice are interrelated predictors of the community in
which physicians practice. 17/ Physicians with non-metropolitan
backgrounds were two to three times as likely to select non-metro-
politan practice as physicians with urban backgrounds.
Overall, 27.4 percent of the active optometrists in the United
States are located in non-metropolitan areas. This statistic
varies somewhat by age of the optometrist. Older optometrists,
those age 55 and over, are somewhat less likely to be practicing
in non-metropolitan areas than those under age 45.
Data from the most recent inventory of optometrists show that
schools of optometry make a varied contribution of optometrists
to non-metropolitan areas. Two schools, the Southern College of
Optometry and the Pacific University College of Optometry have
contributed 48 and 43 percent of their graduates to non-metropolitan
areas, respectively. Three other schools have contributed more than
30 percent of their graduates to these areas - (Illinois, Houston,
and Indiana). Together, these schools account for three out of
four optometrists practicing in non-metropolitan areas.
FORD is LIBRARY GERALD
117
Based upon existing trends and without other intervention, little
change in the proportion of either ophthalmologists or optometrists
practicing in non-metropolitan areas can be expected. The propor-
tion of recent graduates from schools of optometry, age 30 and
younger, practicing in non-metropolitan areas is about the same or
slightly lower for nine out of ten established optometry schools
as compared to the proportion of total graduates practicing in
these areas. In comparing 1968 to 1972 data, a lower proportion
of ophthalmologists were practicing in non-metropolitan areas in
1972. While 16 percent of ophthalmologists were practicing in
non-metropolitan areas in 1938, only 13 percent were practicing
in such areas in 1972.
Volume of Services
If reimbursement coverage under Part B of Medicare were extended
to optometrists, the workload of practicing optometrists may
increase. This is especially true in sections of the country
where the medicare eligible population has not had access to the
services of an ophthalmologist but may now be eligible for reim-
bursement of optometric services. To get an understanding of
possible increases in volume of services rendered by optometrists,
one must look at existing data on productivity of optometrists.
One such measure for which data are available relates to vision
analyses performed by optometrists in 1973. Such data shows little
overall difference between metropolitan and non-metropolitan areas
in average vision analyses per optometrist.
However, within non-metropolitan areas for optometrists practicing
in very small communities, there is a sharp drop off in this
statistic.
This data becomes more significant when one relates utilization of
full time auxiliary personnel, other than secretaries or reception-
ists, to the average number of vision analyses performed by optom-
etrists. While non-metropolitan optometrists showed a somewhat
greater average number of vision analyses than did optometrists in
non-metropolitan areas utilizing auxiliaries. In fact, within non-
metropolitan areas, for these optometrists utilizing full time
auxiliaries, there was also a sharp drop in average vision analyses
in the very smaller communities. The data show that in all areas,
optometrists employing full time auxiliaries were able to perform
about 28 percent more vision analyses, on the average, than were
optometrists not utilizing auxiliaries.
Given the potential of expanded reimbursement coverage for
optometrists under Part B of Medicare, it could be expected that
the effects in terms of increased demands for vision care services
would be felt, particularly, in areas served by optometrists but
not by ophthalmologists. This chapter has sought to demonstrate
that a substantial part of the country, particularly in non-metro-
politan areas, is being served by optometrists only. Such optom-
etrists, as the data have shown, by a basic measure of productivity,
FORD & LIBRARY GERALD
118
may be seeing fewer patients on the average than optometrists
not in these areas. Yet, the data have also shown that the use of
full time auxiliary personnel may potentially relate directly to
growth in productivity. In fact, on a national basis, a U.S.
Department of Labor survey has demonstrated that more than 9 out
of 10 optometric practices have room for additional growth and
that optometrists can care for 30 percent or more patients under
their present structure 18/ Particularly, in areas where the
growth in demand for vision care services may be the greatest is
there potential for additional growth in optometric practice
through the increased use of auxiliaries or by other means.
FORD & LIBRARY GERALD
GERALD FORD LIBRARY
Table 1 Number of Active Ophthalmologists and Optometrists and Ratio to 100,000
Resident Population Age 65 and Over by Division and State: 1973
Ophthalmologists
Optometrists
Division
Active
Resident
per 100,000
per 100,000
and
Non-Federal
Active
Population 65+
Resident Population
Resident Population
State
Ophthalmologists
Optometrists
(000's)
65+
65+
U.S. Total
9,568
19,265
21,329
45
90
Division
New England
625
1,381
1,322
47
105
Maine
39
124
121
32
102
New Hampshire
32
72
84
38
86
Vermont
18
44
50
36
88
Massachusetts
333
749
652
51
115
Rhode Island
36
126
109
33
116
Connecticut
167
266
306
55
87
Middle Atlantic
2,065
3,393
4,044
51
84
New York
1,132
1,590
1,987
57
80
New Jersey
342
675
734
47
92
Pennsylvania
591
1,128
1,323
45
83
East North Central
1,555
4,262
3,967
39
107
Ohio
396
974
1,037
38
94
Indiana
180
538
523
34
101
Illinois
438
1,569
1,125
39
139
Michigan
340
745
787
43
95
Wisconsin
201
436
495
41
88
119
Table 1 (Cont'd.) - Number of Active Ophthalmologists and Optometrists and Ratio to 100,000
Resident Population Age 65 and Over by Division and State: 1973 (Con't)
Ophthalmologists
Optometrists
Division
Active
Resident
per 100,000
per 100,000
and
Non-Federal
Active
Population 65+
Resident Population
Resident Population
State
Ophthalmologists
Optometrists
(000's)
65+
65+
West North Central
689
1,654
1,984
35
83
Minnesota
188
361
425
44
85
Iowa
114
314
357
32
88
Missouri
222
422
583
38
72
North Dakota
17
74
70
24
106
South Dakota
15
87
83
18
105
Nebraska
50
149
189
26
79
Kansas
83
247
277
30
89
South Atlantic
1,422
2,204
3,306
43
67
Delaware
20
38
47
43
81
Maryland
227
210
326
70
64
District of Columbia
77
68
71
109
96
Virginia
198
326
398
50
82
West Virginia
59
135
204
29
66
North Carolina
183
336
456
40
74
South Carolina
84
179
212
40
84
Georgia
158
291
402
39
72
Florida
416
621
1,190
35
52
East South Central
436
893
1,368
32
FORD & LIBRARY GERALD
65
Kentucky
112
225
355
32
63
Tennessee
154
363
414
37
88
120
Alabama
104
181
357
29
51
Mississippi
66
124
242
27
51
Table 1 (Cont'd.) - Number of Active Ophthalmologists and Optometrists and Ratio to 100,000
Resident Population Age 65 and Over by Division and State: 1973 (Con't)
Ophthalmologists
Optometrists
Division
Active
Resident
per 100,000
per 100,000
and
Non-Federal
Active
Population 65+
Resident Population
Resident Populatic
State
Ophthalmologists
Optometrists
(000's)
65+
65+
West South Central
816
1,489
1,992
41
75
Arkansas
67
163
258
26
63
Louisiana
182
225
329
55
68
Oklahoma
95
273
321
30
85
Texas
472
828
1,084
44
76
Mountain
437
786
778
56
101
Montana
35
101
71
49
142
Idaho
33
85
74
45
115
Wyoming
18
40
32
56
125
Colorado
136
208
200
68
104
New Mexico
42
80
82
51
98
Arizona
97
149
196
49
76
Utah
51
75
85
60
88
Nevada
25
48
38
66
126
Pacific
1,523
3,203
2,577
59
124
Washington
167
385
344
49
112
Oregon
131
305
245
53
California
1,169
2,421
1,929
61
Alaska
12
18
8
150
GERALOR FORD LIBRARY 126 124
225
Hawaii
44
74
51
86
145
Sources: American Medical Association, Distribution of Physicians in the U.S., 1972, Volume 2
12
Optometric Association
Bureau of Health Manpower, 1972-73 Inventory of Licensed Optometrists conducted under contract by American
Bureau of the Census Current Population Reports, Series P-25, No. 518, June 1974
TABLE 2- NUMBER OF ACTIVE OPHTHALMOLOGISTS AND OPTOMETRISTS
AND RATIOS TO.100,000 PERSONS 65 AND OVER COVERED UNDER MEDICARE
MEDICAL INSURANCE: 1973
Persons 65+
Ophthalmologists
Optometrists
Active
With Medical
per 100,000
per 100,000
Non-Federal
Active
Insur. Coverage
Persons 65+
Persons 65+
Ophthalmologists
Optometrists
(100,000's)
Covered
Covered
UNITED STATES
9,510
19,265
207.8
45.8
92.7
Metropolitan, Total
8,270
13,987
141.0
58.7
99.2
Metro 500,000 or More
6,152
10,527
103.8
59.2
101.4
Metro - Less than 500,000
2,118
3,460
37.2
57.0
93.0
Non-Metropolitan
1,240
5,278
66.8
18.6
79.0
1/ 1972 estimate of active ophthalmologists in patient care. 1973 estimate - 9,568
Source: AMA Distribution of Physicians in the United States, 1972, Volume 2
Bureau of Health Manpower, 1972-73 Inventory of Licensed Optometrists
DHEW, Social Security Administration, Medicare 1973, Section 2 - Enrollment, 1975
FORD i LIBRARY GERALD
122
Table 3
Distribution of Active Ophthalmologists and Optometrists for Metropolitan and
Non-Metropolitan Areas and Ratios of Practitioners to 100,000
Population 65 and Over Covered Under Medical Insurance Program of Medicare
By Geographic Division: 1973
Active
Active
Ophthalmologists
Optometrists
Ophthalmologists
Optometrists
Ratio to 100,000
Ratio to 100,000
Geographic
Metro
Non-Metro
Metro
Non-Metro
65+ Medicare Eligible Pop.
65+ Medicare Eligible Pc
Division
(1972)
(1973)
Metro
Non-Metro
Metro
Non-Metro
United States
8,270
1,240
13,987
5,278
59
19
99
79
New England
531
75
1,141
240
52
26
112
83
Middle Atlantic
1,954
147
2,963
430
58
26
87
76
South Atlantic
1,147
225
1,484
720
57
20
74
83
East South Central
331
104
442
451
56
14
75
60
West South Central
669
113
968
521
62
13
90
61
East North Central
1,417
163
3,159
1,103
52
14
115
97
West North Central
507
170
643
1,010
63
15
80
87
Mountain
304
120
412
374
74
34
Pacific
1,410
123
2,774
429
66
GERALD FORD LIBRARY
100
108
33
129
115
NOTE: Entries may not add to totals due to rounding in computational process
Sources: Bureau of Health Manpower 1972-73 Inventory of Optometrists conducted under contract by American Optometri
Association
American Medical Association, Distribution of Physicians in the United States, 1972
DHEW, Social Security Administration, Medicare: Health Insurance for the Aged and Disabled, 1973. Section 2 -
Persons Enrolled
124
BIBLIOGRAPHY
1. American Medical Association, Center for Health Services
Research and Development, Distribution of Physicians in the
United States, 1972 - Volume 1/Regional, State, County, 1973
2. American Medical Association, Center for Health Services
Research and Development, Distribution of Physicians in the
United States, 1972 - Volume 2/Metropolitan Areas, 1973
3. American Medical Association, Center for Health Services
Research and Development, Distribution of Physicians in the
United States, 1973, 1974
4. DHEW, Bureau of Health Manpower Inventory of Optometrists in
the United States (Data collected 1972-73 by the American
Optometric Association), 1973 (unpublished)
5. HRA, Bureau of Health Manpower, Manpower Analysis Branch,
Geographic Distribution of Optometrists and Ophthalmologists -
A Statistical Summary, Report No. 76-100, Mar. 1976
6. Marquis Co., Directory of Medical Specialists, 16th Edition,
1974-75, Chicago, Illinois
7. Department of Commerce, Bureau of the Census, Current Population
Reports, Population Estimates and Projections, Series P-25,
No. 418, June 1974
8. Hayes, S. and Randall, G., "Geographic Distribution of Ophthal-
mologists and Optometrists", Arch Ophthalmol, Volume 92,
November 1974
9. DHEW, Social Security Administration Medicare: Health Insurance
for the Aged and Disabled, 1973, Section 2: Persons enrolled
in the Health Insurance Program, June 1975
10. DHEW, HSMHA, National Center for Health Statistics, Ophthalmol-
ogy Manpower: A General Profile - United States - 1968, Series
14, No. 5, December 1972
11. Dorn, W., Mou, T. and Peters, H., A Proposed Regional Plan for
the Expansion of Optometric Education in the South, Southern
Regional Education Board, Dec. 1974
12. National Academy of Sciences, Institute of Medicine, unpub-
lished data on county distribution of Ophthalmologists obtained
from States of Georgia, Michigan and Oregon
13. DHEW, HRA, BHRD, Supply of Health Manpower: 1970 Profiles and
Projections to 1990 (Dec. '74) - Modifications of estimates in
this publication were made
FORD & LIBRARY GERALD
125
14. American Medical Association, Directory of Approved Residencies:
1974-75, 1975 (also previous editions)
15. Mason, H., "Medical School, Residency and Eventual Practice
Location", JAMA, Volume 233, No.1, July 7, 1975
16. DHEW, HSMHA, National Center for Health Statistics, Optometrists
Employed in Health Services: United States - 1968, Series 14,
No. 8, March 1973
17. Cullison, S., Reid, C., and Colwill, J., "Medical School
Admissions, Specialty Selection and Distribution of Physicians",
JAMA, Volume 235, No. 5, February 2, 1976
18. Eger, M. J., "Manpower Strategy U.S. Underutilization", JAOA,
Volume 43, No. 1, January 1972
FORD is LIBRARY GERALD
126
SECTION II-E
COST IMPLICATIONS
Compiled by Larry W. Lacy, M.A.*
Issues and Difficulties
In judging the question of whether optometrists should be reimbursed
for the services they provide to cataract and aphakic enrollees
under Part B of Medicare, consideration must be given to how much
such an extension of coverage would increase Medicare program costs.
The estimate of this cost increase can then be compared with the
benefits provided Medicare enrollees. Extension would benefit
those enrollees who now use an optometrist and who would, under
extension of coverage enjoy greater security from high health costs
as well as those who are now deterred from seeking diagnosis of
their clinically significant cataracts by the cost of optometric
services.
A lack of reliable information on the current use of optometrists
by enrollees, uncertainty of how much enrollees would increase their
utilization of optometric services after coverage extension, and
uncertainty of what would be the exact rules for reimbursement under
extension, prevent exact estimation of the costs to the Medicare
program of the proposed coverage change. Therefore, the results of
the calculations below can only be illustrative of the actual amounts
likely to be realized. Under the assumptions of this section's
analysis, it is estimated that extension of Medicare coverage for
the services in question would result in Medicare payments for
optometrists' services of from $2 million to $5 million a year.
This excludes any higher payments to surgeons and hospitals from
a possibly higher rate of cataract surgery resulting from greater
numbers of diagnoses of cataracts after extension.
Method of Analysis
There are three basic steps in the estimation of the cost to the
Medicare program of extending coverage to include services provided
by optometrists to enrollees with cataracts or aphakia First was
estimation of the existing volume of such services. Second was
determination of what would be the probable charge to the Medicare
program for both a single diagnostic visit and the volume of services
estimated in the previous step. The last step was an attempt to
judge the possible magnitude of the increase in the use of optometrist
*Economist, Manpower Analysis Branch, Office of the Director, Bureau
of Health Manpower, Health Resources Administration, DHEW.
FORD i LIBRARY GERALD
127
services which might follow coverage extension as well as the
added charge to the program for these visits 2/ Because the first
and third steps suffered from a lack of reliable information, two
different estimates of the possible cost increase were made. The
calculations below use 1975 as the base year. To aid understanding,
the flow chart which follows outlines the 3 steps of the analysis.
Derivation of Estimate of Cost to the Medicare Program of Coverage
of Optometrists' Services Provided to Cataract and Aphakic Enrollees
Step 1: Estimation of the current volume of optometric services
which would be reimbursable under extension of coverage.
A. Estimated number of Medicare reimbursed cataract operations
in 1975 -
245,000
B. American Optometric Association estimate of the fraction of
surgical cases originally referred by optometrists - 2/3
C. Study advisor's estimate -
1/3
D. High estimate of current number of reimbursable pre-surgical
diagnostic visits to optometrists (A X B) -
163,000
E. Low estimate (A X C) -
82,000
F. American Optometric Association estimate of the fraction of
surgical cases returning to optometrists for care - 1/3
G. Estimate of current number of reimbursable post-surgical
diagnostic visits to optometrists (A X F) -
82,000
Step 2: Estimation of the cost to the Medicare program of providing
coverage for the current volume of reimbursable optometric
services only.
H. Estimate of average charge to Medicare program of single
diagnostic visit to optometrist under extension -
$14
I. High estimate of the cost to Medicare program of current
volume of reimbursable visits ((D + G) X H) - $3,400,000
J. Low estimate ((E + G) X H) -
$2,300,000
Step 3: Estimation of the additional cost to the Medicare program
of an increase in the number of reimbursable visits after
coverage extension.
K. High estimate of the increase in the number of reimbursable
visits to optometrists which might occur after cover
extension -
82,000
GERALD FORD LIBRARY
128
L. Low estimate -
0
M. Added cost to Medicare program of high estimate of increase
in volume of reimbursable visits (K X H) -
$1,100,000
N. High estimate of total cost to Medicare program for current
and expanded volume of reimbursable visits (I + M) -
$4,500,000
0. Low estimate -
$2,300,000
Step 1
Little data exist on the current number of visits by enrollees with
cataracts or aphakia to optometrists' offices. Even more uncertain
is the number of these examinations which would be labelled "routine"
and hence would not be covered under the Supplementary Medical
Insurance program. Several sources of information, however, do
offer some help in this regard.
The first is the 1975 American Optometric Association Senior Citizens
Survey. Based on results from a national sample of about 3,000
respondents, AOA staff inferred that "optometrists initially refer
to the ophthalmologist two-thirds of those persons for whom cataract
surgery is performed, although such surgery may not be performed
for several years after referral. 113/ The AOA also found that about
one-third of those over 65 who have had cataract surgery went to an
optometrist for the last diagnostic examination they had before the
time of the survey. If it is assumed that (1) only visits for
cataracts which are severe enough to warrant an operation are of
a nonroutine nature and hence would be reimbursable under extension
and (2) only one pre-surgical and one post-surgical examination by
an optometrist would be reimbursable for a single patient, these
fractions (2/3 for pre-surgical and 1/3 for post-surgical) can be
multiplied by the estimated number of Medicare reimbursed cataract
operations in 1975 to obtain a very rough measure of the current
volume of optometrist services that would be reimbursable under the
proposed extension. Since probably some cataracts would be judged
nonroutine but would not be surgically removed, the resultant
estimate would probably be somewhat smaller than what would
actually be reimbursed under extension.
Unfortunately, the AOA did not obtain a random sample of the entire
over-65 U.S. population. Probably underrepresented are the poor,
minority groups, and residents of rural areas. Such problems may
reduce the reliability of the survey's results. Also, study advisors
indicated that probably considerably fewer than two-thirds of Medicare
patients who have cataract operations were referred by optometrists.
The advisors felt that one-third corresponds more closely to the
true figure.
FORD & LIBRARY GERALD
129
The next part of Step 1 was to estimate the number of Medicare
reimbursed operations in 1975. On the basis of claims gathered by
the various Medicare intermediaries, the Social Security Adminis-
tration has provided for this study unpublished estimates of the
numbers of Medicare reimbursed cataract operations for the years
1967 through 1972.
Calendar Year
Number of Medicare Reimbursed Cataract Operations
1967
155,000
1968
159,000
1969
161,000
1970
172,000
1971
172,000
1972
202,000
The upward trend of the SSA figures suggest a 1975 total of from
220,000 to 245,000 cataract operations. Other sources indicate
that the higher number may be more accurate. In unpublished data
the National Eye Institute estimates there were 332,000 annual
operations for cataracts for people of all ages in 1972. According
to unpublished data from the 1971 National Health Interview Survey,
74 percent or 245,000 of all cataracts occur in the over 65 popula-
tion. Therefore, this latter figure will be used as a rough estimate
of 1975 cataract operations reimbursed by Medicare.
Applying the AOA inference that two-thirds of cataract surgical cases
for those over 65 were initially referred by optometrists to the
245,000 figure yields high estimate of 163,000 (2/3 X 245,000)
pre-surgical visits to optometrists which would have been reimburs-
able under the stated assumptions. For purposes of obtaining a
lower estimate, the study advisors' suggestion of one-third referrals
from optometrists to ophthalmologists is multiplied by 245,000 which
reduces the estimate of pre-surgical covered visits to 82,000
(1/3 X 245,000). If one-third of all those enrollees who have a
cataract operation, upon recovery, seek the services of an optometrist,
there would have been 82,000 (1/3 X 245,000) post-surgical visits to
optometrists which would have been covered under extension. Addition
of this amount to the first result above produces 245,000 (163,000 +
82,000) as a high estimate of pre- and post- surgical examinations
which would have been covered under extension. The corresponding
low estimate is 163,000 (82,000 + 82,000 with correction for rounding).
Step 2
To obtain the cost to the Medicare program for these two volumes of
covered visits, each must be multiplied by the average charge to
the Medicare program for each such examination. Unfortunately, the
American Optometric Association does not collect data on the average
fees charged by its members, and neither does the Bureau of Labor
FORD & LIBRARY GERALD
130
Statistics collect the needed information. Several other sources
including the California Medical Program, the National Eye Institute,
and a survey for the Optical Manufacturers Association suggest that
the average fee for an office visit to an optometrist is from
$20.00 to $26.00.5/ For the purposes of the calculations below,
$23.00 serves as the average fee. Not all of this fee, however,
would be chargeable to the Medicare program under extension of
coverage. First, 20 percent must be deducted to reflect enrollee
cost-sharing under Supplementary Medical Insurance regulations which
also require that a second 20 percent must be deducted for the non-
reimbursable refraction portion of an examination. This leaves
about $14 (60% X $23) as the average charge to the Medicare program
per visit.
Multiplying this by 245,000 yields $3,400,000 (245,000 X $14) as a
rough high estimate of the cost of covering only the existing (1975)
volume of services of optometrists which would be reimbursable
under extension. Multiplying by 163,000 produces $2,300,000
(163,000 X $14) as a rough low estimate.
Step 3
It is probable that an extension of coverage would change the extent
and nature of cataract care of the over 65 population. For instance,
if Medicare enrollees who had cataract operations in 1975 had been
covered for services of optometrists, a larger proportion of those
originally referred by an optometrist might have returned to one
immediately after recovery from their operations. The AOA Senior
Citizens Survey suggests that one-third of those who have had
cataracts surgically removed use their optometrists for diagnostic
examinations and glasses. If this fraction rose to two-thirds --
the estimated proportion originally referred by optometrists
according to the AOA -- it would have meant perhaps 82,000
(1/3 X 245,000) additional reimbursable visits to the optometrist
in 1975. This would have added about $1,100,000 (82,000 X $14)
to Medicare program costs. This would raise total costs of
reimbursement extension to $4,500,000 ($1,100,000 + $3,400,000)
using the high cost figure above. If no additional enrollees
returned to optometrists after surgery, program payments would
remain at the levels estimated for the existing (1975) volume of
services only.
The most unpredictable and potentially most important effect on
Medical program costs would be an increase in the number of enrollees
who seek diagnosis of cataracts by optometrists, who subsequently
have surgery, but would not otherwise have obtained any services.
These would primarily be people with limited access to an
ophthalmologist and who would not have been willing to pay the
full cost of service by an optometrist. This is probably a small
group because it means that its members would be deterred from
FORD & LIBRARY GERALD
131
obtaining services by the relatively small cost of an optometrist's
visit. The members of this group would also have to be well
informed of Medicare reimbursement policies, otherwise their
behavior would not change.
Even if this group is very small, it could have large effects
on Medicare program costs. Unpublished figures provided for this
report by the National Eye Institute give a basis for estimating
the current average reimbursable cost to the program of a single
operation for cataracts to be about $1,500.6/ If there are 3,000
additional operations as a result of reimbursement extension,
Medicare program costs would .rise $4,500,000. Ten thousand
additional operations would mean $15,000,000 in increased costs.
It seems possible, therefore, that the chief cause of higher
charges to the program would be a rise in surgical rates. It
should be noted that nearly all of such increased payments resulting
from surgery would not be for optometrists services but for surgical
and hospital services.
Relation to Medicaid Program
A small portion, perhaps 5-10 percent of the Medicare program cost
increases would be offset by a decrease in Federal Medicaid pay-
ments. Thirty-two States, with perhaps 80 percent of the U.S.
population, provide Medicaid coverage for optometrists' services
with the Federal government assuming about 60 percent of total
payments. About 17 percent of all Medicare enrollees are also
eligible for Medicaid benefits. Multiplying all these percentages
together produces 8 percent as a rough estimate of the Medicare
cost increase which would be offset by a reduction in Federal
Medicaid payments
Payments to Ophthalmologists
Under prevailing medical billing practice there would have been no
off-setting decrease in charges for ophthalmologic services. Since
ophthalmologists generally include the cost of post-surgical care
in their surgical fee, there is generally no separate charge for
post-surgical examination and prescription of lenses.
Optometric Malpractice Insurance
It has been suggested that an extension of coverage would change
the nature of optometric practice sufficiently to raise the cost of
malpractice insurance for optometrists. This seems improbable
because the over 65 are only a fraction of an optometrist's
practice and cataract services constitute only a part of the vision
care of enrollees. Also, optometrists would still not perform
surgery, the major source of malpractice claims. Conversations
with the Chairman of the AOA Committee on Insurance and an associate
FORD & LIBRARY GERALD
132
of the major carrier of malpractice insurance for optometrists
support the conclusion that no significant effects on insurance
rates would result from extension.
Summary of Findings
The following chart summarizes this section's cost analysis. As
explained above, these figures are only illustrative due to the
lack of reliable information. The results indicate that extension
of coverage would result in annual Medicare payments for optome-
trists' services of from $2 million to $5 million. A potentially
larger cost to the Medicare program would result if some enrollees,
who under existing reimbursement policy would not receive any
cataract care, react to extension by going to optometrists for
diagnoses which would in turn lead to increased rates of surgery.
On average, each of these surgical procedures would add $1,500
to Medicare expenses. A lack of information prevents estimating
the number, if any, of additional operations which would result
from such extension.
Summary of the Estimated Cost to the Medicare Program of Coverage
of Optometrists' Services Provided to Cataract and Aphakic Enrollees
/
A. Number of visits to optometrists which would be reimbursable
under proposed reimbursement change if enrollees do not increase
rate of visits
Low estimate
163,000
High estimate
245,000
B. Additional number of visits to optometrists which would be
reimbursable under proposed reimbursement change if enrollees
increase rate of visits
Low estimate
-0-
High estimate
82,000
C. Total number of visits to optometrists which would be reimburs-
able under proposed reimbursement change (A + B)
Low estimate
163,000
High estimate
327,000
D. Estimated average charge to Medicare program for each reimburs-
able visit to an optometrist - $14
E. Estimated annual total increase in Medicare program cost (D X c)⁹/
Low estimate
$2,300,000
High estimate
$4,500,000
FORD & LIBRARY GERALD
133
Suggestions for Further Study
The calculations reported above rest upon many simplifying
assumptions. The first is that only diagnostic visits associated
with surgery would be covered. Another is that only one visit to
an optometrist before surgery and only one after would be covered.
A third assumption is that the AOA Senior Citizens Survey produced
data representative of all enrollees. It was also assumed that
Medicare enrollees under 65 years of age would not have cataract
operations. Still another assumption is that all people who have
cataract operations have met the SMI deductible and have not
exceeded hospital day limitations of the Hospital Insurance program.
These assumptions, which were necessary to produce a rough estimate
of program costs implications under time constraints, make the
results of the calculations only illustrative.
Sources:
Many people and organizations were consulted during the preparation
of this section of the report. In particular, an unsuccessful
attempt was made to find a source with useful economic analysis
of the demand for vision services. Those organizations that
provided the unpublished data on which this section is based are
listed as follows:
-- American Optometric Association
- California State Department of Health
--- National Center for Health Statistics, DHEW
---- National Eye Institute, DHEW
-- Social and Rehabilitation Service, DHEW
-- Social Security Administration, DHEW
FORD & LIBRARY GERALD
134
Footnotes and Bibliography
1/ This section will deal only with those enrollees 65 years of
age or older.
2/ If the increase in the use of optometric and ophthalmologic
services were much broader, it could contribute to rises in
the unit price of vision care. Consideration of this last
question, however, lies outside the scope of this paper.
3/ Internal American Optometric Association memorandum of March 1,
1976.
4/ Source: unpublished SSA figures based on 5 percent samples of
beneficiaries.
5/ California and NEI data are unpublished. The Optical Manufacturers
Association figures are from "The Impact of National Health Insur-
ance on the Use and Spending for Sight Correction Service," 11
Gordon R. Trapnell, Consulting Actuaries, 1976.
6/ This includes an initial diagnostic visit to an optometrist plus
a total ophthalmologist fee of $580. Of this total, $480 would
be reimbursable. Fully reimbursable would be five days in the
hospital at $840. Deducting 20 percent for cost-sharing leaves
about $120 as the charge to the Medicare program for post-
surgical examination by an optometrist, prescription, and
provision of lenses ($14 + $480 + $840 + $120 = $1,454).
7/ .8 X .6 X .17 = .081
8/ Numbers refer to 1975 data.
9/ Excludes possible higher payments to physicians and hospitals
resulting from increasing rates of cataract surgery.
FORD & LIBRARY GERALD

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{
    "seq": 1,
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    "mediaId": "cc47426f36eb9c01",
    "ocrText": "The original documents are located in Box 1, folder \"Aging - Optometry Study\" of the\nSpencer C. Johnson Files at the Gerald R. Ford Presidential Library.\nCopyright Notice\nThe copyright law of the United States (Title 17, United States Code) governs the making of\nphotocopies or other reproductions of copyrighted material. Gerald R. Ford donated to the\nUnited States of America her copyrights in all of her husband's unpublished writings in National\nArchives collections. Works prepared by U.S. Government employees as part of their official\nduties are in the public domain. The copyrights to materials written by other individuals or\norganizations are presumed to remain with them. If you think any of the information displayed\nin the PDF is subject to a valid copyright claim, please contact the Gerald R. Ford Presidential\nLibrary.\nHEALTH\nEDUCATION AMERICA :\nDEPARTMENT OF HEALTH. EDUCATION, AND WELFARE\nPUBLIC HEALTH SERVICE\nUSA\nHEALTH RESOURCES ADMINISTRATION\nBETHESDA. MARYLAND 20014\nBUREAU OF HEALTH MANPOWER\nAPR 27 1976\nDear Dr.\nEnclosed is a copy of the Optometry Study which has been forwarded for\nreview in the Department. The report was approved by Dr. Kenneth M.\nEndicott, Administrator of the Health Resources Administration, and\nhas been forwarded to the Assistant Secretary for Health.\nI want to take this opportunity to thank you for your assistance and\ninput to the preparation of the report. As I indicated at the last\nconsultant session, it was indeed a pleasure to work with such a\nknowledgeable and competent and, at the same time, congenial group.\nIt was a rewarding experience for me and for the rest of the staff.\nWe will keep you advised as to the progress of the clearance process.\nSincerely yours,\nDaniel F. Whiteside\nDaniel F. Whiteside, D.D.S.\nDirector\nEnclosure\n1 puby\nFORD & GERALD LIBRARY\nREPORT TO THE CONGRESS\nREGARDING COVERAGE UNDER PART B OF MEDICARE\nFOR CERTAIN SERVICES PROVIDED BY OPTOMETRISTS\nAs Required by Title I, Section 109, of the\nSocial Security Amendments of 1975 (P.L. 94-182)\nApril 1976\nU.S. DEPARTMENT OF\nHEALTH, EDUCATION, AND WELFARE\nFORD & LIBRARY GERALD\nPREFACE\nThis report has been prepared in accordance with Study\nrequirements mandated by Title I, Section 109, of the Social\nSecurity Amendments of 1975. It provides findings and recom-\nmendations, including supportive material, concerning the\nappropriateness of altering current coverage provisions under\nPart B of Medicare to include services related to. aphakic and\ncataract conditions when provided by optometrists.\nThe report has three major segments. Conclusions and\nrecommendations provided by the Department of Health,\nEducation, and Welfare to Congress, as well as additional\nconsiderations raised by expert consultants to the Study, are\nprovided in the beginning. Part I consists of three sections\nwhich provide an overview to the Study framework, the current\nstatus of Part B coverage and reimbursement of interest to\nthe Study, and principal findings and conclusions underlying\nthe recommendations. Part II, in turn, consists of five\nsections which provide detailed supportive material developed\nas part of the Study effort.\n1\nB.E.RD & LIBRARY GERALD\nTABLE OF CONTENTS\nPage\nPreface\ni\nContents\nii\nConclusions and Recommendations\niii\nAdditional Considerations by Study Consultants\nvii\nPART I\n1\nSection I-A - Study Background, Strategy and Methodology\n2\nSection I-B - Current Status of Medicare Coverage\n12\nSection I-C - Findings and Conclusions - Summary\n18\nPART II\n35\nSection II-A - Nature, Incidence and Prevalence of Cataract. 36\nSection II-B - Optometric Practice\n53\nSection II-C - Optometric Education\n92\nSection II-D - Supply and Distribution Considerations\n111\nSection II-E - Cost Implications\n126\nii\nFORD is LIBRARY GERALD\nCONCLUSIONS AND RECOMMENDATIONS\nCONCLUSIONS\nThe following set of conclusions responds directly to the\nCongressional charge concerning whether it is appropriate to alter\nPart B coverage under Medicare for services related to aphakic and\ncataract conditions when provided by optometrists. These conclu-\nsions have been derived from factual information, analytic findings,\nand professional judgements assembled in the study effort.\n1. Qualifications of optometrists. Optometry is a profession\nqualified to provide a broad range of services which are\neffective in patient management, including the management\nof aphakic and cataract patients. These services are\nreasonable, non-experimental, safe, and generally acceptable\nto the vision/eye care community and the public.\n2. Services related to aphakic and cataract conditions. Many\nof these services are the same as the specific diagnostic,\ntherapeutic, and consultative services currently covered\nunder Part B of Medicare when provided to pre- and post-\nsurgery cataract patients by ophthalmologists or other\ndoctors of medicine and osteopathy. (See Table 1, Part I,\nSection I-B.)\niii\nFORD & LIBRARY GERALD\n3. Detection and diagnosis of disease.\nEvidence presented\nduring this study supports the conclusion that optometrists\nare qualified to provide services for the detection and\npreliminary diagnosis of ocular disease and ocular mani-\nfestation of systemic disease. Referral, where indicated,\nis made to ophthalmologists and other health care practi-\ntioners for definitive diagnosis and medical or surgical\ntreatment.\n4. Standards of Procedure. Clinical standards committees of\nprofessional associations have identified effective instru-\nmentation and procedures that are available to and utilized\nby optometrists which are effective in the diagnosis/detection\nof disease, notwithstanding limitation by certain State\njurisdictions regarding the use of topical drugs.\n5. Quality Assurance. Quality assurance is attainable in the\nprovision by optometrists of reasonable, safe, non-\nexperimental, and acceptable services to the Medicare eligible\npopulation. The development of criteria of care for diagnos-\ntic, therapeutic, and consultative services provided by\noptometrists, that are similar to those existing for certain\nother health professional groups, does appear feasible in\nboth organized and independent health care settings. Such\ncriteria currently exist in a number of individual situations\nor are in various stages of development.\niv\n6. Access to services. Vision/eye care services for aphakic\nand cataract patients, as well as for patients more\ngenerally, can be made more accessible to the Medicare\neligible population by expanding present coverage to include\nservices when provided by optometrists. In general, optome-\ntrists are more widely distributed geographically and\npractice in many smaller communities where other vision/eye\ncare practitioners are not available.\n7. Equity. Financial equity can be extended to those Medicare\nbeneficiaries who currently obtain necessary and reasonable\nhealth services from optometrists but who do not currently\nreceive the reimbursement to which they should be entitled.\n8. Delivery patterns. It is reasonable to infer that an\nextension of current Medicare coverage to include services\nfor aphakic patients when provided by optometrists would\nnot significantly alter existing provider delivery patterns\nwithin the vision/eye care community. The impact upon such\ndelivery patterns of an extension of current Medicare coverage\nto include services to optometrists for cataract patients,\nwhile likely to be small, however, is less clear.\n9. Costs. It is reasonable to infer, furthermore, that an\nextension of current Medicare coverage to include services\nrelated to aphakic and cataract conditions when provided by\noptometrists would result in some added costs to the\n>\nGERALD\nMedicare program. These added costs will be to the extent\nof the Medicare enrollees currently served by optometrists\nwithout reimbursement, as well as those patients not now\nreceiving care, who would do so as a result of an extension\nof coverage. Estimates suggest, however, that such added\ncosts would not be significant in the context of overall\nMedicare costs for vision/eye care services and service\nbenefits.\nRECOMMENDATIONS\n1. Based primarily on considerations of patient needs, qualifica-\ntions of optometry to provide services effective in patient manage-\nment, and increased access of Medicare beneficiaries to vision/eye\ncare services, the Department recommends that coverage of services\nunder Part B of Medicare be extended to include services related to\naphakia when provided by optometrists, and that optometrists be\ndefined as \"physicians\" for the purpose of providing these covered\nservices which shall be reimbursable. This recommendation is\npresented in direct response to the requirements of Section 109 of\nthe Social Secutity Amendments of 1975 (P.L. 94-182).\n2. Based on the same considerations as indicated above, the\nDepartment recommends that coverage of services under Part B of\nMedicare be similarly extended to include services related to\ncataract conditions when provided by optometrists. This recommenda-\ntion is in response to the broader legislative intent interpreted\nfor the scope of this study.\nvi\nGERALD FORD LIBRARY\nADDITIONAL CONSIDERATIONS BY STUDY CONSULTANTS\nDuring the course of the study effort, a number of issues and con-\ncerns were identified by the expert consultants to the study which,\nalthough important considerations, represented matters not directly\nresponsive to the specific legislative charge as interpreted. The\nrecommendations and comments below, made unanimously by the consul-\ntants, provides an opportunity to bring these matters to the\nattention of the Department and the Congress.\n1. Refractive services for aphakic patients\nAphakic patients, specifically, should be considered as having\nspecial needs given their disabled condition. Refractive services\nfor such patients represent non-routine and necessary services in\nthe provision of prosthetic devices, i.e., lenses.\nStudy advisors recommend that consideration be given to extending\ncoverage under Part B of Medicare to include refractive services for\naphakic patients when provided by either ophthalmologists or\noptometrists.\n2. Low vision services and aids\nFor those patients who have inoperable cataracts or have less\nthan optimal results from cataract surgery, that is, those who have\nreduced visual acuity, low vision services and aids represent\nessential components of reasonable and necessary health care services\nfor these patients.\nvii\nGERALD FORD (IBRAR)\nStudy advisors recommend that coverage under Part B of Medicare\nbe extended to include the provision of appropriate low vision\nservices and optical aids for the above-referenced patients, when\nprovided by either ophthalmologists or optometrists.\n3. Prevention, health maintenance, and health education\nIn the interests of health care cost advantages, effects on\nproductivity, and the overall improvement of benefits that can be\nafforded our population, the expert consultants recommend that a\nmore effective effort be made to improve preventive, health main-\ntenance, and health education measures. While this is needed in\nall areas of health services, the vision/eye care field offers a\nparticularly promising area for such approaches.\n4. Other service provided by optometrists\nVision/eye care services currently covered by Part B of Medicare,\nwhen provided by ophthalmologists or other physicians,\ninclude eye conditions other than cataract and aphakia. Optometrists\ncan provide appropriate services for some of these conditions. It is\nrecommended that extension of coverage to include the services of\noptometrists for such appropriate conditions is a desirable subject\nfor further consideration.\n5. Administrative considerations\nAlso during the course of the study effort, expert advisors\nraised several concerns pertinent to the administration of the\nMedicare program. These issues, also applicable to other Medicare\nviii\nGERALD LIBRARY\nservices, include the following: (a) inconsistent application of\ncoverage and reimbursement policies by individual carriers, (b) the\nproblem of payment duplication for services and reimbursement for\nsimilar diagnostic procedures when performed for specific individuals\nby more than one provider; and (c) need of improvement in coding and\nbilling proceedures for vision/eye care services.\n6. Cooperative working relationships between vision/eye care\nprofessionals\nIt became clear during the course of this study that more\neffective working relationships between optometry and ophthalmology\nand other providers in the vision/eye care field would enhance\npatient care and result in improved services to individual patients.\nWhile improved interdisciplinary coordination applies to all the\nhealth disciplines and specialties, it is a problem of particular\nconcern in the vision/eye care field. Such working relationships\ncould be significantly strengthened by\na. Development of joint educational programs at the undergraduate\nand graduate levels, including rounds, clinics, conference,\nand meetings and publications;\nb. Establishment of interdisciplinary clinics with optometrists\nand ophthalmologists working together;\nC. Facilitation of referral of patients between the optometrist\nand the ophthalmologist when in the best interest of the\npatient;\nix\nGERALD FORD LIBRARY\nd. Joint development of quality standards for service and\nmaterials by peer review mechanisms. By materials,\nparticular reference should be assigned to varying quality\nof lenses and frames and the need for furnishing laboratory\ninvoices of material costs for reimbursement.\ne. Joint development of appropriate revision to State licensure\nlaws to permit use of diagnostic drugs (mydrictics and local\nanesthetics) by optometrists.\nWhile such joint endeavors are evident in various areas of the couttry,\nthey need to be broadened and routinized.\nX\nGERALD FORD LIBRABY\n1\nPART I\nThe three overview sections presented in this\nfirst part of the report provide the reader\nwith a general summary of the entire study\neffort. The first major section presents an\naccount of the study background, strategy, and\nmethodology. The second major section provides\nthe reader with a synopsis of existing Medicare\nprovisions pertinent to the study query. The\nconcluding major section, in turn, presents\nkey findings and conclusions that have resulted\nfrom this study effort.\nQERALD FORD LIBRABY\n2\nSECTION I-A\nSTUDY BACKGROUND, STRATEGY, AND METHODOLOGY\nThe Department of Health, Education, and Welfare currently pro-\nvides, through a variety of mechanisms, financial assistance for\nthe provision and receipt of health care services. As stated in\nits Forward Plan for Health (June 1975): \"The focus of provid-\ning access to medical services through Federal financing has\ngradually shifted from limited activities for the control of com-\nmunicable diseases among various Federal beneficiary groups, to\nservices for special age and population groups; to care related\nto specific health needs; to comprehensive service delivery\nsystems; to insurance for the aged and disabled; to reimbursement\nof services to the poor and medically indigent. In terms of ex-\npenditures, Medicare and Medicaid represent by far the greatest\nshare of the Department's health financing activities.\"\nSlightly over a decade ago, the Medicare program was promulgated\nas part of the Social Security amendments of 1965, when Congress\nenacted a dual program of health care to meet the growing problems\nof providing services for the aged. In effect, this program was\nintended to provide financing of health care services for benefi-\nciaries who tended to be in poorer health than many other popula-\ntion groups and who often had inadequate financial resources to\npurchase such services. As enacted, Title XVIII of the Social\nSecurity Act consisted of provisions relating to hospital benefits\n(Part A), financed by universal mandatory contributions, and a\nvoluntary supplementary medical benefits plan (Part B), available\nto any person aged 65 or over, irrespective of Social Security\nstatus.\nAt various times furing the past decade of Medicare experience,\ninterest has arisen in the appropriateness of altering provisions\nas originally mandated by the 1965 legislation. Where Congress\nhas favored modifications, changes have been enacted through a\nseries of emendments to Title XVIII of the Social Security Act.\nOne areas of interest in recent years has been directed to the ap-\npropriateness of selectively altering coverage under Part B of\nMedicare to include certain health care services when provided by\nnonphysician professional practitioners. Currently, for example,\nthe Department of Health, Education, and Welfare is engaged in\nseveral efforts directly or peripherally related to this issue.\nThis particular document represents the output of one such effort.\nFORD & GERALD LIBRARY\n3\nLegislative Charge\nDuring the Senate floor debate on December 17, 1975, on H.R. 10284,\nAmendments to the Medicare Law, the following amendment, which was\nlater enacted as Section 109 of P.L. 94-182, was proposed to re-\nquire a study by the Secretary of DHEW, due four months after\nenactment, regarding eligibility under Part B of Medicare for\ncertain vision/eye care services when provided by optometrists:\n\"Sec. 109. The Secretary of Health, Education, and\nWelfare shall conduct a study of, and submit to the\nCongress not later than four months after the date\nof enactment of this section a report containing his\nfindings and recommendations with respect to, the\nappropriateness of reimbursement under the insurance\nprogram established by Part B of Title XVIII of the\nSocial Security Act for services performed by doctors\nof optometry but not presently recognized for purposes\nof reimbursement with respect to the provision of\nprosthetic lenses for patients with aphakia.\"\nThe amendment is essentially the same as the one adopted by the\nSenate two years earlier as part of H.R. 3153, the Social Security\nAmendments of 1973, which did not become law. At that time, it\nwas suggested in the Senate report on the bill that an appropriate\nstudy should be undertaken utilizing the expertise of both\noptometrists and physicians who are not employed directly or in-\ndirectly in governmental agencies, and that at least half of the\nprofessionals consulted should be actively practicing optometrists.\nSupporting his amendment to H.R. 10284 this past December, Senator\nRobert Dole referred to the guidelines set forth in the 1973\nSenate report and added:\n\"\nI would further suggest now that the Secretary\nmight assign the designated task to his Assistant\nSecretary of Health, and that his office in turn\nutilize existing Health Manpower agencies so that\ninformation could be supplied regarding the opto-\nmetric curriculum and the distribution of optometrists\ngenerally. I would also hope that the panel formed\nwould include consumer representatives and than, in\nthe course of their investigation, consideration can\nbe given to services provided the entire cataract\npatient--including precataract cases where appropriate.\"\nGERALD FORD LIBRARY\n4\nInterpretation of Charge\nInterpretation of the charge from Congress was based on the joint\ncontext of the amendment itself and the Senate floor speech. In\norder to meet the requirements intended for the study, consequently,\nthe following question was viewed as the principal query for exam-\nination: What services related to aphakic and cataract conditions\ncurrently covered under Part B of Title XVIII when provided by a\nphysician, are appropriate for coverage when provided by an opto-\nmetrist? Implicit in this interpretation was the expectation that\nany recommendations which might result from the study for alter-\ning Part B of the Medicare program would require legislative\nchange.\nTwo points should be noted in the context of this Departmental\ninterpretation. First, it was deemed appropriate to confine the\nstudy inquiry to optometrists and optometric practice. Accord-\ningly, limited attention was directed within the study framework\nto other providers of vision/eye care services. Second, although\nthe principal focus of the study would be to examine matters\ngermane to the specific legislative charge, it was also viewed\nappropriate to keep the study framework sufficiently flexible to\naccommodate consideration of related areas of interest (e.g.,\nservices presently excluded from Medicare coverage for any pro-\nvider of vision/eye care services).\nDepartmental interpretation of the legislative intent regarding\nsubstantive content of the study, as well as the use of non-\ngovernment expert advisors, is treated in the remainder of this\nsection.\nStudy Strategy\nIn addressing the appropriateness of introducing modifications to\nexisting provisions under Part B of Title XVIII, a balanced assess-\nment must examine considerations of population health care needs,\nthe quality of service delivery provided to the Medicare eligible\npopulation, resource distribution and access concerns, and\nrespective cost implications. The intensity of any study inquiry\ninto such areas, however, must be tempered by the availability of\ntime, resources, and information of relevance. Given the time\nconstraints available for the conduct of this mandated study, the\nDepartment adopted a closely-defined strategy to undertake this\neffort.\nHealth Care Needs. As stated in Vision Research Program Planning,\na report developed under the auspices of the National Advisory Eye\nCouncil and published this past year by the National Eye Institute,\nthe National Institutes of Health, \"the great toll taken each year\nFORD & LIBRARY GERALD\n5\nin the United States by eye diseases is.\nnot measured in terms\nof mortality--few disorders originating in the eye cause death--\nbut rather in degrees of physical limitation and financial burden.\nBut such measurements are inadequate, for they do not convey the\nhardship or mental anguish of having to function in a complex en-\nvironment deprived of normal vision. Perhaps for these reasons,\nAmericans have indicated that they fear blindness more than any\nother physical affliction with the single exception of cancer \"\nAlthough applicable to persons generally, this passage has parti-\ncular relevance for any consideration of vision/eye care disorders\nand their impact upon the elderly members of our society. Persons\nsixty-five years of age and over continue to account for a dispro-\nportionate share of vision/eye problems, a fact that often further\ncomplicates the already complex life conditions faced by many\ngeriatric persons.\nAn assessment of the extent of overall vision/eye care needs of\nthe elderly is itself a difficult undertaking, similar to efforts\naddressing broader health care needs and other population segments.\nJudgments from professional providers or other experts close to the\nsubject yield approximations with wide variation for both overall\nvision/eye care needs as well as needs more pertinent to aphakia\nand cataract. For this brief study effort, it was believed\nreasonable that the identification of relevant incidence and pre-\nvalence data, along with selected data on utilization, would pro-\nvide an adequate information base to address this area.\nQuality of Service Delivery. In an consideration of modifications\nto the Medicare program, an assessment of the qualitative dimen-\nsions of health care delivery is also relevant. It is principally\ndue to a concern for minimizing variability within the qualita-\ntive aspects of health care delivery that de facto adoption of\nState Practice Act provisions, which often exhibit extensive\nvariations from one jurisdiction to another, has not been routinely\naccepted as an exclusive criteria for extending eligibility to\nproviders currently outside the provisions of the program. This\nconsideration has been particularly relevant in situations where\nuniversal coverage experience has not existed.\nGiven this context, the question of relevance is not whether the\nquality of health care delivery should be addressed, but rather\nhow should it best be addressed. The quality of health services\nis admittedly an elusive concept, involving measures that are\noften, at best, imprecise.\nThe strategy of this study, in view of this consideration, was to\ndirect attention to selected structure, process, and outcome variables.\nFORD & LIBRARY 038470\n6\nAs such, consideration was given to the appropriateness of equip-\nment and procedures utilized by optometrists for providing re-\nquired services; the extent to which optometric education and\nusual practice correspond to the skills and experience identi-\nfied for the requisite services; and the existance of any\noptometric practice standards that might exist or be in the\nprocess of development. Bibliographic searches were undertaken\nto uncover the availability of any controlled studies that have\nbeen directed to assess the effectiveness of optometric practice.\nAttention was also directed to an analysis of State Optometry\nPractice Act, primarily to document the extent of uniformity or\nvariability among extant provisions, as well as to supplement\nanalyses of relevant structure or process variables (e.g., the\nextent to which continuing education requirements are stipulated\nin State Practice Acts).\nDistribution, Access, and Cost. Although access to health care\ncan be conceptualized in several ways, such as in terms of finan-\ncial, physical, and attitudinal barriers to obtaining services,\na thorough examination of this issue requires a relatively broad\nview of resource availability and distribution. For example, a\nconsideration of physical access solely in terms of numbers of\navailable health care resources represents a limited input for\npolicy development concerning resource access. Measurement of\nphysical access is better undertaken in terms of the monetary\nand non-monetary costs of obtaining requisite services, includ-\ning considerations of respective transportation, time, and search\ncosts incurred. Insuring physical access in monetary terms, con-\nsequently, should raise the possibility of tradeoffs between\nimproved financial access and improved physical access.\nDespite such broader considerations, including respective impli-\ncations for health manpower education policy, time and data\navailability constraints for this study effort suggested a more\nnarrow course for examination. Attention was focused, therefore,\non the geographic distribution of the Medicare eligible popula-\ntion and the corresponding distributional patterns of opto-\nmetrists and ophthalmologists. The rationale was to conduct a\nfirst-order level of analysis concerning potential impacts upon\navailability of manpower (services) from any potential alterations\nin existing coverage.\nChanges in existing utilization patterns, potential alterations\nin the patterns of service delivery by providers, as well as\npossibilities for duplication of services all represent minimum\nconsiderations for analytic endeavors attempting to assess the\ncost implications of any shifts in prevailing coverage. Attention\nto respective consequences for Medicare program costs and health\ncare costs generally represents an integral part of any inquiry\nFORD & LIBRARY GERALD\n7\nconcerning the appropriateness of potential modifications to exist-\ning Medicare provisions and policy. Given such considerations and\nagain within the time and data constraints for this effort, the\nstudy intent was to provide a rough first-order magnitude of the\nrespective cost implications at issue, as well as to delineate\nseveral key dimensions that might be relevant for any definitive\ninquiry into this matter.\nStudy Methodology\nCurrent and historical studies, as well as data collection efforts\nalready completed, were heavily relied upon for information uti-\nlized in this study. This process was expedited by the use of\nselected bibliographic searches, as no primary data collection\nactivities were undertaken for this effort.\nIn accordance with the legislative charge, furthermore, a panel of\nnine expert consultants was convened. This group of individuals\nassisted the study effort by reviewing material assembled by the\nstudy staff; provided information sources and, where appropriate,\naccess to relevant material for the conduct of the study; and\nserved in a technical advisory capacity. Although the consultants\ncontributed substantially to the preparation of this report, in-\ncluding its conclusions and recommendations, its overall contents,\napart from the statement on Additional Considerations at the begin-\nning of this report, are the responsibility of the Department.\nThe panel consisted of three active practicing optometrists, three\nophthalmologists, one optometric educator, and two public members.\n(See the Attachment to this section for a listing of the names of\nconsultants.) During the course of the study, the panelists were\nconvened on three occasions, although informal dialogue between\nindividual consultants and respective study staff continued\nthroughout the study's duration.\nThe above discussion concerning \"study strategy\" briefly outlined\nthe analytic components of the study. Logistically, during their\nfirst meeting, panelists were presented with a series of questions\nthat study staff intended to address as part of the analytic\nendeavors. Dialogue between panelists and study staff during that\nmeeting, as well as inputs provided by selected organizational\ncomponents of the Department, served to finalize the study frame-\nwork. During the latter part of the effort, the expert consultants\nreviewed findings suggested by study staff, and, at the request of\nstaff, provided their professional views concerning the range of\npotential conclusins and recommendations which might reasonably\nbe related to these findings.\nGERALD ? FORD\n8\nThe Bureau of Health Manpower of the Health Resources Administra-\ntion, PHS, which is directed by Daniel F. Whiteside, D.D.S., had\nprimary responsibility for the staff work. Expert assistance in\nspecific areas of the study was provided by the Office of Policy\nDevelopment and Planning, Office of the Assistant Secretary for\nHealth, PHS; Bureau of Quality Assurance, Health Services Admini-\nstration, PHS; National Eye Institute, National Institutes of\nHealth, PHS; National Center for Health Statistics and National\nCenter for Health Services Research, Health Resources Administra-\ntion, PHS; and the Bureau of Health Insurance and the Office of\nResearch Statistics, Social Security Administration. A listing\nof study staff, as well as formal linkage persons in Departmental\norganizations identified above is also provided in the Attachment.\nIn addition, a number of additional governmental and non-govern-\nmental sources were contacted informally during the course of the\nstudy. Where information was obtained from such sources and\nutilized in this effort, appropriate references are provided in\nthe text of this report.\nGERALD LIBRARY FORD\n9\nATTACHMENT\nLISTING OF EXPERT CONSULTANTS, STUDY STAFF, FORMAL AGENCY LIAISON\nI. Expert Consultants\nRon G. Fair, O.D.\nPracticing Optometrist\nBrighton, Colorado\nJames P. Gills, M.D.\nPracticing Ophthalmologist\nNew Port Richey, Florida\nRobinson D. Harley, M.D.\nPracticing Ophthalmologist\nPhiladelphia, Pennsylvania\nAlbert N. Lemoine, M.D.\nDepartment of Ophthalmology\nThe University of Kansas School of Medicine\nKansas City, Kansas\nCarroll M. Martus, O.D.\nPracticing Optometrist\nMarblehead, Massachusetts\nMichael J. Obremsky, O.D.\nPracticing Optometrist\nAnnandale, Virginia\nHenry B. Peters, O.D.\nDean, School of Optometry\nUniversity of Alabama\nBirmingham, Alabama\nR. Roy Rusk\nDirector, Program\nAmerican Foundation of Overseas Blind, Inc.\nNew York, New York\nWilliam K. Selden, Litt.D.\nPrinceton, New Jersey\nFORD & LIBRARY GERALD\n10\nII. Key Study Staff\nPaul M. Schwab, M.A., M.P.H.\nOffice of the Administrator\nHealth Resources Administration\nThomas D. Hatch\nNathan Watzman, Ph.D.\nGrace Madison, J.D.\nDavid B. Hoover, M.P.H.\nDivision of Associated Health Professions\nBureau of Health Manpower, HRA\nStuart Bernstein, B.A.\nLarry W. Lacy, M.A.\nManpower Analysis Branch\nOffice of the Director\nBureau of Health Manpower, HRA\nIII. Formal Agency Liaison\nSamuel W. Kidder, Pharm.D., M.P.H.\nOffice of the Assistant Secretary for Health\nLinda L. Cohen, M.D.\nBureau of Quality Assurance, Health Services Administration\nLuigi Giacometti, Ph.D.\nNational Eye Institute, National Institutes of Health\nPeter W. Ries, Ph.D.\nNational Center for Health Statistics, Health Resources Administration\nAlvin Abrams, M.D.\nNational Center for Health Services Research\nHealth Resources Administration\nHarold Fishman\nBureau of Health Insurance, Social Security Administration\nJames Caple\nOffice of Research Statistics, Social Security Administration\nGERALD FORD LIBRARY\n11\nIV. Secretarial and Meeting Coordination Assistance\nShirley G. Miller\nRoberta Light\nFrances A. Gaetano\nDivision of Associated Health Professions\nBureau of Health Manpower, HRA\nV. Library and Reference Services\nElizabeth Martinsen\nManpower Analysis Staff\nOffice of the Director\nBureau of Health Manpower, HRA\nGERALD FORD\n12\nSECTION I-B\nCURRENT STATUS OF MEDICARE COVERAGE-\nIn order to provide the basis for a review of the question of the\nappropriateness of extending coverage under the insurance program\nestablished under Part B of Title XVIII of the Social Security Act\nof services to cataract patients provided by optometrists, but not\npresently recognized for coverage, it is essential to understand\nthe current status of coverage. The purpose of this section is to\nprovide that understanding.\nPart B of Title XVIII of the Social Security Act (Sec. 1831-1879)\nentitled \"Supplementary Medical Insurance Benefits,\" in contrast\nto the hospital benefits program (Part A), is a voluntary program\nfor eligible individuals who elect (or in certain cases do not\ndecline) to enroll. It is financed from premium payments by\nenrollees and from contributions from fxnds appropriated by the\nFederal Government. Eligible enrollees include persons who have\nattained the age of 65 years and (after 1973) certain persons under\nage 65 who are disabled or suffer from chronic renal disease. As\nthe title implies, the program supplements the benefits provided\nunder the hospital benefits program by covering physician and\ncertain other practitioners' services, additional home health\nvisits, plus a number of other medical and health services not\ncovered by the Hospital Benefits program. There are, however,\nlimitations on the benefit entitlements in the form of deductibles\nand coinsurance, as well as exclusions relating to specific services.\nThe implementation of the Social Security Act is vested, by statute,\nwith the Secretary of Health, Education, and Welfare. Operational\nresponsibility for the Medicare program is carried out by the\nSocial Security Administration.\nCoverage is defined by the statute and by regulations promulgated\npursuant to the statute by the Department of Health, Education, and\nWelfare. It is also important to recognize the importance of\n\"legislative history\" to both the formal regulatory process and\nimplementation of the program. Thus, where more than one inter-\npretation may be made from the statutory language itself, various\ncongressional documents, particularly reports issued by Congres-\nsional committees, are utilized to determine congressional intent.\nAlso, one cannot underestimate the importance of the staff of the\nDepartment of Health, Education, and Welfare, particularly the\nSocial Security Administration which has responsibility for\nimplementing the program within the law and regulations in a\nconsistent manner.\nFORD\nGERALD\nLIBRARY\n13\nThe program is administered on a day to day basis through contracts\nnegotiated between the Federal Government and health insurance\ncarriers whereby the carriers reimburse from the trust fund estab-\nlished from premium payments of enrolled beneficiaries and Federal\ncontributions. The Federal Government may also enter into agreements\nwith States for coverage of eligible individuals who are concurrently\nreceiving payments under public assistance programs provided through\nthe Social Security Act.\nIt is the responsibility of the carriers (or State agencies) to\ninterpret policies regarding benefits and limitations in accepting\nor rejecting bills submitted for reimbursement and to determine that\ncharges made for covered services are reasonable and necessary. To\nassist carriers in this process, the Social Security Administration\nissues Health Insurance Manuals (HIM's). There are active contracts\nwith more than 70 carriers and one State agency agreement for\nimplementation of Part B.\nAs of July 1, 1973, 23.5 million aged and disabled persons were\ninsured under Medicare. Of these, 22.5 million were enrolled under\nPart B, with 22.2 million covered under both Part A and Part B,\nand 244, 000 under Part B only. Part B enrollees included 20.9\nmillion persons over age 65 and 1.6 million under age 65\nBasic Services Covered by the Supplementary Medical Insurance Program\nThe Social Security Act (Sec. 1832) divides the scope of benefits\ncovered by Part B into three basic elements: (1) \"home health\nservices, \" (2) \"medical and other health services, \" and (3) \"out-\npatient physical therapy services. 113/ In general, reimbursement to,\nor on behalf of, enrolled beneficiaries is made for such services\nsubject to the Definition of Services, Institutions, etc.; and the\nExclusions from Coverage outlined in Part C of Title XVIII (Sec. 1861\nand 1862).\nMedical and Other Health Services are defined (Sec. 1861 (s)) to\ninclude:\n(1) physicians' services\n(2) services and supplies furnished as an incident\nto a physician's professional services\n(3) diagnostic X-ray laboratory and other diagnostic tests\n(4) X-ray, radium and radioactive isotope therapy\n(5) surgical dressings, and splints, casts and other\ndefices used for reduction of fractures and dislocations\n(6) rental or purchase of durable medical equipment\n(7) ambúlance service\n(8) prosthetic devices\n(9) leg, arm, back, and neck braces\nFORD\ns\nGERALD\nLIBRAR,\n14\nThe Act (Sec. 1861 (q) and (r)) further, defines \"physicians'\nservices\" and \"physician.\"\nThe term \"physicians' services\" means \"professional services\nperformed by physicians, including surgery, consultation, and home,\noffice, and institutional calls \" (except those services\nprovided by interns and residents, which are outlined separately.)\n\"The term 'physician,' when used in connection with the performance\nof any function or action, means (1) a doctor of medicine or\nosteopathy legally authorized to practice medicine and surgery by\nthe State in which he performs such fxnction or action\n\"\nDentists, podiatrists, optometrists and chiropractors are also\ndefined as \"physicians\" for certain specific and limited purposes\nwithin the Act.\nSection 1862 sets forth exclusions from coverage under the Act,\nprohibiting payment, notwithstanding any other provisions of\nTitles A or B, for any expenses incurred for certain items and\nservices. A list of thirteen exclusions is specified. Of\npertinence to this study are items or services\n- \"which are not reasonable and necessary for the\ndiagnosis or treatment of illness or injury or\nto improve the functioning of a malformed body\nmember;'\n- \"where such expenses are for routine physical\ncheck-ups, eyeglasses or eye examinations for\nthe purpose of prescribing, fitting, or changing\neyeglasses, procedures performed (during the\ncourse of any eye examination) to determine the\nrefractive state of the eyes, hearing aids or\nexaminations therefor, or immunizations.\"\nCurrent Coverage for Services Provided to Persons with Cataracts\nIn general, diagnosis and treatment of cataract conditions are\nservices to which beneficiaries enrolled under Part B are entitled.\nHowever, there are certain limitations to this coverage, both as to\nspecific services for which reimbursement may be made as well as to\nthe nature of the practitioner who provides the service. Exclusions\nrelating to the services for which expenses are not covered are as\nfollows:-\n1. Routine physical checkups. Thus, for example, the\ndiagnosis of cataracts, if made during the course of\na routine physical examination, would not be covered.\nFORD i LIBRARY GERALD\n15\n2. Provision of eyeglasses or contact lenses, except\nboth temporary and permanent post surgical lenses\nwhich, after the natural lens of the eye has been\nremoved, are considered to be prosthetic devices.\n3. Eye examinations for the purpose of prescribing,\nfitting, or changing eyeglasses or contact lenses\nfor refractive error only.\n4. Procedures performed in the course of any eye\nexamination to determine the refractive state of\nthe eye.\nLimitations to the nature of the practitionér who provides covered\nservices to a cataract patient are principally related to the\ndefinition of \"physician\" for purposes of the Act.\nAs noted above, in addition to doctors of medicine and osteopathy,\nthe Act defines other practitioners, including optometrists, as\n\"physicians\" for specific purposes within the program. In the case\nof optometrists, this definition is limited to \"establishing the\nnecessity for prosthetic lenses. 115/ Regulations clarify this by\ndefining an optometrist as a \"physician\" \" only for the purpose\nof attesting to the necessity of prosthetic lenses. \"6/\nRegulations further state that \"The prescription or order of a\ndoctor of optometry will be accepted as evidence of the medical\nneed for prosthetic lenses. However, optometric examinations for\nany purpose are not covered. 1171\nInclusion of the above definition relating to doctors of optometry\nwas made by amendment to the Social Security Act in 1972. Prior to\nthat time, while prosthetic lenses were reimbursable when provided\nby an optometrist, it was necessary for the patient to have a\nprescription from a physician. The intent of the amendment was to\neliminate the necessity for an aphakic patient to obtain a physician's\norder for prosthetic lenses by recognizing the ability of an\noptometrist to determine a beneficiary's need for such lenses.\nThe reports of both the Senate and House Committees made it clear,\nhowever, that the purpose of the amendment was solely for the\npurpose of establishing or attesting to the medical need for\nprosthetic lenses, and did not provide for coverage of services\nperformed by optometrists other than those previously covered\n8/\nIn summary, current Part B coverage for cataract patients includes,\nwhen provided by any doctor of medicine or osteopathy, (1) eye\nexaminations, except that part of the examination related to\nrefraction, if the examination is carried out in relation to a\nspecific patient complaint; (2) surgical and related professional\nservices carried out in connection with removal of the lens; and\nFORD & LIBRARY GERALD\n16\n(3) services in connection with the provision of both temporary and\npermanent prosthetic lenses, including fitting and providing the\nlenses themselves. The only services for which optometrists may be\nreimbursed are dispensing services in connection with the actual\nfitting and provision of prosthetic lenses. Table 1 delineates\nthe status of Part B reimbursement for services within the scope\nof practice of both physicians and optometrists.\nTABLE 1\nPart B Reimbursement Status of Services to Cataract and Aphakic\nPatients which are Provided by both Physicians and Optometrists\nEligible for Part B\nReimbursement Under\nService*\nCertain Conditions\nMD/DO** OD\nPersonal and Family Health History,\nSymptoms and Vision Requirements\nX\nVisual acuity - distance and near, with\nand without correction\nExternal examination (eye and adjacent structures)\nDirect and indirect ophthalmoscopy\nBiomicroscopy\nTonometry\nCentral and peripheral visual fields\nOphthalmometry/Keratometry\nRefraction - objective and subjective,\ndistance and near\nOcular motility and binocular function\nVisual perception, color vision, Stereopsis, motor\nX\nEvaluation for contact lenses\nEvaluation for low vision aids\nEvaluation for vision training therapy\nOphthalmic prosthesis and services\nX\n*\nServices listed include only those within the scope of practice\nof both physicians and optometrists. All of the listed services\nwould not necessarily be provided by either provider to every\ncataract or aphakic patient during the course of each examination.\nMost of these services, when provided by physicians, are typically\nprovided only by those specializing in Ophthalmology. However,\nany doctor of medicine or osteopathy is authorized to carry out\nany of the services listed and could be reimbursed for any covered\nservices provided.\nFORD & LIBRARY GERALD\n17\nFootnotes and Bibliography\n1/ Basic information included in this section is derived from the\n\"Social Security Act and Related Laws (including Amendments\nthrough January 2, 1976), \" Committee on Finance, United States\nSenate, February 1, 1976; Federal Regulations No. 5, 39 F.R.\n28624 (Aug. 9, 1974); and \"Health Insurance Manuals\" (HIM's)\nissued by the Social Security Administration as instructions\nto carriers. A useful supplementary compilation of the various\npertinent documents is \"1974 Social Security and Medicare\nExplained -- Including Medicaid --,\" Commerce Clearing House,\nInc., Chicago, Ill., 1974.\n2/ U. S. Department of Health, Education, and Welfare, Social\nSecurity Administration \"Medicare 1973,\" DHEW Publication No.\n(SSA) 76-11705, U. S. GPO, Washington, D.C., 1975, P. 1.\n3/ Since home health services and outpatient physical therapy\nservices are not pertinent to this study, they will not be\ndiscussed further.\n4/ See Social Security Act, Part B, Section 1862 (a) (7); Regulations\nNo. 5, Subpart C, paragraph 405.310; Medicare Carriers Manual,\nHIM 14-3 paragraphs 2320, 4125, 5217. See also Social Security\nAct, Part B, Sec. 1861 (s) (8).\n5/ Social Security Act, Title XVIII, Part B, Sec. 1861 (r).\n6/ Regulations No. 5, paragraph 405.232 (a) (4).\n7/ Regulations No. 5, paragraph 405.232 (c).\n8/ See United States Senate Report of the Committee on Finance to\naccompany H.R. 1, Senate Report No. 92-1230, September 26, 1972,\npp. 43-44; and U. S. House of Representatives Report of the\nCommittee on Ways and Means on H.R. 1, House Report No. 92-231,\nMay 26, 1971, PP. 117-118.\nGERALD FORD CIBRARY\n18\nSECTION I-C\nFINDINGS AND CONCLUSIONS -- SUMMARY\nThis section provides a summary of the key study findings and con-\nclusions which underlie recommendations presented in the beginning\nof this report. The points highlighted below have been documented\non the basis of\nstatistical or factual information, or pro-\nfessional judgements concerning what would represent reasonable\nand likely inferences given professional experience. Detailed\ninputs to the study, which were used in the preparation of this\nsection, are provided in Part II of the report.\nVision/Eye Care Needs of the Elderly\nGeriatric patients are likely to suffer from multiple symptoms and\nvarious interrelated disabilities, with underlying pathology that\nis complex and that requires a range of diagnostic, therapeutic,\nand domiciliary care services. Their health conditions are often\nfurther complicated by social, psychological, and economic insta-\nbility, requiring various health consultative services as well.\nThe elderly population accounts for a disproportionate share of\nvision/eye problems, including cataract and aphakia, and requires\nvision/eye care services provided in a professional, compassionate\nmanner. Lack of mobility, as well as dependency and depression,\nrepresent but a few examples of life conditions experienced by\ngeriatric patients. Vision problems, furthermore, may precipitate\nother problems, such as consequences of accidents and injuries\nattributable to visual difficulties.\nCataract, as a structural definition, refers to any opacity of the\ncrystalline lens. Since such opacities result in most instances\nfrom the normal physiological process of aging, it is therefore\nnot unusual for large numbers of the elderly to have varied degree\nof cataract in technical terms. Although respective stages in the\nprogression of cataract can be generally classified, there does\nnot currently exist a means for objectively and consistently deter-\nmining these stages. Consequently, general agreement does not\nexist in the provider community concerning appropriate functional\ndefinitions for cataract.\nDuring the course of this study, the panel of expert consultants\ndid agree upon a functional definition of cataract for diagnostic\npurposes:\nFORD & LIBRARY GERALD\n19\nA clinically significant cataract is any opacity of the lens* that\nreduces visual acuity and may be functionally disabling or dis-\nruptive of the normal life style, more particularly for near or\ndistant vision (e.g., reading or driving). This definition served\nas a framework for addressing requisite patient services and pro-\nvider qualifications. Given the lack of concensus within the pro-\nvider community on functional definitions, as well as considerations\nrelevant for administering Medicare, this definition was not\nnecessarily formulated as a disease-specific criteria for Medicare\nregulation-drafting purposes.\nStatistical profiles on cataracts, despite definitional variations,\nremain informative in addressing the general magnitude of this\neye disorder. Approximately three-fourths of an estimated inci-\ndence of 912,000 new cases of cataract per year, for example, is\naccounted for by the elderly. Among eye disorders, furthermore,\nthe relationship between cataract and blindness is particularly\nsignificant.\nAlthough senile (senescent) cataract accounts for approximately\nninety percent of the documented cases, it should also be noted\nthat most cataract of this type has no demonstrable etiology.\nApproximately one out of every ten persons with senescent cataract\nhas overt diabetes millitis. Typical diabetic cataract usually\ndevelops in patients with severe, prolonged poorly-controlled\ndiabetes. These patients are most commonly seen in later years\nof life, although they may be seen early in their youth.\nAt the present time, surgery is the only method for treating cat-\naract. There is no medical treatment available that will dissolve\nthe opacity or prevent its development and progression. It is\nestimated that in 1972 somewhat over 300,000 surgical operations\nwere performed for cataract extraction, with the largest propor-\ntion occuring among the elderly. Most aphakic patients, that is,\nthsoe who do not have their natural lens(es), have lost their\nnatural lens(es) as a result of surgery performed for cataract.\nApproximately five percent of cataract extractions have signifi-\ncant complications and most of these complications occur during\nor soon after cataract surgery. Within this group, some common\ncomplications consist of vitreous loss, intraocular hemorrhage,\ncystoid maculopathy, a shallow anterior chamber, postoperative\nintraocular infection, Elschnig pearls, glaucoma, and retinal\ndetachment.\nGERALD FORD LIBRARY\n20\nRefractive services are particularly important for the aphakic\npatient. Optical correction of aphakia usually begins within a\nday or two after surgery utilizing temporary eye glass correction.\nA final permanent prescription is not given until two to three\nmonths and sometimes longer after the extraction. Rarely are con-\ntact lenses prescribed before six weeks following surgery. However,\nthere are several varieties of soft, hydrophilic contact lenses\nnow available which are prescribed early in the post-operative\nperiod. These are prosthetic devices used to replace an excised\nbody organ.\nPatient rehabilitation is initiated prior to surgery and is con-\ntinued afterwards, beginning when final physiological changes sub-\nsequent to surgery have taken place. With most patients, stabil-\nity tends to occur within six to eight weeks after surgery; in\nsome instances, however, the final fitting of prosthetic lenses\ncannot be undertaken until six months or more have elapsed. For\ncertain patients, rehabilitation in the use of prosthetic devices\nis necessary to assist the patient with spatial orientation and\nmobility.\nSince aphakic patients tend to be older, difficulties may result\nin adapting to contact lenses. For example, physical disabilities\nsuch as tremor and arthritis may require a lengthy period of\nsupervised use of contact lenses or preclude their use entirely.\nIn these patients, the structure of the eye lids may be soft and\nflaccid, which may cause difficulties in contact lens removal or\nmay cause the lens to ride low with its center below the center of\nvision. Other circumstances, such as abnormally large pupils or\ncornea scarring resulting from surgery may complicate the adapta-\ntion process as well.\nFor certain aphakic patients, the use of prosthetic devices such\nas spectacles and contact lenses, or the implantation of a plastic\nlens within the eye following cataract surgery after removal of\nthe natural lens, does not provide optimal vision for their life-\nstyle and occupational requirements. The Study consultants recom-\nmended that such patients be considered for low vision aids, such\nas special microscopic reading glasses and telescopic spectacles.\nSuch devices have been very effective, when properly applied, in\nproviding the best possible vision function for certain lifestyle\nactivities, a requirement that is most important to the physical\nand mental well-being of these patients.\nAccess To Vision/Eye Care Services\nThe management of cataract and aphakic patients requires a range\nof diagnostic, consultative, and therapeutic services, apart from\nsurgery specifically. As outlined earlier, many of these services\nGERALD FORD LIBRARY\n21\nrelated to the eye are eligible for coverage under current Medi-\ncare provisions. For the most part, in addition, doctors of\nmedicine and osteopathy, when legally authorized to practice med-\nicine and surgery by States in which they practice, are the practi-\ntioners recognized by Medicare to render and be reimbursed for\nthese services.\nIt is virtually self-evident that currently covered vision/eye\ncare services related to aphakic and cataract conditions can be\nmade more accessible to the Medicare eligible population by expand-\ning the present coverage for services to include services provided\nby optometrists. As a minimum, greater financial equity can be\nextended to those Medicare beneficiaries who currently obtain\nnecessary and reasonable health services from optometrists without\nMedicare reimbursement.\nThis conclusion is principally supported by analyzing comparatively\nthe distributional patterns of optometric and ophthalmologic man-\npower. It should be noted that ophthalmologists are not the only\nphysician group rendering vision/eye care services and included\nunder Medicare provisions. Among physician providers, however, it\nis reasonable to infer that ophthalmologists provide the bulk of\noverall vision/eye care services.\nIn 1973, there were approximately two active optometrists for\nevery one active ophthalmologist in the United States. Respective\nactive supply estimates numbered 19,300 and 10,500. On a compara-\ntive basis, the supply of optometrists was more evenly distributed\nacross the country. The study effort, utilizing data assembled\nfrom American Medical Association records, the 1972-73 optometry\ninventory conducted by the American Optometric Association and\nsupported by the Bureau of Health Manpower, and statistics collected\nby the National Center for Health Statistics, DHEW, identified\nspecific findings relevant for examining overall supply and dis-\ntributional patterns between the two provider groups.\nDespite the national two-to-one relationship, most States exceeded\nor approximated this ratio, as a number of large, heavily populated\nareas statistically influenced the overall figure. Active ophthal-\nmologists exceeded the number of active optometrists in only two\nareas of the nation, Maryland and the District of Columbia. In\nseven States, in contrast, there were greater than three times as\nmany optometrists than ophthalmologists.\nThe overall national relationship largely reflects distributional\nexperiences in the nation's metropolitan areas. For example, in\n1973, there were approximately 1.7 optometrists for every ophthal-\nmologist in metropolitan areas, in contrast to a ratio of 4.2 in\nnon-metropolitan areas. A total of 5,300 active optometrists were\nlocated in non-metropolitan areas, or slightly more than one-fourth\nGERALD LIBRARY FORD\n22\nof the overall active optometric supply; this compared with 1,200\nactive ophthalmologists, or somewhat more than one-tenth the supply\nof this provider group. In terms of persons sixty-five years of\nage and older, there were 55 ophthalmologists and 99 optometrists\nper 100,000 persons in metropolitan areas, in contrast to ratios\nof 19 and 79, respectively, in non-metropolitan areas.\nIt should be noted that such metropolitan and non-metropolitan\ndifferences vary by size of the respective areas and by regional\nsetting. For example, available data indicate that there are\nsomewhat higher ratios of both ophthalmologists and optometrists\nto the Medicare eligible population in areas of 500,000 population\nor more than in smaller metropolitan areas. In non-metropolitan\nareas of the North Central States, for example, there are between\nsix and seven optometrists for every ophthalmologist, in contrast\nto four and five-to-one relationships evidenced in the South, and\nthree-to-one relationships in the remaining non-metropolitan areas\nof the nation.\nOne-third of all counties in the nation had the services of ophthal-\nmologists in 1968 (latest data available), compared with two-\nthirds of the countries for optometrists in 1973. Here, also,\nmore specific variations can be noted concerning metropolitan and\nnon-metropolitan counties. Overall, in comparing 1968 ophthal-\nmologist data with 1973 optometrist data by county, 1,251 or 40\npercent of the counties had one or more optometrists and no ophthal-\nmologists; 33 or 1 percent had one or more ophthalmologists and\nno optometrists; 1009 or 32 percent had both optometrists and\nophthalmologists; and 851 or 27 percent had neither provider group\nrepresented.\nBased upon existing trends, little change in the proportion of\neither ophthalmologists or optometrists practicing in non-metro-\npolitan areas can be projected. The proportion of recent graduates\nfrom schools of optometry, aged 30 and younger, practicing in non-\nmetropolitan areas is about the same or slightly lower for nine out\nof ten established optometry schools as compared to the proportion\nof total graduates practicing in these areas. In comparing 1968\nto 1972 data, a lower proportion of ophthalmologists were practic-\ning in non-metropolitan areas in 1968, only 13 percent were\npracticing in such areas in 1972.\nIn terms of overall supply, the Bureau of Health Manpower projects\nthe overall number of active ophthalmologists in the United States\nto rise to 13,300 in 1980 and to 18,400 by 1990; this compares with\nprojected levels of 22,000 and 28,200 for optometrists in the same\ntime intervals. The proportion of ophthalmologists as a percent of\ntotal professional vision care manpower it projected to grow from\n35 percent in 1973 to 38 percent in 1980 and 39 percent in 1990.\nGERALD FORD LIBRARY\n23\nAvailable data preclude such projections on a detailed geographic\nbasis. (Note: These estimates should be interpreted cautiously,\nand should be undertaken in the context of written documentation\navailable from the Bureau of Health Manpower.\nAvailable documentation, in sum indicates that there are a number\nof areas in the country, particularly in non-metropolitan settings,\nwhere population groups are only served by optometrists. An exam-\nination of basic measures of productivity further suggests that\nsuch optometrists may be seeing fewer patients on the average than\noptometrists not practicing in these areas. This observation\nresults from an examination of data on average vision analyses\nperformed by optometrists and the utilization of auxiliaries by\noptometrists. While non-metropolitan optometrists showed a some-\nwhat greater proportionate utilization of auxiliaries than did\noptometrists in metropolitan areas, optometrists in metropolitan\nareas utilizing auxiliaries had a somewhat greater average number\nof vision analyses than did optometrists in non-metropolitan areas\nutilizing auxiliaries.\nThe above discussion has focused on access considerations pertinent\nto Medicare beneficiaries in need of vision/eye care services, in-\ncluding cataract and aphakic patients specifically. Attention\nneeds to be focused at this point, however, on the optometry pro-\nfession itself, including its respective scope of practice, as\nwell as its qualifications for providing reasonable and necessary\nservices as required by law.\nOptometric Practice\nThe Institute of Medicine of the Natinal Academy of Sciences, in\ndescribing primary health professions who are direct providers of\npatient care, defined optometry as follows: \"The Doctor of Optometry\n(O.D.) is a health professional who performs eye examinations to\ndetermine the presence of visual, muscular, or neurological abnorm-\nalities, and prescribes lenses, other optical aids, or therapy,\nsuch as eye exercises to enable maximum vision. Optometrists are\ntrained to recognize disease conditions of the eye and ocular mani-\nfestations of other diseases, and to refer patients with these\nconditions to the appropriate health professional.\"\nThis definition, as well as available documentation on the utili-\nzation of optometric services, points to the optometrist's role\nas a provider of primary health care services. In this role, the\noptometrist functions as a principle point of contact within the\nhealth care system for persons having visual complaints, including\ncertain numbers who have symptoms or conditions that require re-\nferral to other health practitioners.\nGERALD FORD LIBRARY\n24\nThe scope of practice for optometry, similar to that for other\nhealth care providers, is difficult to define precisely. Here also,\ninformation is available from a number of sources to develop valid\nconcepts of a profession's role and function. Such sources in-\nclude State laws, judgements of courts concerning the responsibi-\nlities of practitioners, the usual and customary practices of the\nprofession, and the objectives, content, and standards of educa-\ntion and training for the profession.\nAn examination of a variety of such sources in the study effort\nsuggests persuasively that optometry is a profession qualified to\nprovide a broad range of services which are effective in patient\nmanagement, including the management of aphakic and cataract\npatients. (See discussion in Part II of this report for detail on\nsources cited and information examined.) It is reasonable to infer\nthat such services correspond to many specific diagnostic, thera-\npeutic, and consultative services currently reimbursable under the\nPart B provisions of Medicare when provided to pre- and post-\ncataract surgery patients by ophthalmologists or other doctors of\nmedicine.\nExpert advisors to the study detailed more specifically the broad\nrange of services provided by optometry. These include personal\nand family health history (symptoms and vision requirements);\nvisual acuity, distance and near (with and without correction);\nexternal examination; direct and indirect ophthalmoscopy; biomicro-\nscopy; gonioscopy; tonometry; central and peripheral visual fields;\nmacular integrity, fixation; ophthalmometry/keratometry; refraction,\nobjective and subjective, distance and near; ocular motility and\nbinocular function; visual perception, color vision, stereopsis,\nmotor; evaluation for contact lenses; evaluation for low vision\naids; evaluation for vision training therapy; and the provision of\nophthalmic prosthesis and services.\nIt was the further opinion of the study consultants that such\nservices comprise appropriate therapeutic modalities in eye care\nincluding: prescription of lenses (spectacles or contact lenses),\nvision training, rehabilitative services, including the teaching\nof patients to use prescription devices properly, and post-surgical\nmonitoring of referred patients. Furthermore, the professional\njudgement of the provider as to which therapy or combination of\ntherapies above should be used, is dictated by the presence or\nabsence of related ocular disease and complications of systemic\ndisease, as well as the occupation and life style of the patient.\nIn terms of practice setting, most optometrists are solo practitioners\nand, therefore, serve in independent settings. Partnerships or\ngroup practice arrangements account for approximately one-eighth of\nGERALD FORD LIBRARY\n25\nthe optometric manpower supply. In independent settings, speci-\nfically, similar to situations evident for many other health pro-\nvider groups, it is difficult to determine the extent to which\nindividual practitioners provide the detailed range of services\narticulated for the profession overall.\nAdvisors to the study effort indicated that, in their collective\nprofessional judgement, most of these services would be provided\nby optometrists. Variations in services provided by practitioners\ngenerally would likely reflect differences in professional judge-\nment and the circumstances specifically characterizing the patient\npresented. Given the variations in cases presented to vision/eye\ncare providers, it would be difficult to rigidly identify \"cataract-\nspecific\" vision/eye care services; such services, for example,\nmight often vary depending upon the type of cataract. In addition,\nthe nature of such services would also likely differ if the patient\nwere pre- or post-surgical.\nSome documentation on this issue is available from the survey of\noptometric practice, which was funded by the Bureau of Health\nManpower, DHEW, in 1968. The survey indicated that, as of that\nyear, most optometrists who were educated in the preceding twenty-\nfive years did report providing a broad range of services. The\nextent to which the above-referenced services are provided by opto-\nmetrists is more easily documented, however, in organized health\ncare settings.\nIn settings such as the armed forces, health maintenance organiza-\ntions, and, to a lesser extent, the Veteran's Administration faci-\nlities, optometrists are used extensively for initial vision exam-\nination purposes, and, therefore, serve largely in the role of\nprimary care providers. In larger military medical facilities,\nfor example, optometry is a section of the department of ophthal-\nmology, while in smaller installations the optometrists generally\nwork under the supervision of the director of hospital clinics,\nbut without close professional supervision. Overall, ophthalmolo-\ngists in military installations do not provide services without\nthe assistance of optometrists. In this setting, furthermore, the\npractice of triaging has been implemented successfully, where ophthal-\nmologists, optometrists, and medical corpsmen are utilized together.\nThe Veteran's Administration, in contrast, has relied much more\nheavily upon ophthalmology than optometry. The lower rate of opto-\nmetric utilization results in part from the establishment of non-\ncompetitive civil service salary rates for optometrists, and, in\npart, by only limited affiliation of VA hospitals with optometry\nschools. A multidisciplinary committee within the VA has recom-\nmended that training affiliations be established or strengthened\nwith the nation's optometry schools. The Opthalmological Advisory\nGERALD FORD LIBRARY\n26\nCommittee of the VA, furthermore, has endorsed and fully imple-\nmented the concept of expanding the present emphasis on eye health\ncare to the more comprehensive concept of vision care via inter-\ndisciplinary team delivery.\nOn a parallel note, optometric services have been included in a\nnumber of reimbursement systems, including various Medicaid pro-\ngrams. Of relevance to the study query, conditions of participa-\ntion in a number of State programs itemize explicitly the content\nof a visual examination which is covered for reimbursement to opto-\nmetrists. Although perhaps circumstantial, there does exist a\nclear correspondence between these service listings for participa-\ntion and the detailed range of services identified above.\nQuality Indicators and Controls\nSimilar to considerations pertinent to defining the scope of prac-\ntice for health professions, the precise delineation of the practi-\ntioners' area of professional competence is equally difficult to\nset forth. Here also, a variety of sources must be examined and\nconsulted to provide reasonable and highly probable inferences.\nThis is particularly the case given the limited availability of\nany carefully undertaken, controlled investigations that have been\ndirected to assess the effectiveness of services provided by in-\ndividual practitioner groups.\nAs indicated earlier, a principal conclusion from the study review\nis that optometry is a profession qualified to provide a broad\nrange of services which are effective in patient management, in-\ncluding the management of aphakic and cataract patients. It is\nreasonable to infer from information examined in the study, further-\nmore, that such services are reasonable, non-experimental, safe, and\ngenerally acceptable to the vision/eye care community and the public.\nEvidence presented, in addition, supports the conclusion that opto-\nmetrists are qualified to detect and make preliminary diagnosis of\nocular disease and ocular manifestation of systemic disease.\nMaterial provided in Part II of this report presents the detailed\nsupportive findings which underlie these conclusions. The following\ndiscussion, in turn, highlights several points of particular rele-\nvance to this issue.\nOptometric Education\nOptometrists are primary providers of health care and as such are\nresponsible for determining whether the problem of the patient is\nwithin his scope of treatment or whether the patient should be re-\nferred to another health provider. Optometric education includes\nspecific curriculum and clinical training related to the detection\nand diagnosis of ocular disease and ocular manifestation of systemic\ndisease. Schools include on their faculty and in their clinical\nDERALD FORD LIBRAR,\n27\nprograms physicians, and particularly ophthalmologists, in the\ntraining of optometric students. Particular attention is paid to\nthe detection and diagnosis of cataract, the complications follow-\ning cataract surgery and the procedures for the management and pro-\nper followup of aphakic patients. On the basis of this educational\nand clinical experience, the optometric student demonstrates a\nmastery of the skills and knowledge necessary for the diagnosis\nand management of the cataract and aphakic patient--for both gradu-\nation and licensure.\nAlthough each of the individual schools and colleges of optometry\nhas developed its own philosophy and objectives for optometric\neducation, certain principles are stated by all of the institutions.\nChief among these are the provision of a high-quality educational\nprogram intended to prepare each graduate to conduct a practice\nwhich is competent, service oriented and ethical; and the stimu-\nlation of any research which will further existing knowledge in\nthe visual sciences, usually through the medium of graduate programs.\nWhile certain curricular components may be particularly relevant\nconcerning care for the cataract and aphakic patient specifically,\nthe basic curricular elements of schools of optometry are targeted\nto overall evaluation and anlyses of patients, followed by a selec-\ntion of treatment based on all of the disorders present, the needs\nand characteristics of the patient, the prognosis, and the possible\ninterrelated effects of the proposed treatment procedures.\nThe basic curricular elements of optometry schools include the\nfollowing: biological science knowledge base; physiological optics\nknowledge base; pathology knowledge and skills base; optics know-\nledge and skills base; professional orientation knowledge and skills\nbase; clinical patient care knowledge and skills base; and patient\ncare experience. Each of these generic areas are subdivided into\nmore specific areas for study and, where appropriate, to clinical\nexperience.\nClinics maintained by the schools provide students with supervised\nclinical experience with a variety of patients, including cataract\nand aphakic cases. The clinical experience for the optometry stu-\ndent now commences in the second year and expands until, in the\nfourth year, the optometric student devotes at least half-time to\nwork under supervision in a clinic setting. In the clinical area,\nexperience is gained in such areas as contact lenses, low vision,\nchildren's vision and vision therapy, in addition to basic visual\nanalysis and the prescription of lenses.\nBERALD FORD NEBRARY\n28\nSome areas of the optometric curriculum, as noted above, have more\ninformation on or are directed more toward the care of the patient\nwith cataract or aphakia. In particular, these include considera-\ntions of geriatric, low vision, pathology, optic, and visual per-\nformance matters.\nSimilar to developments in education for all health professional\ngroups, the educational process and structure for optometry has\nbeen strengthened overtime. The accreditation process of optometry\nschools, for example, was informally iniated with the establish-\nment of the International Association of Boards of Examiners in\nOptometry (IAB) in 1922. At this time, all optometric schools are\naccredited by the regional college accrediting associations.\nPrior to 1968, uniform requirements as to length of training were\nnot mandated for all schools of optometry. The requirement of\nfour years of training in an optometry school was made mandatory\nby the Council on Optometric Education of the American Optometric\nAssociation for all schools for the entering class of 1968. The\nlength of study currently in accredited schools of optometry is\nfour years following pre-optometry college studies.\nIn addition to the basic four-year curriculum in optometry schools,\na number of institutions offer advanced degrees as well. By the\n1974-75 academic year, a total of sixty-six students were enrolled\nin graduate programs. Recent trends suggest that this figure is\nlikely to increase further.\nThe strengthening of the overall educational process and structure\nfor optometry students has been particularly bolstered by efforts\nundertaken by the Association of Schools and Colleges of Optometry\n(ASCO).\nIn 1941, this Association was formally established with the goal\nof \"aid in the advancement of optometry by giving attention to the\nproblems of the education of optometrists, and by formulating and\nsupporting desirable educational standards and policies.\" The\nAssociation, representing all U.S. schools and two programs in\nCanada, was incorporated in 1972 and established a staffed national\noffice in 1974 which publishes a monthly newsletter and quarterly\npublication.\nThis Association currently maintains standing Councils in three\nmajor educational areas: Academic Affairs, Student Affairs, and\nInstitutional Affairs. Beginning in 1973, the Council on Academic\nAffairs began development of a major statement concerning curri-\ncular standards for optometry schools. Guidelines for optometric\nresidency programs and post-graduate pharmacology training have\nbeen developed as well.\nFORD & LIBRARY 97V839\n29\nState Practice Acts and Licensure. The regulation and control of\nprofessional services to the public is a function of individual\nState jurisdictions. For many health professions, including opto-\nmetry, State Practice Acts define (with varying degrees of preci-\nsion) permissible and impermissible acts of individuals who are\nlicensed by the State to practice the profession.\nTo qualify for licensure, an applicant must be a graduate of an\napproved school with a program leading to a Doctor of Optometry\nDegree. All States require applicants to pass a written examina-\ntion as a condition precedent to licensure. A National Board\nExamination is currently accepted in lieu of the State written\nexamination in eighteen States.\nIn 1951, the National Board of Examiners in Optometry was established\nto resolve the problem of varying content and quality of the State\nboard examinations for graduating optometrists. The National\nBoard Examination, which emerged from this initial concern and\nsubsequent efforts, is currently administered over a two-day period\nand involves examination in the broadly ranging areas of visual\nscience; ocular pathology; theory and practice of optometry; theo-\nretical optics; ophthalmic optics; ocular anatomy; social, legal,\nethical, economic, and professional aspects of optometry; and\nocular pharmacology.\nContinuing Education. Similar to many other health professional\ngroups, the training of optometrists does not cease upon graduation.\nMost States require that optometrists, as well as other health pro-\nfessionals which are licensed, continually upgrade their skills.\nFor the few States without formal requirements, a number of State\noptometric associations have instituted a system of continuing\neducation requirements for membership purposes. Currently, forty-\nthree states require continuing education for license renewal by\noptometrists.\nContinuing optometric education courses are offered by over 100\nagencies, including the 51 State associations affiliated with the\nAmerican Optometric Association. It is estimated by the Associa-\ntion that between 17,000 and 18,000 licensed optometrists have and\nwill continue to participate in continuing education courses.\nCurrently, the Council of Academic Affairs of ASCO is developing a\nproposal to study the feasibility of conducting an organized and\nstructured national program of continuing education for practicing\noptometrists, using existing schools and colleges as a base for\nsuch training. This development is consistent with overall\nFORD & LIBRARY GERALD\n30\nendeavors of the profession continually to upgrade and make uni-\nform its respective educational programs. (Detailed documentation\non the existing content and overall nature of continuing education\nofferings is provided in Part II of this report. )\nOther State Developments. Apart from the above discussion, other\nindicators of professional competence can be suggested. For example,\noptometrists are increasingly being included in various health\ncare programs. A 1975 Kansas statute allows nonprofit corporations\nto be created specifically to provide group optometric care pro-\ngrams. In 1974, California included optometrists in prepaid health\nplans. In 1975, Rhode Island included services by optometrists in\nits State catastrophic health insurance program. In 1974, Maryland\nincluded services of optometrists in group health insurance policies.\nAnd, in 1973, Colorado added optometry to services which certain\ncorporations may make available to health benefit subscribers. The\nfact that optometric services have been included for reimburse-\nment purposes in many State Medicaid programs has been noted earlier.\nOptometrists appear to be infrequently subject to malpractice suits,\nin part reflected by the existing insurance premium for optometrists\n(i.e., $280.00 per year). Suits have been brought, however, and\nstudy staff examined cases available to shed further light on the\nquestion of professional competence. A number of courts have em-\nphasized that diagnostic services, specifically, are within the\nrealm of the optometrists' professional competence. In approxi-\nmately ten decisions examined, all cases emphasized this role in-\ndicating that optometric competence included the ability to dis-\ncover, detect. and/or recognize eye disease.\nAmong recent developments in State Practice Acts, several statutes\nhave revised the definition or scope of practice of optometrists,\nraising reasonable inferences concerning professional competence.\nIn 1974, Wisconsin construed the meaning of \"physicians\" to include\noptometrists in all accident and sickness policies. New York, in\n1974, included optometrists with other professionals who receive\nlegal immunity for service on utilization review committees.\nCalifornia law now indicates that in determining whether an indivi-\ndual is blind, the patient may be examined either by a physician\nskilled in diseases of the eye or by an optometrist.\nReferral Patterns and Provider Relationships. Studies of referral\npractices of private practitioners would, if adequately conducted,\nlikely provide valuable insight into the extent to which optometrists,\nas well as certain other health care providers, are able to detect\ndispositions. Although studies have been undertaken in this area,\nmarked variations tend to exist in comprehensiveness, quality, and\noverall objectivity. (The reader is ferred to Part II for detailed\ndiscussion on studies examined during this study effort.)\nFORD\nGERALD\nLIBRARY\n31\nEthical standards within the optometric profession speak directly\nto the responsibilities of optometrists to refer patients to other\nproviders of vision/eye care services where appropriate. Ten of\nthe States expressly require by statute or regulation that an opto-\nmetrist refer patients in need of other professional care to the\nappropriate practitioner.\nReferral rates from optometrists to physicians typically may be\nhigher in organized settings than in the independent setting. A\nnumber of studies examined during the course of this study indi-\ncated that between two and three percent of patients examined by\noptometrists in independent settings require referral to a physi-\ncian; within the military setting, in contrast, referral rates\nranged between three and seven percent of the patients seen. A\n1968 study of vision care within the Kaiser-Permanente prepaid\ncare plan in the Los Angeles area, however, indicated that 2.75\npercent of the patients seeing an optometrist were referred to\nophthalmologists.\nThe collective judgement of the study advisors was that working\nrelationships between providers in the vision/eye care arens are\nquite good and constructive. Although documentation on relation-\nships between respective practitioner groups are generally lacking,\nstudy staff were able to uncover a recent effort that specifically\nsurveyed physicians about their relationships with optometry. This\nparticular effort was quite supportive of the viewpoint expressed\nby study advisors.\nTonometry, A Case in Point. The provision of vision/eye care\nservices raises controversial issues within the provider community\nconcerning what services and procedures shouls be undertaken, re-\nspective levels of effectiveness of such services and procedures,\nand what types of specific manpower group should be engaged in\nthese functions. For example, tonometry is a relatively simple\nprocess used for the determination of intraocular pressure and the\ndetection/diagnosis of glaucoma. In some clinic and group practice\nsettings, tonometry is only undertaken by ophthalmologists; in a\nnumber of others, by any doctor of medicine. In other instances,\noptometrists do tonometry, and in what appears to be an increasing\nnumber of cases, technicians are being trained to undertake this\nprocedure.\nThe Department of Medicine and Surgery of Harvard Medical School,\nin a 1974 study, found justification for glaucoma screening by\ntechnicians in medical and ophthalmology clinics for all patients\nGERALD FORD LIBRARY\n32\n40 years or more of age. Elsewhere, however, professional judge-\nments have been documented that, at least for patients with vision\ncomplaints, tonometry should be a routine part of the optometric\nexamination for younger patients and for all adults.\nSuch disagreement within the provider community extends beyond\ntonometry and glaucoma to other services and respective abnormali-\nties of the eye. Although this area lacks adeauate documentation\nto resolve controversy, a number of inferences can reasonably be\ndrawn for relevance to this study effort.\nFirst, the detection of cataract and/or aphakia is essentially an\nuncomplicated process. Optometrists, as well as ophthalmologists,\nare qualified to carry out requisite diagnostic services. Second,\nmany of the functions and procedures in dispute are being under-\ntaken currently by optometrists. The primary care role outlined\nearlier for optometrists in organized settings, for example,\nspeaks to the capabilities of the profession to effectively under-\ntake such functions.\nAlthough legal constraints exist in most State jurisdictions con-\ncerning the use of topical drugs by optometrists, this issue re-\nlates more to potential limiting factors in optometric capabili-\nties rather than to questions of professional competence. Despite\nsuch constraints, suitable instrumentation and procedures afford-\ning quality performance are identified by the clinical standards\ncommittees of professional associations and are available for\ndiagnostic purposes.\nOverall, agreement exists within the provider community that the\nbroad range of services identified earlier in this report does\nrepresent reasonable and necessary vision/eye care services, and\nconstitutes safe and non-experimental practice. The evidence\navailable to attest to the professional competence of optometry is\npersuasive for one to conclude that the quality of such services\nis not compromised when provided by optometry.\nQuality Control\nThe development of standards of care for diagnostic, therapeutic,\nand consultative services provided by vision/eye care practitioners\ngenerally, and including optometrists specifically, does appear\nfeasible in both organized and independent health care settings.\nSuch standards do currently exist in a number of individual situa-\ntions or are in various stages of development. As such, quality\nassurance is attainable in the provision of reasonable, safe,\nnon-experimental, and acceptable services by optometrists to the\nMedicare eligible population.\nGERALD\nLIBRARY\n33\nCriteria and methodologies for performing review of the quality of\noptometric practice under the aegis of Professional Standards\nReview Organizations (PSRO) are just beginning to be developed.\nThe concepts of peer review utilizing explicit criteria basic to\nthe PSRO program are applicable to review of optometry practice in\nthe ambulatory care settings, even though PSRO emphasis is currently\non the review of inpatient care services. The optometry profession\nrecognizes its obligation for leadership in the development and on-\ngoing refinement of quality measurements.\nCost Considerations\nWidespread interest exists in seeking ways to make the health care\ndelivery system more effective and efficient. Apart from consider-\nations of patient needs, provider qualifications, and access con-\ncerns, attention in the study was also directed to the potential\ncost implications of an alteration in Medicare coverage. It is\nreasonable to infer that an extension of current Medicare cover-\nage to include services related to aphakic and cataract conditions\nwhen provided by optometrists would result in some added costs to\nthe Medicare program. Rough calculations suggest, however, that\nsuch added costs (i.e., between two and five million dollars)\nwould not be significant in the context of overall Medicare costs\nfor vision/eye care services.\nAn uncertain cost effect results from any increase in cataract\nsurgery rates that might occur given the change assumed in the\nanalysis for reimbursement. Expert advisors to the study viewed\nthe likelihood of such increased rates as negligible. Nonethe-\nless, it should be noted that, for every additional operation\nthat might occur for Medicare eligible patients, Medicare program\ncosts would rise by roughly $1,500.\nIt has been suggested, furthermore, that such an extension of\ncoverage might change the nature of optometric practice suffici-\nently to raise the cost of malpractice insurance for optometrists.\nStudy staff did not have an opportunity to examine this matter in\ndetail; although a number of factors suggest such an occurrence\nto be highly unlikely. First, the elderly represent a small\nfraction of optometric practice and cataract services represent a\nstill smaller proportion. Second, optometrists would obviously\nnot be performing surgery, the major source of malpractice claims.\nThird, in areas where Medicaid has extended coverage and reimburse-\nment to optometric services, there is no evidence that malpractice\npremiums have changed significantly.\nGERALD FORD LIBRARY\n34\nBroader Concerns and Review\nThe material assembled and examined in the study effort, as out-\nlined above, is highly supportive of recommendations to extend\ncoverage for currently covered services under Part B of Medicare\nto include diagnostic, consultative, and therapeutic services re-\nlated to aphakic and cataract conditions when provided by optome-\ntrists. Considerations of particular relevance include patient\nneeds, qualifications of optometrists to render effective and\nnecessary services, and concerns in assuring equitable access to\nrequisite services by the Medicare eligible population.\nMuch of the information reviewed pertains to vision/eye care\nservices generally, rather than to services related to aphakic and\ncataract patients specifically. In part, this situation reflects\nthe available level of specificity in existing documentation. To\nsome extent, however, such as is the case with cataract patients,\na number of vision/eye care services are not disease specific and\nextend equally to circumstances where different eye disorders may\nbe presented.\nIn inference arises from this last observation that it may be ap-\npropriate to consider a broader scope of inquiry regarding the\nprovision of vision/eye care services and Medicare coverage. This\nstudy effort, however, did not provide an opportunity to consider\nsuch a broader concern in any detail.\nGERALD FORD LIBRARY\n35\nPART II\nDetailed staff contributions to this study\neffort are provided in this second part of\nthe report. Specific sections include\ndiscussions concerning cataract conditions\nand aphakia; State law and optometric\npractice; optometric education; access\nconsiderations; and potential cost impli-\ncations of altering current reimbursement ement\nunder Medicare Part B.\nBERAL FORD LIBRARY\n36\nSECTION II-A\nNATURE, INCIDENCE AND PREVALENCE OF CATARACTS\nCompiled by\nNathan Watzman, Ph.D. *\nA cataract is an opacity of the crystalline lens of the eye. For\nthe purposes of this paper, a clinically significant cataract is\ndefined as an opacity of the lens that reduces visual acuity\n(sharpness of vision) and may be functionally disabling or dis-\nruptive of the normal life style, more particularly for near or\ndistant vision, e.g. reading or driving. The most effective treat-\nment of cataract is the surgical extraction of the opaque lens.\nThis results in the condition of aphakia (the absence of the\ncrystalline lens).\nThe lens is one of the most unique tissues in the body. It is a\npowerful refracting organ of the visual system, transparent and\nwithout a blood supply.- It is also unique for another reason:\ncells in other parts of the body are constantly being broken down\n(catabolism) and rebuilt (anabolism). Yet in the lens there is no\napparent protein synthesis or cell machinery present to maintain\nthe protein. It is, therefore, interesting that protein synthesized\nduring the embryonic period remains the same for sixty or more\nyears throughtout the life of an individual and still the lens\nremains transparent. 1/ As one progresses through life, however,\ninternal and external factors can impinge upon the lens to cause\nin it's transparency. For example, normal physiological changes\nin protein content of this structure will bring on changes in\ntransparency.\nThe refractive power of the lens depends upon its curvature (variable\nin the young eye), its refractive index (a function of its compo-\nsition), and its location. Cataracts usually affect vision by\naltering the refractive index more than by change in size or\nlocation of the lens and by the resultant opacity blocking the\npassage of light to the retina.\nSymptoms of Cataract\nThe visual symptoms of cataracts usually consist of a slowly pro-\ngressive, painless decrease in visual acuity while some patients\n*Acting Associate Director for Regional Programs, Division of\nAssociated Health Professions, Bureau of Health Manpower, Health\nResources Administration, DHEW.\nGERALD\nLIBRARY\n37\nexperience a rapid loss of acuity over a period of months, weeks\nor even days. Visual function will vary according to the location\nof the opacity in the lens. For example, if the opacity is diffuse,\nthe haze will be constant, both indoors and out, and may be some-\nwhat worse in bright light. If the opacity is confined to the\nfront area of the lens, the individual will experience a \"glare\",\nespecially outdoors or in intense light (which brings the pupil\ndown over the opacity and cuts down the vision) This person may\nfunction normally in a house or dim light, but be \"blind\" outdoors.\nIf the center or nucleus of the lens is opaque, there will be a\nconstant haze and the individual will feel like he is looking\nthrough a \"dirty window\". The patient may be visually limited\n(blur, glare, distortion) in the tasks of driving and reading to\nthe point that he/she is disabled in his/her every day life style\nor handicapped in the performance of his/her occupation.\nIt should be noted that a characteristic common to elderly patients\nwith cataracts is the renewed ability to read news print without\nglasses, in spite of a decrease in distance acuity. This so called\n\"second sight\" is due to a slow progression of nuclear sclerosis\nand acquired myopia (nearsightedness) 2/ related to swelling of the\nlens, an early diagnostic sign of cataract usually preceding opacifi-\ncation.\nReduced color vision in cataract patients is not common because\ndiscrimination of color changes very gradually. However, a\n\"yellowing\" of vision is frequently experienced because the shorter\nwave lengths of the visual spectrum (violet and blue) are select-\nively absorbed and the longer yellow and red wave lengths are\ntransmitted.\nIt should be noted that cataract can be associated with nearsighted-\nness which is attributable to nuclear sclerosis or farsightedness\nwhen the cortex is affected disproportionately. In either circum-\nstance, areas of the lens with different refractive indexes can\ncause a beam splitting effect which results in projection of two\nimages on the retina. Thus, there is monocular diplopia (double\nvision) ; where present, it is usually related to early stages of\ncataract.\nIt is important to emphasize that cataracts can cause almost the\nfull spectrum of loss of vision ranging from a very mild impair-\nment to a severe degree of impairment characterized by minimal\nlight perception and poor appreciation of the direction from which\nlight enters the eye. Cataracts alone, however, are not respon-\nsible for total blindness , but, surely account for a substantial\nproportion of legal blindness.\nFormation of Cataracts\nThe formation of a cataract is a highly complicated physico-chemical\nLIBRAR\n38\nprocess, whether it be a result of normal physiological aging,\nexternal physical insult, or internal metabolic changes. Two major\nelements appear to be implicated in the generation of lenticular\nopacities, namely, the water content and nature of the protein\nwithin the lens. Relative to the first element, one important\nmechanism in maintaining the viability of the lens is the capacity\nof the electrolyte pump to maintain a normal state of hydration\n(water content). As long as a normal equilibrium between the\nintraocular fluids outside the lens and the fluids within the lens\ncan be maintained in terms of sodium and potassium ion content,\nthe lens will remain normal. If on the other hand, an imbalance\noccurs in the pump equilibrium system, causing the lens membrane\nto leak, high levels of water-retentive sodium will move into the\nlens from the intraocular fluids causing osmotic swelling which is\na common feature of many cataracts 3,4/ The other important\nmechanism of cataract formation is related to the relative concen-\ntrations of soluble and insoluble protein within the lens. The\nnormal lens has a water content of approximately 65% and a protein\ncontent of about 35%.3/ As the lens ages, there is a decrease in\nwater content, and more and more of the soluble protein becomes\ninsoluble. Increases in concentration of insoluble protein are\nrelated to the development of cataracts 3/ Also associated with\nand probably directly related to the changing character of lens\nprotein (increase in insoluble and decrease in soluble protein)\nis a progressive hardening of the lens which usually becomes\nclinically manifest after age 40.2/ Thus, some loss of transparency\nof the lens with age is as inevitable as the wrinkling of the skin\nand greying of the hair. For an excellent review of the more\nrecent biochemical studies on lens protein and enzymes, lens lipids,\nwater balance in the lens, etc., the reader is referred to an\narticle by Kirsch 3/ and a symposium entitled \"The Human Lens In\nRelation to Cataract\" 5/\nClassification of Cataracts\nWhile the physico-chemical processes involved in the formation of\na cataract are fairly well delineated, the etiology or causes\ninitiating the aforementioned sequence of events leading to a\ncataract are not clear. However, studies- 67 of the close asso-\nciation of cataracts with systemic, hereditary and metabolic\ndiseases as well as externally-induced chemical and physical agents,\nprovide a great deal of insight into the possible causes of cataracts.\nOne of the preferred classification of cataracts is based upon\nthe above considerations:\nNote: For vision terminology, see \"Current Optometric Information\nand Terminology\" 35/\nLIBRARY\n39\nA. Primary\n1. Senile (Senescent)\n2. Congenital\nB. Secondary\n1. Metabolic\n2. Endocrine\n3. Inflammatory\n4. Toxic-chemical agents\n5. Traumatic-physical injury\nThe word senile (more appropriately senescent) is commonly used in\nassociation with primary cataracts developing in older persons.\nNinety percent of all cataracts are of the senescent type which\nno demonstrable etiology The only relevant history may be that\nof a familial occurrence. Nevertheless, there may be some under-\nlying factor which may aggravate the development of this type of\ncataract. For example, approximately 10% of patients with\nsenescent cataracts have overt 27 diabetes mellitus. Other patients\nhave a history of glaucoma.\nThe mature senescent cataract is seen as a diffusely opaque lens\nthat is usually white from complete cortical opacification. A\nyellow nucleus is often detectable and in some cases the entire lens\nis brown or even black in color 2/\nA large variety of congenital lens opacities exists buy may not\ncause visual impairment Virus damage from maternal rubella is\ncommon; many cases of rubella catarcts were diagnosed during the\nAmerican rubella epidemic of 1963-1964 3/ Congenital cataracts\nare also a prominant feature of a number of multiple congenital\ndisease syndromes 3/ such as the oculo-cerebro-renal syndrome of\nLowe, Werner's syndrome (premature aging) and a host of others 2/\nCataracts have also been associated with inborn errors of meta-\nbolism involving genetic enzyme deficiencies. Examples are:\ndiabetes mellitus and galactosemia as well as syndromes with iden-\ntified chromosomal abnormalities such as mongolism and dwarfism. 2/\nFor a more complete discussion and insight into the etiology of\ncataracts, including the congenital type, the reader is referred\nto Harley 8/ and Table A Evidence seems to indicate that con-\ngenital (infantile) cataract is not a single disease but a part\nof a disease affecting other systems and caused by different\nfactors\n9/\nLens damage may be caused by metabolic disturbances such as\nmaternal or 7/ infantile bypocalcemia, galactosemia, and diabetes\nmellitus.\nDiabetes mellitus was the first metabolic disorder\ndnown to be associated with cataract formation. This disease is\nnow one of the leading causes of blindness in the United States\n40\nTABLE A\nA Practical Classification of Cataracts\nI. Congenital (Present at Birth)\nA. Genetic origin\n1. Congenital cataracts without other abnormalities (autosomal dominant, autosomal\nrecessive, sporadic, rarely sex-linked); many morphologic varieties such as nuclear,\nzonular, mature\n2. Lens opacities without visual impairment such as Mittendorf dot, anterior polar\n\"cataracts,\" sutural \"cataracts\"\nB. Maternal origin\n1. Secondary to maternal infections, e.g., rubella, syphilis\n2. Secondary to amniocentesis\nII. Infantile or Juvenile Onset (Genetic Origin)\nA. Inborn errors of metabolism, e.g., diabetes mellitus, galactosemia, hyperlysinemia,\nhomocystinuria, hepatolenticular degeneration (Wilson's disease), oculocerebrorenal\n(Lowe's) syndrome\nB. Syndromes with identified chromosomal abnormalities, e.3., trisomy of chromosome 21\n(mongolism, Down's syndrome), monosomy of X chromosome (Turner's syndrome),\ntrisomy of chromosome 13 (Patau's syndrome)\nC. Syndromes of unknown etiology, e.g., familial craniofacial dysostosis, heredofamilial\natrophic dermatoses (Rothmund's syndrome), muscular dystrophy,\nidiopathic hypoparathyroidism\nD. Various ocular syndromes, e.g., persistent hyperplastic primary vitreous, Rieger's\nanomaly, aniridia, microphthalmia, retinitis pigmentosa\nIII. Late Onset (Senescent Type)\nA. Without associated familial or acquired disease\nB. With contributory factors such as diabetes mellitus, familial incidence, ocular trauma,\nglaucoma, intraocular surgery, Paget's disease of bone\nIV. Secondary\nA. Directly related to acquired systemic disorders, e.g., tetany (hypocalcemia),\nstarvation, aortic arch syndrome\nB. Related to acquired ocular disease\n1. Inflammatory, neoplastic, e.g., heterochromic iridocyclitis, intraocular neoplasms\n2. Physical trauma and physical agents, e.g., blunt injuries, perforating injuries,\nradiation (atomic, infrared), electric shock (lightning)\nC. Secondary to local or systemic chemical agents, e.g., steroid therapy, chlorpromazine,\nergot, dinitrophenol, thallium, intraocular deposition of iron (siderosis) or\ncopper (chalcosis)\n41\nand over 50% of the visual loss is due to abnormalities of the lens\nor retina\n10/\nTypical diabetic cataracts usually develop in\npatients with severe, prolonged, poorly controlled diabetes. They\nmay be seen as early as seven years of age but most commonly in the\nadvanced years.\nExamples of endocrine diseases that are associated with cataracts\nare hypothyroidism and hypoparathyroidism. 3/\nInflammatory diseases of the interior of the eye may lead to the\ndevelopment of a lens opacity. Acute and chronic iridocyclitis\nwith synechia formation (adhesions of the iris to the anterior\ncapsule of the lens) may severly compromise the clarity of the lens.\nChronic uveitis and vitritis frequently leads to posterior capsular\nopacity and may be referred to as cataracta complicata. At times,\nthe entire lens may become opaque in association with chronic uveitis.\nThe literature documents many agents that will provide chemical\ninsult upon the lens to produce a toxic cataract 10/\nCorto-\ncosteroids administered systemically or topically, naphthalene,\nparadichlorobenzol, ergot alkaloids, oral contraceptives, miotics,\nand the tranquilizer, chlorpromazine are but a few of the many\nexamples.\nThe exposed eye ball is extremely valnerable to flying objects and\nparticles which may cause severe injury. High velocity particles\nstriking the head may injure the eye via transmission of kinetic\nenergy from the point of impact in the head or face to the eye. 10/\nPenetrating injuries more commonly enter the eye through the cornea\nthan through the sclera. Violation of the lens capsule by a flying\nchip of steel penetrating the eye will admit fluid into the lens,\ndisrupt metabolism and result in cataract. Rupture of the eye\nball may also follow injury by an explosive blast which causes an\nenormous increase in the atmospheric pressure. Traumatic cataract\nis encountered more frequently in military men, particularly during\nwar, as well as men engaged in hazardous industrial occupations.\nBlows to the eye while participating in active sports--boxing,\ngolf, tennis, and skiing may also produce cataracts. Thus, traumatic\ncataracts may be caused by three types of physical insult: blunt\ninjuries with or without rupture of the lens capsule, explosive\nblasts, and penetrating injuries of the globe.\nDetection Procedures\nThe objective means of clinically determining the existence of a\ncataract involves the use of the ophthalmoscope, retinoscope, and\nslit-lamp biomicroscope 11/ The objective sign of cataract is,\nof course, the presence of opacities in the lens. While an\nadvanced cataract is readily detected with simple instrumentation,\na more accurate assessment of early opacities is made by transmitted\nGERALD FORD LIBRARY\n42\nlight when opacities, obstructing the light reflected from the\nfundus (back of the eye) appear black in the pupillary reflex.\nAccurate information can also be obtained by direct observation,\nusing local illumination of the ophthalmoscope or biomicroscope\nslit-lamp. The objective clinical examination is, therefore,\nmost satisfactorily started by observing the fundue reflex with\nthe ophthalmoscope or retinoscope, at first, at a distance 117 of\nabout one third of a meter and then with a +20 D lens.\nDobree\n12/ recommends use of the ophthalmoscope with a +10 D to\n+8 D lens to obtain accurate information as to position, form\nand nature of lens changes. For the best view of the interior of\nthe eye, such an examination should be done with a widely dilated\npupil. One can also assess the integrity of the retina at the\nsame time. The use of an indirect ophthalmoscope is particularly\nuseful in studing the periphery of the retina. Examination with\nthe slit-lamp, however, provides information of even more value,\nsince it permits a detailed microscopic view of the lens by direct\nor transmitted light and by indirect lateral illumination by\nwhich fine changes and vacuoles can be detected. By its means,\nnot only can an accurate knowledge of the type and form of any\nopacity be gained but it reveals the density of any opacity.\nPathological changes can be accurately localized topographically\nin the cortex as well as in the nucleus of the lens. Most\nimportantly, the optical significance of the opacity can also be\nobjectively evaluated.\nComplications of Cataract Surgery\nAbout 5% of cataract extractions have significant complications\nduring or soon after the operation but most can be managed satis-\nfactorily and good vision obtained 2/ Poor vision following\ncataract extraction is usually the result of unrelated degenerative\nchanges such as macular disease, corneal dystrophy or glaucoma.\nThe macula is a small yellowish area of the retina containing the\nfovea centralis, the region of most acute vision. 13/ In the\npresence of cataract, it is not always possible to accurately\nevaluate the functioning of the macular prior to surgery.\nSome complications of cataract surgery are: vitreous loss, intra-\nocular hemorrhage, cystoid maculopathy, shallow anterior chamber,\nintraocular infection (e.g. endophthalmitis), Elschnig pearls,\nretinal detachment, glaucoma, corneal decompensation, would\nrupture, posterior capsule opacification, uveitis, vascular occlusion,\nhyphema, vitritis, optic atrophy, changes in astigmatism, and dis-\nlocation of intraocular lenses. Only some of the more frequent\ncomplications will be discussed.\nVitreous loss is the most undesirable of the common complications\noccurring at the time of surgery. The vitreous humor is a gel-\nlike substance which bathes the lens and occupies a large portion\nGERALD FORD LIBRARY\n43\nof the intraglobal space. If drawn into the anterior chamber of\nthe eye, it will transmit traction into the retina increasing the\npossibility of retinal detachment. Just as important, vitreous\nwhich migrates to the anterior chamber after cataract extraction\ncan come in contact with the posterior surface of the cornea and\ndamage the endothelial cells producing an intractable corneal\nedema. Vitreous loss does occur in 2 to 4 percent of cases in\nspite of all operative measures to avoid vitreous disturbances\nat the time of surgery 2/\nIntraocular hemorrhage, another complication, may arise from the\niris, the wound, but only rarely from the posterior segment of the\neye. The latter is of major significance because bleeding from\nthat area can cause an outflow of intraocular contents at the time\nof cataract extraction. Hemorrhaging from the iris or wound is\nusually self limiting and manageable. /\nCystoid maculopathy is a fairly common complication characterized\nby onset of macular edema in the early weeks following cataract\nextraction. This condition occurs with greater frequency follow-\ning vitreous loss, in blue-eyed individuals, and in patients with\npost-operative inflammation of the anterior segment. Vision may\nbe reduced as low as 20/200. The condition is most readily diag-\nnosed by fluoroscein angiography which reveals a typical stellate\nappearance of leaking dye at the macula or by measurement of\nelevation with the slit-lamp and Hruby or Goldmann lens. The\ncondition is usually considered self-limiting.\n2/\nA shallow anterior chamber usually results from wound leakage in\nthe early post-operative period. Permanent damage to the eye does\nnot result if management is appropriate and prompt. Less frequently,\nshallowing of the anterior chamber is a result of spontaneous\nhemorrhage of the choroid. This fluid accummulation leads to a\nmarked displacement of both choroid and retina and to detachment\nof the ciliary body. Usually, however, the fluid is reabsorbed\nand there are no lasting effects. Pupillary block glaucoma is\nstill another cause of a shallow anterior chamber following\ncataract extraction. The pupil becomes occluded by formed vitreous\nbut the pressure can be relieved by a surgical procedure.\nPost-operative intraocular infection occurs in approximately 1 or 2\npatients per five thousand operations, usually within a day or two\npost-operatively 2/ A diagnosis is suspected by the occurrence of\nocular pain, lid swelling, and increase redness of the globe. Slit-\nlamp examination reveals inflammatory cells in both the anterior\nchamber and the vitreous. Because prompt control of the infection\nis mandatory, the aqueous should be aspirated and bacteriologically\ncultured. Appropriate broad spectrum antibiotics should be pre-\nscribed until culture reports and sensitivity studies are avail-\nable.\nBERALD FORD LIBRARY\n44\nElschnig Pearls appear as small translucent vacuoles arranged in\nclusters following surgery. They are remnants of lens epithelium\nwhich remain in the eye following incomplete extracapsular cataract\n2/\nsurgery\nThe incidence of retinal detachment following surgery for acquired\ncataracts is reported to be approximately 2% 14, The average\ninterval between cataract surgery and the development of the retinal\ndetachment has been reported as 33.3 years 15/ Routine examination\nof the retina through a dilated pupil is highly desirable on an\nannual basis for the remainder of the patient's life.\nGlaucoma in the aphakic eye may have pre-existed, may develop\nde novo as primary open angle glaucoma following uncomplicated\ncataract extraction, or may result as a surgical complication. The\nvarious causes of aphakic glaucoma and their treatment are summa-\nrized by Francois 16/ The latter type of glaucoma mentioned above\nis termed aphakic obstructive glaucoma and is usually due to the\nblockage of the normal circulation of aqueous humor, resulting in\ninflammation and angle obstruction. For the aphakic patient, the\nrefractive error, particularly astigmatism, may change signif-\ncantly, post-operatively. Such changes will affect the visual\nacuity of the patient and may require modification of his/her\nprosthesis.\nIncidence and Prevalence\nThe actual extent of the problem of cataract and aphakia in this\ncountry is not clear from the data available. There is no known\nreport of the numbers of individuals who have cataracts and have\nnot sought professional services or who have had cataracts diag-\nnosed and have not had surgery.\nIt is, however, clear from the data available, both published and\nunpublished, that cataracts are a condition, most predominantly,\nof the elderly and a result of the normal physiological aging\nprocess. Congenital, metabolic, endocrine and toxic cataracts do\nnot occur with the frequency to be epidemiologically significant.\nSenile (senescent) cataracts, on the other hand, account for\napproximately 90% of all of the documented cases 2/\nData that is available on the incidence and prevalence of cataract\nprovides some general idea about the magnitude of the problem.\nThe National Ambulatory Medical Care Survey (1973) 17/ indicates\nthat 2,723,000 visits were made to physicians' office for cataract\n(primary diagnosis) for the period May 1973 to April 1974. During\nthe same period of time, 4,400,000 visits were made in which\ncataract was only one of the diagnoses 18 While there is no\ndocumented data on the incidence and prevalence of aphakia, it is\nFORD & LIBRARY GERALD\n45\nestimated that approximately 1,000,000 visits were made for aphakia\nduring the same period of time.\n18\nData on cataracts from the Health Interview Survey (1971)\n19/\nindicates a prevalence of about three million persons which is\nequivalent to 14.9 cases per 1,000 persons. It also reported that\napproximately 2,764,000 individuals or 13.7 per 1,000 persons had\nvisual impairments resulting from cataract. This is equivalent\nto about 1.5 cases of all ages per one hundred people in the\nUnited States. The following table (Table B below) 18/\nprovides\nthe prevalence data by age grouping:\nTABLE B\nPrevalence of Cataract and Number of Cases Per 100 People\nAge\nNo. of Cataracts\nNo. per 100 People\nUnder 17\n17-44\n197,000\n0.3\n45-64\n565,000\n1.4\n65+\n2,212,000\n11.4\nUnpublished data from the National Eye Institute\n20/\nindicate:\nthat there is estimated to be about 912,000 new cases of cataracts\nper year, based upon first visits to physicians, exclusive of\nreferrals. About three fourths of these were first diagnosed at\nages 65 and over. The incidence for women is considerably higher\nthan for men. In addition, there were estimated to be approxi-\nmately 332,000 cataract surgeries performed in 1972. The only\ndata (Table C below) available, indicating the number of cataract\nsurgeries by age grouping, 217 is that obtained from short-stay\nhospitals in 1972.\nTABLE C\nEstimated number of cataract operations in short stay hospitals\nby age. U.S. 1972\nAge\nEst. No. Cataract Operations*\n10-29\n3,000\n30-39\n3,000\n40-49\n9,000\n50-59\n30,000\n60-69\n64,000\n70-79\n90,000\n80+\n42,000\nTotal\n241,000\n* first listed diagnosis of cataract in combination with lens\nextraction.\nFORD & LIBRARY GERALD\n46\nTable D provides incidence and prevalence data for blindness by\nage groupings. It is clear from all of the data shown above\nthat the extent of the problem of cataracts is greatly magnified\nwith advancing age and becomes a socio-economic health problem\nof national significance.\nTABLE D\nPROJECTION OF CATARACT BLINDNESS IN L1975 BY AGE\nAge\nNewly blind from cataract\nBlind from cataract\nGroup\nrate/100,000\nMinimum\nrate/100,000 Minimum\nNumber\nNumber\n(Incidence)\n(Prevalence)\n5\n.9\n143\n1.9\n302\n5-19\n.7\n411\n6.4\n3758\n20-44\n.4\n290\n8.2\n5951\n45-64\n3.5\n1524\n23.0\n10015\n65-74\n4.9\n680\n52.6\n7208\n75-84\n14.0\n931\n128.4\n8539\n85+\n40.8\n766\n492.2\n9239\n-\nEstimated Total\n4745 or 4700\n45,102 or 45,000\n1/ Age specific rates/100,000 of all additions to registers, 14 MRA\nstates, average 1969 and 1970 in Kahn, H.A. and Moorhead, H.B:\nStatistics on Blindness in the Model Reporting Area, 1969-1970.\nDHEW Publication No. (NIH) 73-927, U.S. Government Printing\nOffice, 1973.\n2/ Number resulted from applying the incidence or prevalence rate\nto the July 1975 resident population in the United States.\nPopulation estimates are from: Current Population Reports.\nPopulation estimates and Projections, Bureau of the Census.\nSeries P-25 No. 614, November 1975.\n3/ Age specific rates/100,000 of persons on register, 14 MRA States,\nDec. 31, 1970 in Kahn, H.A. and Moorhead, H.B: Statistics on\nBlindness in the Model Reporting Area, 196901970. DHEW\nPublication No. (NIH) 73-927, U.S. Government Printing Office,\n1973.\nFORD is LIBRARY GERALD\n47\nAphakia\nAphakia is defined as the absence of the lens of the eye.\nRemoval of the lens renders it highly hyperopic (requiring a\nstrong convex lens) and without accommodation. One fourth of the\nnormal static power of 60 diopters is lost and the refractive\nsystem is reduced only to the refractive power of the cornea.\nSome degree of astigmatism is always present after cataract\nextraction 22/\nOptical Correction of Aphakia\nOne of the great causes of disappointment to a patient following\nsurgery is the unexpectedly poor vision without glasses and\ndistortion of vision with glasses which may occur after cataract\nsurgery. The spectacle lenses required for the compensation of\nthe removal of the eye lens are of high power. Such lenses create\nsubstantial magnification and distortion which results in spacial\ndisorientation for the patient. Since the retinal image is\nmagnified, the patient feels that all his surroundings are crowded\non top of him. Spherical aberration in the spectacle lens causes\nflat surfaces to appear curved; 23, peripherally, lines are dis-\ntorted, \"blind\" zones are present and there is a reduction in\npanoramic vision. In addition, there may be colored fringes\naround everything seen and if only one eye is being used, a serious\ndisturbance of depth perception will be present. During the early\npost-operative period, the patient continuously finds himself\nreaching short of objectives and stepping too high for stairs well\nbelow his feet. As a result, care has to be taken in negotiating\ncurbs and in going up and down stairs. Fortunately, with adapt-\nation, these distortions become less noticeable, but in a few\ncases, the difficulty persists for a year or longer. It is not\nan easy period for the young and it may be a hazardous time for\nthe aged. For many patients, the post-operative period is\nparticularly challenging. It is thus imperative that, prior to\nsurgery, the patient fully understands the effects that cataract\nextraction will have on his vision. 2/\nMonocular aphakia occurs when a cataract operation is performed\non one eye only and in this case, either the operated or unoperated\neye may be used, but the two eyes can no longer function together\nusing eye glass correction for the aphakic eye. This situation\noccurs because the retinal image as seen through an eye glass lens\nin front of an aphakic eye is usually about 25% larger than the\nimage on the retina of the normal eye. The brain simply can not\nfuse two such vastly different images together (double vision).\nIf a contact lens is used, however, the discrepancy in image size\nbetween the operated eye and the normal eye is limited to\napproximately 2 8% and therefore, single binocular vision is\npossible.\nGERALD FORD LIBRARY\n48\nCorrection of refractive errors in aphakic patients is usually\ndone by either eye glasses, contact lens or the new implanted\nintraocular lens.\nGenerally speaking, optical correction of aphakia usually begins\nwithin a day or two after surgery, utilizing temporary eye glass\ncorrection. A final permanent prescription is not given until\ntwo to three months and sometimes longer after the extraction\n2/\nRarely are contact lenses prescribed before six weeks following\nsurgery. However, there are several varieties of soft, hydro-\nphilic contact lens now available which are prescribed early in\nthe post-operative period 2/\nFor the purpose of this paper, only spectacles and contact lenses\nwill be discussed since optometrists in their practice do not\nutilize intraocular implants which involve a surgical skill.\nVarious lenses have been advocated to solve problems of aphakic\ncorrection. Regardless of type, the severity of visual difficulties\nhas been reduced, to some extent, by improved lens grinding\ntechniques.\nSpectacle lenses have inherent optical defects which are not\nappreciated by individuals that wear glasses in the power range\nof + or -3 diopters (vast majority of patients) 24/ The four\ncomponents of false orientation in aphakic spectacles are: false\ndepth, false projection, swim and distortion 24/ It should be\nnoted that modern light-weight, aspheric, plastic eyeglass lenses\nare superior to the heavy glass lenses of the past.\nWhile lenticular, aspheric spectacle lenses have been utilized in\nthe past, corneal contact lenses are being used more as improve-\nment occurs in contact lens material and fitting. Development of\nlenticular cut types of corneal contact lens has greatly enhanced\nfitting of aphakic patients because they rest on the eye ball,\nform part of the optical system, and move with the eye; with\nspectacles, however, the lens are situated in air at a distance\nfrom the eye and are immoveable with relation to the eye globe 22/\nThe literature abounds with articles on the use of contact lenses\nfor aphakia 25-32/ In bilateral aphakia, one study33/ reported\nsuccess in 200 cases with continuous use of tiny, hard corneal\nlenses.\nIn the case of monocular aphakia, where the other eye has good\nvision, the treatment of choice is to place a contact lens on the\naphakic eye; this results in single, binocular vision and is\nsatisfactory for a majority of these patients.\nUse of hydrophilic (soft) lenses 34/ in aphakic patients gave\nexcellent visual acuity and was more comfortable than hard lenses.\nFORD\nGERALD\nLIBRARY\n49\nIn the case of monocular aphakia, where the other eye has good\nvision, the treatment of choice is to place a contact lens on the\naphakic eye; this results in single, binocular vision and is satis-\nfactory for a majority of these patients.\nUse of hydrophilic (soft) lenses 34/ in aphakic patients gave\nexcellent visual acuity and was more comfortable than hard lenses.\nThe main advantages of the soft lens over eyeglasses are the lack\nof spectacle blur, increase in visual fields and simplicity of\nfitting. Contact lenses also provide an almost normal field of\nvision with negligible magnification of the retinal image as com-\npared to eye glasses. Some 80% of aphakic patients can learn to\nwear contact lenses if properly instructed 2/ In the elderly\npatient, however, decreased manual dexterity may hinder the use\nof contact lenses unless professional assistance is available.\nIt should be noted here that no matter how well cataract extraction\nis tolerated, the visual result is largely determined by the state\nof the retina as well as such factors as senile macular degeneration\nand diabetic retinopathy which will cause poor vision even after\nan excellent cataract operation 21/ Therefore, a careful assess-\nment of the function of the macula and the peripheral retina is\nimportant pre-operatively SO that the patient may be warned if\nthe visual outcome of the operation seems doubtful even with the\nbest optical correction available. Such assessment may be\ndifficult or impossible in advanced cataracts.\nWhere indicated, rehabilitation training of patients in the use\nof his/her prosthetic devices and aiding the patient in spacial\norientation and mobility is extremely important. In addition,\nsome post-surgical aphakic patients do not experience optimal\nvision for their living or occupational requirements through the\nuse of regular (spectacles, contact lenses, intraocular lens\nimplants) ophthalmic prosthesis. These patients should be\nconsidered for low vision aids such as special microscopic reading\nglasses, telescopic spectacles and other such devices. These\nhave been very effective, when properly applied, in providing\noptimal vision function for certain life style activities, a\nrequirement which is most important to the physical and mental\nwell-being of these patients.\nFORD\nGERALD\nLIBRARY\n50\nBIBLIOGRAPHY\n1. Zinn, E.M., and Mockel-Pohl, S., \"The Lens and Zonules\",\nInt. Ophthalmol. Clin., 13(3): 143-155 (1973).\n2. Paton, D., and Craig, J.A., \"Cataracts, Development, Diagnosis,\nManagement\", Clinical Symposia, Ciba Foundation Symposium,\n26(3): 2-32 (1974).\n3. Kirsch, R.E., \"The Lens\", Arch. Ophthalmol. 93: 384-314 (1975).\n4. Kinoshita, J., \"Mechanisms Initiating Cataract Formation\",\nInvest. Ophthalmol., 13(10): 713-724 (1974).\n5. \"Symposium on the Human Lens - In Relation to Cataract,\nLondon, 1973\", Ciba Foundation Symposium 19, Associated\nScientific Publishers, Amsterdam, P. 324 (1973).\n6. Newell, F.W., and Ernest, J.T., \"The Lens\", Ophthalmology:\nPrinciples and Concepts, The C.V. Mosby Co., St. Louis,\n3rd Ed., pp. 313-327 (1974).\n7. Whitwell, J. \"Inherited Eye Disease\", The Practitioner, 214:\n621 (1975).\n8. Harley, R.D., Ed., Pediatric Ophthalmology, .A.Saunders,\nPhiladelphia, pp. 375-378 (1975).\n9. Merin, S. and Crawford, J.S., \"The Etiology of Congenital\nCataract\", Can. J. Ophthalmol., 61: 178-182 (1971).\n10. Bellows, J.G., Ed., Cataract and Abnormalities of the Lens,\nGrune and Stratton, Inc., N.Y., PP. 217-283, 285-297, 421-\n491 (1975).\n11. Duke-Elder, W. Stewart, Textbook of Ophthalmology, Vol. III,\nThe C.V. Mosby Co., St. Louis, PP 3115-3244 (1941).\n12. Dobree, J., Modern Ophthalmology, Vol. IV, Butterworth, Inc.,\nWashington, D.C., p. 624 (1964).\n13. Best, C.H., and Taylor, N.B., The Living Body, Henry Holt\nand Co., N.Y., 4th Ed., p. 579 (1958).\n14. Scheie, H.G. Morse, P.H., Aminiari A., Incidence of Retinal\nDetachment Following Cataract Extraction\", Arch. Ophthalmo.,\n89: 293-295 (1973).\n15. Kanski, J.J., Elkington, A.R., and Daniel, R., \"Retinal\nDetachment After Congenital Cataract Surgery\", Brit. J.\nOphthalmol., 58: 92-95 (1974).\nGERALD FORD LIBRARY\n51\n16. Francois J., \"Aphakic Glaucoma\", Ann. Ophthalmol., 5:\n429-442 (1974).\n17. The national Ambulatory Medical Care Survey: 1973 Summary,\nU.S. May 1973-April 1974, Series 13 - Number 21, DHEW\nPublication No. HRA 76-1772.\n18. National Center For Health Statistics (HRA), Unpublished Data.\n19. Prevalence of Selected Impairments, U.S., 1971, Health Interview\nSurvey, Series 10 - Number 99, DHEW Publication No. HRA\n75-1526.\n20. National Eye Institute (NIH), Unpublished Data.\n21. U.S. Hospital Discharge Survey - 1972, National Center For\nHealth Statistics (HRA), Unpublished Data.\n22. Beasley, H., \"The Visual Fields in Aphakia\", Trans, Am.\nOphthalmol. Soc. 63: 363-416 (1965).\n23. Foulds, W.S., \"Cataract\", The Practitioner, 197: 5-12 (1966).\n24. Benton, Jr., C.D., and Welsh, R.C., Spectacles For Aphakia,\nCharles C. Thomas, Springfield, pp. 5, 22-25 (1966).\n25. Stone, J., \"Optical Comparisons Between Haptic and Corneal\nLenses For Aphakia\", Amer. J. Optom. and Arch. Amer. Acad.,\nOptom., 45(8): 528-531 (1968).\n26. Koetting, R.A., \"Special Considerations in the Fitting of\nContact Lenses in Aphakia\", Am. J. Optom. and Arch. Amer.\nAcad. Optom., 41(4) : 248-259 (1964).\n27. Kumar, D., Goel, B.S. Srivastava, M.S., \"Contact Lenses in\nMonocular Aphakia\", Contacto, 12(3): 35-39 (1968).\n28. Welsh, R.C., \"Contact Lens For Aphakia\", Amer. J. Optom. and\nArch. Amer. Acad. Optom., 48(11) : 949-952 (1971).\n29. Polse, K.A., \"Contact Lens Fitting in Aphakia\", Amer. J. Optom.\nand Arch. Amer. Acad. Optom., 46(3): 213 219 (1969).\n30. Crossen, F.J., \"Aphakia-Contact Lenses-Hard-Soft-None\",\nContact Lens Med. Bull., 6: 11-14 (1973).\n31. Clahr, L. \"Continuous Wear of Soft Contact Lenses By Aphakic\nPatients\", Contact Lens Med. Bull., 6: 35-37 (1973).\nFORD & LIBRARY GERALD\n52\n32. Stein, H., Scott, B., \"Contact Lens After Cataract Surgery:\nA Review of 200 Aphakic Patients Fitted With Soft Lenses\",\nCan. J. Ophthalmol., 9: 79-80 (1974).\n33. Welsh, R.C., \"Continuous Use of Tiny Hard Corneal Lenses For\nAphakia (200 cases)\", Ann. Ophthalmol., 5: 1003-1004 (1973).\n34. Shaw, E.L., and Gasset, A.R., \"Experience in the Use of Soft\nContact Lenses For the Correction of Monocular and Binocular\nAphakia\", Ann. Ophthalmol., 5: 937-943 (1973).\n35. Milkie, G.M. and Miller, S.C., Eds., Current Optometric\nInformation and Terminology, 2nd. Ed., St. Louis, American\nOptometric Association (1975).\nFORD & LIBRARY GERALD\n53\nSECTION II-B\nOPTOMETRIC LAW AND PRACTICE\nCompiled by Grace W. Madison, J.D.* and David B. Hoover, M.P.H.**\nThe scope of practice and area of competence of the health professions\nare of increasing importance as we attempt to improve the organization\nand operation of the health care system. While precise definition\nis not possible, information is available from several sources from\nwhich to develop valid concepts of a profession's role and function.\nThe sources are:\n- State laws which authorize activities and responsibilities\nof health workers.\n- Board regulations which implement and enforce activities\nand responsibilities of health workers.\n- Decisions by the courts concerning the responsibilities\nof practitioners.\n- The usual and customary practices of the professions.\n- The objectives, content, and standards of education and\ntraining for the profession.\nThis section presents information about the legal bases for the\npractice of optometry, and draws upon evidence of how optometrists\nfunction in present day practice. All health professions including\noptometry are in a state of professional growth--i.e., an expansion\nor re-definition of their responsibilities and functions--in response\nto new professional specialties, and the changing demands of society.\nTypically, professional growth is first observed in certain practice\nsettings, usually those where clinical, academic, or economic\npressures encourage the most efficient and effective use of personnel.\nProfessional education will quickly reflect this growth and encourage\nits spread throughout the rest of the professional community.\nEventually, changes in legislation and regulation will be made to\naccommodate the new responsibilities and functions.\n* Program Analysis Officer, Division of Associated Health Professions,\nBureau of Health Manpower, Health Resources Administration, DHEW.\n**Associate Director for Planning and Evaluation, Division of Associated\nHealth Professions, Bureau of Health Manpower, Health Resources\nAdministration, DHEW.\nGERALD FORD LIBRARY\n54\nTherefore, in attempting to state what optometrists or other health\npersonnel can and should do, it is important to examine what they\nare actually doing and what trends in professional growth can be\nobserved.\n*\n*\n\"The Doctor of Optometry (O.D.) is a health professional who performs\neye examinations to determine the presence of visual, muscular, or\nneurological abnormalities, and prescribes lenses, other optical\naids, or therapy such as eye exercises to enable maximum vision.\nOptometrists are trained to recognize diseased conditions of the\neye and ocular manifestations of other diseases, and to refer patients\nwith these conditions to the appropriate health professional.\n/\n\"Optometry as a profession is concerned with the problems of human\nvision. Optometrists examine the eyes and related structures to\ndetermine the presence of any visual, muscular, neurological, or\nother abnormality. They prescribe and adapt lenses or other optical\naids and may use visual training aids (orthoptics) when indicated to\npreserve or restore maximum efficiency of vision. Most optometrists\nfit and supply the eyeglasses they prescribe. They do not prescribe\ndrugs, make definitive diagnosis of or treat eye diseases, or perform\nsurgery. 112/\nThese definitions of optometry reflect the optometrists' role as a\nprovider of primary health care. In this role he functions as a\nprincipal point of contact with the health system for individuals\nwho have visual problems, some of whom will have symptoms or\nconditions which require referral to other health practitioners.\nA more complete description of optometric functions has been\npreviously published by the Department 3/\nThe optometrist's role as a provider of primary care has been of\nsteadily increasing concern and importance. This trend has received\nadditional sitmulus in recent years from the larger role assumed by\noptometrists in health care in military settings, and in institutional\ncare as typified by health maintenance organizations, where he may\nevaluate all patients who present themselves with visual problems.\nAlso, most States have specific statutory provisions prohibiting\ndiscrimination between ocular practitioners in public and private\ninsurance programs, thereby giving persons the freedom to select\nthe practitioner to perform vision care services.\nAll of the health professions have experienced, in the last half-\ncentury, tremendous growth in the scope and depth of their discipline,\nand optometry is no exception. Optometrists have displayed a high\ndegree of responsiveness to technological change, and have made\nnoteworthy efforts to adopt new techniques as part of their practice\nand to improve the scientific content of their education\n55\nOptometric Practice Authorized By State Law and Board Regulations\nThe practice of optometry is governed by statute in every jurisdic-\ntion. While no single definition of optometry is used in all state\nlaws, certain descriptive and limiting phrases recur in almost all\nStates defining this profession. Generally, an optometrist may be\ndefined by statute as one who, having met the requisite legal and\neducation requirements, is licensed to examine eyes and to correct\nrefractive errors through ocular exercises or by prescribing and\nfitting corrective lenses, but not through the use of drugs or\nsurgery. The optometrist is also expected to recognize, but not\ntreat, disease of the eye. This definition has been broadened by\na few States in recent years to authorize the use of diagnostic drugs.\nAnother significant source of information is regulations of State\nBoards of Optometry. State Boards are delegated the authority to\nmake rules and regulations governing the practice of optometry which\nthey deem necessary for the effective enforcement of State laws.\nCourt decisions stemming from malpractice suits constitute a reliable\nbody of information with legal significance for the determination of\nthe scope, responsibilities, and proficiencies of a profession.\nHowever, in optometry, malpractice suits have been rare, and there\nare few such decisions to which we may turn.\nA systemic analysis of State optometric practice acts is difficult\nbecause of variations in phrasing and coverage of the acts. The\nvariations arise from the nature of the existing legal code of which\nthe act is a part, or conditions giving rise to the need for the law,\nor for a revision thereof, in a given State. Differences in\nexpression and the use of terminology among authors of laws also\nresult in variations which make authority and intent difficult to\ncompare.\nIn determining the scope of practice of optometrists, i.e., what\nprocedures or functions they may perform, several indicators may be\nconsidered. In rare cases, a statute or regulation will define the\nterm \"optometry\" or \"practice of optometry\" so as to detail specifi-\ncally what procedures fall within the scope of practice. More\nfrequently, the law or regulation defines its terms broadly,\ndiscussing specifics elsewhere. Many States include in their laws\na schedule of the minimum procedures which must be performed on\nevery patient being examined by an optometrist. These schedules\nare perhaps the most valuable tool available for determining how\nexpansive the scope of practice is in a given State. A less\nvaluable tool, but nonetheless an indicator, are the statutory or\nregulatory provisions outlining the equipment which each optometrist\nmust have in his or her office. If the minimum equipment schedule\nincludes a refractor and an ophthalmoscope, it may be concluded that\nan optometrist may or should perform internal ophthalmoscopic\nexaminations and refractions in that State.\nFORD & LIBRARY GERALD\n56\nA first procedure undertaken by this study was to use these\nindicators to compile a chart of functions or procedures specifically\nauthorized in the laws and regulations of each State. The authori-\nzation may be either expressed or implied as explained above.\nThe results of this effort-the chart and a discussion of findings--\nare provided in Attachment A of this chapter. Although, the chart\ngives an indication of how optometry is viewed by State legislatures\nand regulatory bodies, it can be relied upon only as a partial\nindicator of what optometrists should or should not do. For example,\nonly 24 States specifically mention refraction or measurement of\nrefractive powers among the permitted or required functions of an\noptometrist, but, by definition, refraction is an essential component\nof optometric practice in every State. Thus, from analysis of\npractice acts and related regulations, with few exceptions, the law\nis unclear as to what services optometrists may perform.\nOptometrists As Providers of Primary Care\nOf particular relevance to this study, is the extent to which optome-\ntrists are permitted by law ot provide a portion of primary care.\nPrimary health care by first-contact health professionals involves\nthe detection of disease or abnormality and proper disposition of\nthe patient.\nState laws were examined to determine the extent to which they hold\noptometrists responsible for, or require them to be knowledgeable\nabout this primary care function. In recent years, several States\nhave amended the laws to redefine optometry, notably, Alabama,\nConnecticut, Idaho, Pennsylvania and Tennessee. The new definition\nreflects further recognition of optometrists as primary care providers\nby expressly enabling practitioners to ascertain the presence of\ndisease or pathological conditions and to refer the patient to the\nappropriate medical practitioner for further diagnosis.\nFurther mention of such a requirement or ability is made in\nAttachment B.\nOptometrists are seldom subjected to malpractice suits, the very\nlow rate of insurance ($280.00 per year) reflecting this fact. Suits\nhave been brought, however, and it is informative to note the extent\nto which courts hold that optometrists are responsible for the care\nof their patients.\nAn optometrist has the duty to refer a patient to a physician for\npathological conditions which he recognizes. Optometrists have been\nfound both liable and not liable for malpractice in the prescribing\nand fitting of corrective lenses and for failing to refer, and\ndifferent standards of care are used by the courts.\nFORD & LIBRARY 07V830\n57\nIn a Maryland optometric malpractice case in 1971, the court equated\nthe duty of an optometrist to advise patients with that of a\nphysician. 6/ The Supreme Court of the State of Washington has\napparently held, in a 1974 ophthalmological malpractice case, that\nstandards of eye care will be fixed by the court if professional\nstandards are found wanting-- a case which has significant implications\nfor optometry. 7/\nThe question of the duty and ability of an optometrist to discover\npathology was explored in a New Jersey case in which the Superior\nCourt, Law Division, stated that -discovery of pathology is\nincluded within the scope of the responsibility and the minimum\nexamination to be administered by an optometrist. \" This and other\nprecedents were cited in an opinion of the Attorney General of the\nState of New Jersey that authorizes optometrists to utilize local\nanesthetics. The opinion is quoted at length in footnotes to this\nchapter 8/\nAnother aspect of the redefinition of optometry has to do with the\nuse of topical drugs for diagnosis. Prior to 1971, optometry law,\nalmost without exception, used the phrase, \"any means except drugs\nto diagnosis ocular abnormalities, \" in defining the manner in which\noptometry may be practiced. Since that time, several States have\namended the law to permit the use of drugs and appear to have\nbroadened the scope of practice. These recent changes in State\nlaw support the conclusion that the States view optometrists as\nfirst-contact primary vision care personnel.\nEight States now permit the use of topical drugs for diagnostic\npurposes and require an examination in pharmacology as it relates\nto optometry. One State, West Virginia, also permits optometrists\nto use drugs in the treatment of the eye. The language of the\nstatutes vary from a general statement as to the use of topical\ndrugs to a specific statement as to the precise drugs to be used.\nAttachment B summarizes recent laws and regulations respecting the\nuse of drugs.\nThe Assurance of Quality in Optometric Practice\nTo this point, this chapter has explored the legal basis for the\nprivate practice of optometry as it is set forth by the respective\nStates. Several general conclusions can be drawn:\n- There is wide variation among States in the manner in\nwhich optometry is defined.\n- State laws and Board regulations are often inconsistent\nin specifying functions of optometrists.\nGERALD FOAD\n58\n- Statutes relating to the practice of optometry have\nbeen construed both strictly and broadly by the courts\nand attorneys general.\n- The legal basis for optometric practice does not antici-\npate the professional growth of practitioners, but rather\n(as is typical for other licensed health professions)\nfollows developments in education and practice.\n- It is not the intention of State legislative and regulatory\nbodies to restrict the practice of optometry to refraction\nand the provision of lenses.\nA further issue relevant to this study is the assurance of quality\nin vision care. Quality in health manpower is difficult to define\nor measure, but it may be said to consist of proficiency- the\nknowledge and skill of the practitioner--and performance--th\nextent to which that knowledge and skill is fully applied in the\ncare of patients.\nIn health professions, both proficiency and performance are of\nincreasing public concern. Proposals to require periodic\nre-examination of practitioners reflect a concern that proficiency\nis maintained. Professional Standards Review (PSRO) is an attempt\nto examine performance-- to determine, for example, that economic\nincentives are not overruling professional judgment in the handling\nof cases.\nIn investigating the current quality of any health profession, we\nmust expect considerable frustration. Statistical evidence of the\nquality of care which also shows the reasons for any deficiencies\nis hard to come by. So many variables in addition to the proficiency\nor performance of the practitioner influence the outcome of a case\nor dictate the need for a certain procedure or treatment that little\ncan be inferred about the practitioners involved. Individual case\nexperiences allow no generalization to a profession as a whole,\nand of course, they come to our attention through malpractice\nsuits, disciplinary actions, and news accounts of patient's\ncomplaints. They are, therefore, almost uniformly negative in\ntone and there is no corresponding body of anecodotal evidence in\ngeneral circulation that reflects positively on a health profession.\nNevertheless, there is information from which we can make, cautiously,\nsome general deductions about the quality of a health profession.\nPrincipally we have:\n- The content and duration of basic education for the\nprofession.\n- The nature and extent of organized evaluation and control\nof basic education (i.e., accreditation).\nGERALD FORD LIBRARY\n59\n- Requirements for licensure and/or other forms of\nprofessional credentialing (such as certification by\na voluntary professional board or agency).\n- Requirements for periodic re-licensure and/or\nre-certification.\n- Continuing education: its availability, content, and\nthe extent to which practitioners avail themselves of it.\n- Ethical codes and standards of practice promulgated by\nprofessional associations.\n- The disciplinary procedures and actions within the\nprofession.\nEducation and accreditation are discussed elsewhere in this study,\nas part of a review of optometric education. It is convenient to\nlook at licensure, re-licensure, and continuing education in\noptometry simultaneously, since these are inter-related. (This\nis unusual among health professions, most of which unlike optometry\nare not required to meet any quality-related criteria in order to\nretain licensure or certification).\nInitial Licensure Requirements\nTo qualify for licensure as an optometrist, an applicant must be a\ngraduate of an approved school with a program leading to a Doctor of\nOptometry degree. Four States require applicants to complete an\ninternship as a prerequisite to being examined for licensure. The\nlength of the internship varies: three months in Alabama, six\nmonths in Delaware and Rhode Island and one year in Oregon. North\nCarolina does not require an internship but does require the\napplicant to have completed a two week practice orientation.\nMost States also specify some courses or subjects that must have\nbeen included in basic optometric education or (more usually) that\nmust be covered in a licensing examination. The course which appears\nmost frequently in State statutes and regulations is ocular anatomy.\nThirty States examine candidates on this subject and/or require the\ncourse for licensure. Twenty-three States require a course in or\nan exam on ocular pathology. Twenty-three States require practical\noptometry. Ocular physiology appears as a requirement in the laws\nor regulations of 20 States, while theoretical optics appears in 19,\nphysiology in 18, and general anatomy in 15.\nThirteen States require course work or exams on pathology and on\nvisual training and orthoptics. A course in contact lenses is\nrequired by 11 States, while optics is prescribed in ten.\nQERALD FORD LIBRARY\n60\nA number of subjects appear in less than ten of the State's\nrequirements. Refraction and geometric optics appear in nine\ntimes each. Eight States require course work in psychology.\nPhysics and hygiene appear six times each, as does prescription\nand fitting. Pharmacology is tested in five jurisdictions as\nis clinical optometry. Optical laboratory and clinical work,\nmathematics, and psychological optics each appear in four\nState's examination requirements. Physical optics, ocular\nmyology, and ocular neurology are examined on in three States\neach. Tonometry, mechanical optics, and case analysis are\nrequired course work in two States.\nAttachment C shows in tabular form the subject matter to be\nmastered for licensure in each State.\nAll States require applicants to pass a written examination as\na condition precedent to licensure. There is a National Board\nExamination in Optometry which is used at the discretion of the\nState Boards and in 18 States is expressly accepted in lieu of\nthe State written examination. Sixteen States also require\napplicants to pass an oral examination. In five other States,\nan oral examination is optional. Twenty-eight States require\npractical examinations and in two others, practical exams may be\nrequired at the Board's discretion. Requirements of States for\ninitial licensure are presented in tabular form as Attachment D\nto this chapter.\nContinuing Education and The Renewal of Licensure\nOptometry has taken formal steps to assure that practitioners are\nrequired to continually upgrade their diagnostic and treatment\nskills. Beginning with Iowa in 1938, forty-three States have\nadopted, either by Board rule or statutory law, some form of\ncontinuing education requirement for license renewal. Of the\nremaining States without formal requirement, several State\noptometric associations have instituted a system of continuing\neducation requirements for membership purposes\nContent of continuing education courses also varies widely as do\nthe institutions and entities providing such services. 10/,11/,12/\nThe Southern Council of Optometrists recently provided 102 clock\nhours of education to some 1200-1300 registered participants. A\nseparate listing which itemizes course offerings related to manage-\nment of the patient with cataract or aphakia is appended. 13/ The\nlist supplied by the Division of Education and Manpower, American\nOptometric Association, samples courses offered over the last five\nyears.\nFORD\nGERALD\nLIBRARY\n61\nContinuing optometric education courses are offered by over 100\nagencies. This includes the 51 State associations affiliated with\nthe American Optometric Association, the twelve U.S. schools and\ncolleges, national organizations such as the American Academy of\nOptometry, American Optometric Foundation, and the Armed Forces\nOptometric Society, and the seven regional councils of optometrists\n(Central States, North Central States, Northeast States, Mountain\nStates, Southwestern States, and Southern). Several other organiza-\ntions offer courses either individually or in conjunction with State\nand regional annual meetings, e.g., the College of Optometrists in\nVision Development, The Vision Institute of America, The National\nOptometric Association, and the Optometric Extension Program.\nSome State Boards are also providing coursework related to changes\nin optometry statutes and rules.\nThe presentation of continuing education can be described in two\ngeneral categories: that which is primarily clinical and laboratory\nwork (offered by schools and colleges) and the lecture form. The\nlatter frequently incorporate sophisticated learning aids, including\nprint in all forms, including motion pictures, film strips, photo-\ngraphs and models, recordings, and the like. Practitioners involved\nin continuing optometric education include at a minimum, all licensed\noptometrists in the States that require it for license renewal. It\nis estimated that some 17-18,000 of the reported 21,000 licensed\nDoctors of Optometry are currently obtaining continuing education.\nAdditional sources for maintaining knowledge of advances in optometry\nare the various professional journals available to practicing\noptometrists. These include the Journal of the American Optometric\nAssociation (which contains a feature on continuing education self\nassessment), the American Journal of Optometry, as well as many\npublications from related professions and sciences. Most State\nassociations have periodicals for distribution to members which\ncontain case histories and new technique information.\nThe nature of the requirements for continuing education that forty-\nthree States impose varies considerably. Most States specify that\ncredit may be given for optometric or other scientific education,\nlectures, symposiums or courses approved by the board, post-graduate\nstudy at a school of optometry, or a course given by the optometric\nassociation.\nThere is no uniform amount of time required. Requirements range\nfrom eight to 25 hours. The requirement is generally a prerequisite\nto license renewal and consequently must be fulfilled within the\nrenewal period. Attachment E summarizes the license renewal\nprovisions for continuing education in the various States.\nBRARY\n62\nIn common with other major health professions, optometry has codified\nethical standards and mechanisms for disciplining members of State\nassociations independent from any actions of regulatory boards. Of\nparticular interest here is the position of optometry on referral to\nother sources of health care. The fifth precept of the Code of Ethics\nadopted by the House of Delegates of the American Optometric Associa-\ntion, at Detroit, Michigan, June 28, 1944, states that \"It Shall Be\nThe Ideal, the Resolve, and the Duty of the Members of the American\nOptometric Association TO ADVISE the patient whenever consultation\nwith an optometric colleague or reference for other professional\ncare seems advisable. \"\nInformation on disciplinary actions of professional organizations\nmight indicate the extent to which the promulgated professional\nstandards are actually enforced. However, this information is not\nmade available (to do so would raise serious questions of the respect\nof privacy and due process), and special efforts would be required\nto undertake any assessment of the effectiveness of this method of\nensuring professional quality.\nOptometry In Organized Health Care Settings\nThe capabilities of optometry are most easily examined in organized\nsettings such as military establishments and health maintenance\norganizations. Here, in contrast to private practice, their\nresponsibilities and functions are more clearly defined and their\naccomplishments and professional relationships with medicine are\nmore apt to be a matter of record.\nMost optometrists are in private practice and data on the nature of\ntheir practice and the efficiency of the provision of vision care is\nlacking. Any amount of anecdotal evidence--single case histories or\nthe procedures and experience of single optometrists or ophthalmolo-\ngists--is available to support the contention that optometrists\nfunction effectively as primary care personnel, but from this one\ncan draw no firm conclusions about how the \"average\" optometrist,\nor the majority, do in fact function.\nHowever, utilization of the optometrist in an organized health care\nsetting does offer insight into how the private practitioner can\nfunction. Organized settings include the armed forces, the Veteran's\nAdministration, and health maintenance organizations.\nThe armed forces employ 302 ophthalmologists and 521 optometrists.\nProportionately more optometrists are employed in the Air Force\n(176 vs. 58 ophthalmologists), and fewer in the Navy (127 optometrists\nto 130 ophthalmologists). In larger medical installations, optometry\nis a section of the department of ophthalmology, while in smaller\ninstallations the optometrists will work in the department of surgery\nor under the director of hospital clinics but without close professional\nGERALD FORD LIBRARY\n63\nsupervision. In military installations, ophthalmologists do not\nprovide services without the assistance of optometrists. Referral\nrates from optometrists to physicians range between three and seven\npercent of the patients seen, a higher percentage than that found\nin civilian clinics.\nPosition descriptions for optometrists in Federal service emphasize\nthe breadth of the discipline. 14/ The services recognize examinations\nperformed by civilian optometrists. For example, the U.S. Navy\nrecruiting manual, Section 4, \"Physical Qualification, 11 C-1401\n\"general\" contains the following statement: \"Statements from optome-\ntrists will be accepted on all matters pertaining to eye examinations\nexcept definitive diagnosis of disease. This does not preclude the\nacceptance of a statement from an optometrist regarding certain\nconditions of the eyes or a statement that there is no disease of\nthe eye. 15/\nThe military have successfully instituted optometric triaging using\nmedical corpsman supplemented by optometrists. 16/ In this setting,\noptometrists successfully function as primary care personnel. The\nCivilian Health and Medical Program of the Uniformed Services\n(CHAMPUS) provides or reimburses for health services for armed\nforces retirees, dependents and others. CHAMPUS authorizes payments\nto optometrists:\n- for eye examinations performed for the purpose of ruling\nout pathology even though the examination may result in\nthe determination that no pathology exists.\n- for spectacles or special lenses required in the surgical\nor medical treatment of pathological conditions.\nbut does not reimburse for lenses needed solely for the purpose of\ncorrecting refractive error.\nIn the provision of vision care the Veteran's Administration has\nrelied heavily upon ophthalmology and to a much lesser extent upon\noptometry. It uses the full-time equivalent of 100 ophthalmologists\n(including 188 residents, 85 staff, and 90 consulting or attending\nophthalmologists) but only 8 full-time, 13 part-time and less than\n40 attending or consulting optometrists. 17/ This low rate of\nutilization of optometrists is partially explained by non-competitive\ncivil service salary rates established for them, and partially by\nthe lack of affiliation of VA hospitals and clinics with optometry\nschools. An exception is the VA Hospital in Birmingham, Alabama,\nwhich is affiliated with the School of Optometry, University of\nAlabama. The VA, however, has recently established a Vision\nImpairment Committee (with representation from Ophthalmology,\nGERALD FORD LIBRARY\n64\nOptometry and Blind Rehabilitation) which has recommended that\ntraining affiliations be established or strengthened with schools\nof or colleges of optometry. The VA's Ophthalmological Advisory\nCommittee has endorsed the concept of expanding the present emphasis\non eye health care to the more comprehensive conncept of vision care\nvia interdisciplinary team delivery 18/\nHealth maintenance organizations provide a setting in which optometry\nhas well-defined relationships with the other health professions.\nGroup Health Association of Washington provides primary care for\nabout 50,000 people, utilizing 55 full-time and 75 part-time\nphysicians supported by 400 ancillary personnel. 19/ Vision care\nin Group Health Association is provided by two full-time ophthalmolo-\ngists and 5 full-time and 2 half-time optometrists under the super-\nvision of the Chief of Ophthalmology, a physician. Optometrists\nevaluate all patients with visual problems, refer them to ophthalmolo-\ngists as necessary, do refractions, determine visual fields, and fit\ncontact lenses. Ophthalmologists rarely refract and then only in\nconnection with pathology. Experience here and in other health\nmaintenance organizations shows that extensive utilization of the\noptometrist's capabilities is compatible with high quality health\ncare.\nOptometrists are effectively utilized in providing vision care\nservices under various Medicaid programs. The Medical Assistance\nProgram of New York City (Medicaid) for example, utilized optometrists\nat the onset. It defined comprehensive public funded health care as\nmeaning a vigorous participation of all relevant professional\ndisciplines: medicine, dentistry, pharmacy, optometry, podiatry,\nclinical psychology, etc. 20/ Under this program, the patient is\nfree to choose the practitioners, and the majority of vision services\nare provided by optometrists. New York City Medicaid reimburses\noptometrists for all aspects of optometric practice.\nInsurance coverage per se cannot be considered as a decisive factor\nin the utilization of eye care services. In a New York City survey\ndone seven years after the introduction of the Medicaid program,\nindividuals with insurance coverage had significantly lower\nutilization rates than those without 21/ Ninety-four percent of a\nsample of adults had had an \"eye examination\" sometime during their\nlife; of these, twenty percent were not able to state what type of\npractitioner provided their last examination, \"reflecting the wide-\nspread confusion among consumers about eye care disciplines and\npractitioners. 11 Of the individuals who could distinguish between\npractitioners, 59% had last utilized optometrists, and 41%\nophthalmologists. An apparent majority of this urban population,\ntherefore, obtained vision care from optometrists, a finding con-\nsistent with other surveys. This survey also showed that utilization\nof optometrists as opposed to ophthalmologists is apparently unrelated\nto race and slightly related to socio-economic rank (with the highest\nrank more often utilizing the physician).\nGERALD FORD LIBRARY\n65\nThis survey found substantially less utilization of optometrists\nin the population over age 60 than among younger age groups. A\ngreater proportion of the older population is, no doubt, seeking\ncare from ophthalmologists. Two reasons for this are apparent:\nthe older population suffers to a greater extent from eye disease\nrequiring medical diagnosis and treatment, and present medicare\nreimbursement policies lead patients requiring optometrist's services,\nwhich are not reimbursable, to ophthalmologists, whose service is\nreimbursable in part. This and other surveys point out that a\nmajority of the population chooses to rely or must rely upon\noptometrists for primary vision care. 25/\nFrom experience in structured multidisciplinary health care settings\nit is clear that optometrists can function as primary health care\nproviders, with efficient relationships with medicine. Data from\nprivate practice suggest that many or most in that setting are\nequally effective, but that a proportion of private practitioners\nneed better working relationships with medicine than they have been\nable to establish.\nOther Information Bearing on Optometric Practice\nIt is accepted that optometrists are well-grounded in physical and\nphysiological optics and competent to refract and provide prosthetic\nlenses. Such documentation of optometric care as exists deals only\nwith these aspects of practice and shows a high quality of service. 26/\nSome insight into their effectiveness in providing other components\nof patient care can be gained by examining practices of referral of\npatients to physicians.\nA considerable body of optometric literature has to do with referrals\nto physicians--criteria for referral, procedures to detect systemic\ndisease, information that should be provided the physician, etc.\nOptometric educators, administrators of vision care departments in\ninstitutions or group practices, and leading practitioners are clearly\nconcerned with improving vision care by establishing more efficient\nand effective working relationships with medicine in the detection\nof abnormalities 27 For example, the Black Hills District Optometric\nSociety has, since the early 1960's, had periodic meetings which\ninclude local ophthalmologists in order to devise and refine criteria\nand procedures for referral of patients and to encourage good referral\npractices 28/\nVarious studies indicate that between two and three percent of patients\nexamined by optometrists require referral to a physician. Reliable\ndata are not available to show how this rate varies by age of patient,\nor the extent to which optometrists may over or under-refer. No\nsatisfactory study of referrals to and from optometrists in private\npractice has been done; the best information comes from data collected\nin group practices and clinics.\nFORD\nGERALD\nLIBRARY\n66\nA 1968 study of vision care within the Kaiser-Permamente prepaid\ncare plan in the Los Angeles area, for example, showed that 2.75\nof the patients seeing an optometrist were referred to ophthalmolo-\ngists. Patients suffering from neurological disorders (e.g.,\ncerebral-vascular accidents, multiple sclerosis, suspected tumors)\nare referred from physicians to optometrists for visual field testing\nand examination of the fundus. The optometrist's findings are used\nin arriving at a diagnosis.\nA study of pathology detected, and of referrals in an inner-city\nvision care clinic staffed by optometrists, optometry students, and\nophthalmologists showed a relatively high rate of detection by\noptometrists and students of abnormalities requiring referral to\nphysicians\n29\nGlaucoma was the most prominant condition detected,\naccounting for 21% of all referrals, with nuclear cataracts\naccounting for a further 9%. Diabetic retinotopathy caused 6% of\nthe referrals. These represent only conditions for which there was\nno previous record of diagnosis and treatment. The relatively poor\nstate of health and vision care of elderly innercity populations is\napparent from data this clinic, in which 17% of the patients in the\nage group 51 to 60, and 27% of those in the group 61 to 70, required\nreferral to physicians. In 2.85% of the population of this clinic,\nthe detection of ocular abnormalities by optometrists or optometry\nstudents led to the diagnosis of previously unrecognized and untreated\nocular or systemic disease.\nFrom experiences in organized health care settings, it is apparent\nthat optometrists can be effective in the detection of abnormalities\nof the vision system and in selection of patients who require medical\ncare. There is a definite trend toward utilizing technicians and\nassistants of various types to carry out much of the initial\nexamination, subject to farther screening by the optometrists.\nStudies of referral practices of private practitioners would, if\nadequately done, provide valuable insight into the extent to which\noptometrists are able to detect abnormalities of the visual system\nand their disposition of such cases. Unfortunately, no reliable data\nare available. A mail survey in 1960 of a sample of optometrists\nrevealed only that the overall referral rate to physicians was 2.19%\nof cases, with 54% of these referrals being to ophthalmologists 30/\nNo information was obtained with which to judge whether this rate\nis adequate, excessive, or inadequate.\nRelationships between optometrists and physicians have considerable\nbearing on the mode of practice of the optometrist. Most optometrists\nhave a working relationship with one or more ophthalmologists. Of\nthe information available about the ability and proper role of the\noptometrist as seen by the physician, little has been collected in\nany rigorous manner from a defined sample of respondents, and in no\ncase is it available in sufficient detail to allow more than the\nFORD\nGERALD\nLIBRARY\n67\ngrossest speculation about the origin and nature of the opinions of\noptometry that a minority of physicians hold. It seems likely,\nhowever, that any negative opinions are based upon experience with\na few individual optometrists, most probably older practitioners who\nwere trained to and do restrict their practice to little more than\nrefraction and dispensing. Hafner's data 31 and findings from the\nNational Center for Health Statistics 1968 Survey of Optometry\nPractice support this contention. The latter survey in particular\nshowed that many optometrists educated before 1940 (now constituting\nabout 13% of active optometrists) may not attempt to function as\nprimary care personnel and may not make a thorough attempt to detect\nsystemic disease which may have ocular manifestations.\nA survey of California physicians concerning their relationships\nwith optometry was published in 1974 32/ General practitioners,\ninternists, and neurologists were surveyed and 372 usable replies\nwere obtained. 61% of the general practitioners had had patients\nreferred to them by optometrists while 55% of the neurologists and\n39% of the internists had had such referrals. All but a few of\nthese physicians were of the opinion that the referrals were\nproperly handled and served the patient's best interests. Approxi-\nmately the same proportion of physicians in this study who had\npatients referred to them by optometrists referred their patients\nto optometrists, and almost all reported that these referrals were\nhandled in a satisfactory manner. Of the responding physicians,\n70% reported that it is in the patient's best interest for optome-\ntrists to check for ocular pathology and ocular signs of systemic\ndisease. These findings confirm an impression that on the individual\nlevel, the majority of physicians and optometrists in practice enjoy\na fruitful and on the whole harmonious relationship, permitting a\nhigh quality of patient care.\nEarlier, reference was made to the National Center for Health\nStatistics Survey of Optometric Practice conducted in 1968. The\nsurvey was repeated in 1973, but only the 1968 study asked respondents\nto check off the types of procedures performed in their office.\n(Data from the 1973 survey is only now being produced, and has not\nbeen published except as a series of reports by State).\nThe 1968 survey listed 14 services or procedures for the responding\noptometrist to report as being done in his practice. The data\nsuggested that some optometrists do not perform an examination\nthat is sufficiently complete to serve as an adequate screen for\npathology. However, additional analyses were obtained and methods\nof collection of the data were reviewed. After discussion, the\nadvisors and staff to this study were of the opinion that this data\ncannot be taken as a reliable indication of the state of optometric\npractice then or now 33\nFORD\nGERALD\nLIBRARY\n68\nThere are numbers of other minor studies of optometric practice\nwhich either do not address the proficiency or performance of\noptometrists or are deficient to the point that they provide no\nbasis for generalization.\nIn view of this lack of definitive data, any comments about the\ncapabilities, or lack thereof, of all optometrists to provide\nadequate vision care including primary care must be recognized as\nhaving an unsteady base. It can be assumed that in optometry, as\nin other health professions, there are individuals whose skill and\nprocedures do not conform with the standards set by the professions.\nIt cannot be said, however, that in this respect optometry is in a\nworse position than any other health discipline.\nThe situation is not helped by disagreements about what constitutes\noptical screening or an optometric examination, or disagreements\nabout what types of manpower should be entrusted with various\nresponsibilities and procedures. As we have seen, laws and regu-\nlations vary widely when addressing these subjects. This is a\nreflection of a general disorganization in the provision of vision\ncare.\nTo a notable degree in this field there are unresolved issues about\nwhat procedures should be carried out and what types of manpower\nshould be employed. For example, tonometry, a relatively simple\nprocess for the determination of intraocular pressure and the\ndetection of glaucoma is an important component of vision care.\nConsiderable ingenuity has been expended in devising sophisticated\ndevices to determine intraocular pressure. However, in some medical\nclinics and group practices tonometry is reserved to ophthalmologists,\nin others it is done by any physician. In some other instances,\noptometrists do tonometry while in an increasing number of cases,\ntechnicians are being trained for this. It seems that considerations\nother than cost effectiveness are determining the utilization of\nmanpower in glaucoma screening. There is also some disagreement\nabout when tonometry should be done. The Department of Medicine\nand Surgery of Harvard Medical School in 1974 study found justifi-\ncation for glaucoma screening (by technicians) in medical and\nophthalmology clinics for all patients 40 years or more of age\n34/\nElsewhere, however, we have opinions recorded that, at least for\npatients with vision complaints, tonometry should be a routine\npart of the optometric examination for younger patients.\nOptometric Therapy\nTherapy provided for patients who have cataract/aphakia relates to\nthe prescribing of pre- and post-surgical care that rehabilitates\nthe patient to the best possible visual acuity while providing clear\nsingle binocular vision (fusion).\nGERALD FORD LIBRARY\n69\nDiscussions with expert consultants to the study indicated that\nsuch therapy may include referral and consultation relating to\nsecondary disease processes that are encountered by the optometrist\nsubsequent to the surgery (see Part II, Section A, Complications\nof Cataract Surgery).\nIt was further concluded that the prescribing of lens therapy by\nspectacles or contact lenses, vision training and rehabilitative\nservices, including the teaching of patients to use new prescription\ndevices properly, are part of the therapy prescribed. It was felt\nby the consultants also that the post-surgical monitoring by the\noptometrist of referred patients, especially in remote areas where\nophthalmologists are not available, constitutes an appropriate\nform of therapeutic care. The optometrist may examine the post-\nsurgical patient on several visits to determine the rate of his/her\nprogress toward complete recovery.\nContact lens therapy is especially appropriate in the following\nconditions: monocular aphakia, corneal disease, corneal injuries,\nscarred corneas, irregular astigmatism, aniseikonia and kerataconus.\nBoth hard and soft lenses serve specific therapeutic purposes when\nprescribed for rehabilitative care.\nThe complications of general systemic disease play an important\nrole in the method of treatment the optometrist may prescribe.\nFor example, arthritis may inhibit the patient from safely and\nefficiently handling contact lenses, thus, requiring that alterna-\ntive methods of correction be considered and selected. The total\nlife style as well as occupation of the patient must be considered\nin the rehabilitation process.\nAnother example of where the optometrist adapts the therapeutic\nlens prescription to the patient's individual needs occurs during\nthe progressive visual changes that frequently occur in diabetes.\nRapid development and changes in less than three months, associated\nwith the diabetic type of cataract, may require frequent prescription\nchanges to maintain adequate corrected visual acuity and permit the\npatient to perform daily functions. The complications of diabetic\nretinopathy may further compound the need for frequent examinations\nand prescription changes. The patient may also require frequent\nconsultation between optometrists and ophthalmologists where medical\nand surgical treatment is indicated. Prescription changes of a\nmajor nature may be necessary during the dynamic phase of the\ncataract/retinal complications associated with diabetes.\nOther diseases, requiring similar prostheses, as well as frequent\nexaminations and lens changes, are associated with hypertensive\nretinopathy, senile macular degeneration and arteriosclerosis, all\nof which may require the prescribing of specific lens modifications\nGERALD FORD LIBRARY\n70\nbecause of the effects that the disease process has on the\nperformance of the eye and vision. These and similar disease\nprocesses are best managed, according to the study consultants,\nby optometrists working together in a complimentary relationship\nwith general physicians and ophthalmologists to enhance the\npatient's life style.\nTrends in Optometric Practice\nThe regulation of the practice of optometry has undergone a number\nof changes since 1973. The most frequent change has been the\nincrease in continuing education requirements. Thirteen States\nintroduced continuing education as a prerequisite to license\nrenewal. In addition, Nevada, in 1975 (Ch. 659), strengthened\nits requirement by giving its Board the power to suspend the\nlicenses of optometrists who fail to fulfill the continuing\neducation requirement. The suspension automatically becomes a\nrevocation if the requirement is not fulfilled within one year of\nthe suspension.\nThe second major change has been in the relationship of optometrists\nto programs for delivering health services. Optometrists are\nincreasingly being included in various health care programs. A\n1975 Kansas statute (H. 2554) allows nonprofit corporations to be\ncreated specifically to provide group optometric care programs.\nCalifornia (Ch. 1141 (Laws 1974)) has included optometrists in\nprepaid health plans. Rhode Island, in 1975 (Ch. 288), included\nservices by optometrists in the State's catastrophic health insur-\nance programs. Maryland (Ch. 482 (Laws 1974)) has included\nservices of optometrists in group health insurance policies. And\nfinally, Colorado, in 1973 (H.B. 1106), added optometry to services\nwhich certain corporations may make available to health benefit\nsubscribers.\nSome statutes have revised the definition or scope of practice of\noptometrists. Wisconsin (Ch. 275 (Laws 1974)) construed the meaning\nof \"physicians\" to include optometrists in all accident and sickness\npolicies. New York (Ch. 74 (Law 1974)) included optometrists with\nother medical professionals who received legal immunity for service\non utilization review committees. California states that in\ndetermining whether an individual is blind, the patient may be\nexamined either by a physician skilled in diseases of the eye or\nby an optometrist.\nEspecially in organized health care settings more attention is being\npaid to quality assessment in health care, including vision care.\nThe difficulties of making judgments about quality of care, and\nespecially of practitioner proficiency and performance, have been\nmentioned. Nevertheless optometry for the most part deals with\nreadily visualized or measurable conditions, and is more amenable\nFORD\nGERALD\nLIBRARY\n71\nto the comparison of practice to standards than are many health\nprofessions. Some progress is being made in this, and organized\noptometry is generally cooperative in these efforts.\nPeer review is an approach which may be used to measure and assure\nthe quality of medical and optometric practice. Optometrists have\na role in the review responsibilities of the Professional Standards\nReview Organizations (PSROs). Although the current emphasis on\nreview of inpatient care or services leaves little opportunity for\nreview of optometric services under the aegis of PSRO at this time,\nthe concepts are applicable to the ambulatory care setting.\nFurthermore, guidelines and possible protocols now exist.\nStandards of vision care as they relate to peer review and guide-\nlines for peer review have been developed by many organizations.\nThe American Optometric Association Peer Review Committee Standards\nwere adopted in 1972 and supplementary guidelines for peer review\nwere produced by AOA's Community Health Division's Committee on\nClinical Standards in 1973. The National Center for Health Services\nResearch and Development has developed a protocol for the cataract\npatient which is applicable both to hospital admissions and to\noutpatients 35/\nThe New York State Optometric Association has developed standards\nfor the New York State Regional Health Department Audit and Review\nwhich involve site visits to practitioner's offices, clinic visits,\nrecords review, and examination of utilization rates. The accepta-\nbility of the examination findings is assessed 36/\nIn May of 1975, the American Medical Association drafted \"Model\nScreening Criteria to Assist Professional Standards Review Organi-\nzations. Standards for hospital admission of patients with cataract,\ncorneal disease, glaucoma, retinal detachment and strabimus were\ndeveloped by the American Academy of Optomology and Otolaryngology\nand the American Association of Ophthalmology. Although optometrists\ndo not admit patients to hospitals, the concepts involved in these\nstandards are applicable to review of optometric practice and in\ngeneral have been endorsed by the American Optometric Association\n37/\nAlso, in 1975 the National Academy of Sciences published the \"First\nInterprofessional Standard for Visual Field Testing,\" in which both\nophthalmologists and optometrists participated 38/\nThe California Optometric Care Foundation, a statewide non-profit\ncorporation, has developed an optometric care review program outlined\n(in an unpublished document of the Foundation) in September 1975.\nTheir review of optometric services is concentrated in two areas,\ndiagnosis and treatment, and materials prescribed. This review\nwould monitor optometric practice principally through statistical\nprofiles of the types of services received by patients in various\nage groups, of ICDA codes, and similar data.\nBERALD FORD LIBRARY\n72\nThus, it is apparent that within particular defined limits of\npractice, standards and review mechanisms can be developed for\nvision care as a means of quality control. It is encouraging to\nnote that much of the development of these mechanisms is being\ninitiated within or with the cooperation of the optometric\nprofessions itself. 39/\nFORD is LIBRARY GERALD\n73\nFootnotes and Bibliography\n1. Costs of Education in The Health Professions.\nReport of a\nStudy. The Institute of Medicine, National Academy of Sciences.\nWashington, D.C., 1974.\n2. Health Resources Statistics, 1974. National Center for Health\nStatistics, U.S. Department of Health Education, and Welfare.\nRockville, Maryland, 1974.\n3. The Health Careers Guidebook published jointly by the Department\nof Health, Education, and Welfare and the Department of Labor\ndescribes optometry as follows:\nAn optometrist, Doctor of Optometry (O.D.), is educated\nand trained to examine eyes to detect vision problems.\nHe may prescribe eyeglasses or contact lenses as needed,\nor he may recommend other optical treatment to preserve\nor to improve eyesight. If evidence of eye disease or\ninjury is observed, he refers the patient to an opthal-\nmologist for diagnosis or treatment. In addition, an\noptometrist may render service in any or all of the\nfollowing areas:\nContact Lenses: Recent years have seen greatly increased\nuse of contact lenses. Much of the research and develop-\nment has been done by optometrists. Some optometrists\nnow devote their entire attention to prescribing and\nfitting contact lens. To others it has become an ever\nincreasing part of their general practice.\nChildren's Vision: Optometry is playing a leading role in\ndiscovering and solving children's vision problems, espe-\ncially in the development and use of vision training and in\northoptics. Many optometrists specialize in children's\nvision; others serve as consultants to schools and school\nsystems.\nAids for the Partially Sighted: Many of the effective aids\nfor the partially sighted have been developed by optome-\ntrists. Through their research, telescopic and microscopic\nlens systems have been improved to benefit many in the older\nage group; these aids have also helped thousands of children\nwith seriously impaired vision.\nVision Training: Vision training has long been recognized as\nan effective method of correcting some types of crossed eyes.\nIt is also useful as a way to sharpen visual perception and\nto improve vision for reading. Some optometrists devote a\nlarge part of their time to this specialty; others include it\nas one of several services.\nFORD & GERALD LIBRARY\n74\n4. Roberts, Bertram L., \"Communication Between Optometrists. \"\nJ. American Optometric Association. V. 42, No. 1, January 1971.\n5. An example of change in the scope and depth of optometry\noccurred in the 1940's when it became apparent that in the\ncontrol of blindness due to glaucoma, early detection and treat-\nment was essential. Optometric education was modified to\nemphasis this and to stress the importance of a case history,\nphysical findings, and the measurement of intraocular tension.\nOptometrists have been quick to use the latest technical advances\nin tonometry.\n6. Tempchin V. Sampson, 277 A. 2nd 67.\nThe court, in its opinion, equated the duty of an optometrist to\nthat of a physician and stated the general rule to be: \"The liabi-\nlity of an optometrist to a patient is to be tested by standards\nanalogous to those used to test physicians and surgeons--whether\nor not he did fail to exercise the amount of care, skill and dili-\ngence as [an optometrist] which is exercised generally in the\ncommunity in which he was practicing by [other practitioners]\nin the same field\".\n7. Helling V. Carey, 519 P.2d 981.\n8. In New Jersey, the question raised was whether an optometrist may\nbe permitted to utilize a local anesthetic in performing a normal\ntonometric examination during the course of examining the eyes for\nthe purpose of prescribing lenses. The Attorney General's opinion\nstated: \"It is clear that the New Jersey Supreme Court has indi-\ncated that optometrists have the right to recognize pathology.\nSince glaucoma is a pathological condition an optometrist has the\nright, during the course of an examination for determining whether\nor not such pathological impairment exists. However, while the\noptometrist has the training to diagnose the pathology to medical\ndoctors because the Code of Ethics of New Jersey Optometric\nAssociation, Section 1, prohibits optometrists from the care or\ntreatment of injuries, growths or diseases of the eye. Formal\nOpinion 1961, No. 8, Attorney General David D. Furman. \"\n9. Washington Optometric Association, Continuing Education Guidelines.\nWashington State Optometric Association, 1974.\n10. 53rd Annual Southern Education Congress of Optometry, Atlanta,\nGeorgia, 1976.\n11. Ellerbrock Memorial Continuing Education Courses, American Academy\nof Optometry, Columbus, Ohio, 1975.\n12. University of Alabama in Birmingham, School of Optometry descriptive\nbrochures of courses in ocular manifestations of hypertension,\ndiabetes, and blindness prevention, 1973-75.\nFORD & LIBRARY GERALD\n75\n13. Continuing Education Courses Directed Toward Care of the Ahakic\nPatient. Compiled by Division of Education and Manpower,\nAmerican Optometric Association, 1976.\n14. The United States Army's MOS Code 3340, \"Optometry Officer\",\nlists the duties of the optometrist:\n\"Conducts examinations of eyes and, when appro-\npriate, prescribes corrective treatment without\nthe use of medicine or surgery. Determines by\nmeans of ophthalmic instruments and optometric\nprocedures, vision abnormalities which may be\ncorrected or improved by contact or ophthalmic\nlenses, prisms or other ophthalmic devices; pre-\nscribes corrective lenses; refers patients for\nmedical treatment or surgery when ocular manifes-\ntation of disease is detected; develops and\nmonitors eye and vision protection programs; super-\nvises optician technicians in fabricating and\ndispensing spectacles, manages optical service unit\nor lens laboratory; instructs and supervises subor-\ndinate personnel in optical and optometric procedures;\nengages in vision research; provides optometric\nconsultant services; records optometric data on\napproved forms and records.\"\n15. Chapman, W. Judd, O.D. \"Optometry's Role in the Dection of\nPathology\". Military Med. 136:904, 1971.\n16. Johnson, David E., O.D., M.P.H. \"Optometric Triage in Military\nScreening. Optometry Weekly. 62 (36), September 9, 1971.\n17. Myers, Kenneth J., O.D. \"Veterans' Administration: We Train\nHealth Professionals.\" J.Opt. Ed., V. 1 No. 2, Spring 1975.\n18. Ibid.\n19. Segadelli, Louis J. \"Group Health Association - A Working HMO.\"\nOpt. Weekly. 65(5): 133-135. January 31, 1974.\n20. Alexander, Raymond, M.B.A., M.S., Bellin, Lowell, M.D., M.P.H.,\nKavaler, Florence, M.D., M.P.H., and Rosenthal, Jesse, M.S., O.D.\n\"The Participation of Optometrists in New York City's Medicaid\nProgram. \" Pub. Health Reports, V. 84 No. 11, November 1969.\n21. Haffner, Alden N., O.D., Ph.D., Jolley, Jerry L., O.D., M.P.H.,\nand Soroka, Mort, M.P.A. \"The Utilization of Optometric\nServices.\" J. Am. Opt. Assn., v.49 No. 10, October 1974.\n22. The National Center for Health Statistics, Optometric Manpower:\nCharacteristics of Optometric Practice, United States - 1968.\nDHEW Pub. No. (HRA) 74-1808, 1974.\nFORD is LIBRARY GERALD\n76\n23. Coate, Douglas C., Studies in the Economics of the Profession\nof Optometry. Unpublished doctoral dissertation, City\nUniversity of New York, 1974.\n24. Dorn, W., Mou, T., and Peters, H., A Proposed Regional Plan for\nthe Expansion of Optometric Education in the South. Southern\nRegional Education Board, Atlanta, Georgia, 1974.\n25. Haffner, Alden N., O.D., Ph.D., A National Study of Assisting\nManpower in Optometry. Report of Department of Labor Contract\nNo. 81-34-70-11, 1971. DOL, Washington, D.C.\n26. Alexander, Belling, et.al. (op.cit.)\n27. Robert, Bertram L. (op.cit).\n28. Wick, Ralph E., O.D., D.O.S., F.A.A.O. \"Interprofessional\nRelations-A Case Report.' J. Am. Opt. Assn. V. 39, No. 11,\nNovember 1961.\n29. Hirsch, Jerome A., O.D., The Incidence of Pathology in an Inner\nCity Population. An unpublished study from the Pennsylvania\nCollege of Optometry, 1976.\n30. Kintner, Galen F., O.D. \"Optometry's Role in Health Maintenance-\nA Study of Referrals.\" Am. J. Pub. Health, V. 51, No. 11,\nNovember 1961.\n31. Haffner, Alden N. and Jolley, Jerry L. (op. cit.).\n32. Silva, Gregory M., O.D., and Smith, Gary, E.M., O.D. \"A Survey\nof California Physicians Concerning Their Relationships With\nand Opinions of Optometry. 11 J. Am. Opt. Assn. V. 45, No. 40,\nOctober 1974.\n33. The National Center for Health Statistics. Optometric Manpower:\nCharacteristics of Optometric Practice. United States, 1968.\n(op. cit.)\nTable 3, p. 23 of this report shows that of 18,238\noptometrists providing refraction, 16,928 provided\nophthalmoscopy, 13,780 examination of visual fields,\n12,098 tonometry, and 5,907 biomicroscopy. The\nproportions for solo practitioners only proved much\nthe same. Non-performance of diagnostic procedures\nproved to be highly correlated with age, year of\ngraduation, State of practice, and school.\nThe reliability of this data is open to question since\nthe procedures were listed and the respondent was asked\nto check if they were done but to make no mark if they\nwere not done. Therefore, incomplete response is treated.\nas non-performance of the procedure. Furthermore,\nFORD & LIBRARY GERALD\n77\nrefraction headed the list and to many optometrists\n(especially those relatively long out of school) the\nterm \"refraction\" covers all normal diagnostic proce-\ndures. (A principal textbook of optometric practice\nis titled simply \"Refraction\"). The use of the term\nrefraction in this larger sense is thought to be\nassociated with the school and year of graduation and\nto some extent with the State of practice. After much\ndiscussion, therefore, it was concluded that these\ndata cannot be taken at face value.\nIn addition, the data were collected in 1968. In the\nintervening eight years two things have happened:\nmany of the older or part-time optometrists who reported\nminimal diagnostic procedures have retired, and the\nactive optometric work force has upgraded practice\n(although to an unknown extent) as standards have risen\nin the profession, practitioners have been pressured to\nmeet the new standards, and continuing education has\nbeen emphasized. It therefore becomes even more difficult\nto draw conclusions respecting optometrists active in\n1976 from this data.\n34. Spector, Renold, M.D.; Lightfoote, Johnson B.; Cohen, Phin, M.D.;\nand Claylack, Leo T. Jr., M.D. \"Should Tonometry Be Done by\nTechnicians Instead of Physicians?\" Arch. Intern. Med. V. 135,\nSeptember 1975.\n35. American Optometric Association, Committee on Public Health and\nOptometric Care. A.O.A. Guidelines on Vision Screening. J. Am.\nOpt. Assn. V. 43, No. 8, August 1972.\n36. New York State Optometric Association. NYSOA Proposed Standards\nfor New York State Regional Health Department Audit and Review\nStandards. N.Y.S.O.A., July 1975.\n37. American Medical Association. Draft Model Screening Criteria to\nAssist P.S.R.O.s. A.M.A. (unpublished). May, 1975, with\nunpublished comments of the American Optometric Association.\n38. National Academy of Sciences. First Interprofessional Standard\nfor Visual Field Testing. Committee on Vision, Assembly of\nBehavioral and Social Sciences, N.A.S., Washington, D.C., 1975.\n39. California Optometric Care Foundation. An Outline of the\nCalifornia Optometric Care Foundation's Optometrical Peer\nReview Program. c.o.c.f. (unpublished), September 1975\nLIBRARY GERALD R. FORD\n78\nATTACHMENT A\nSPECIFIC PROVISIONS FOR THE PRACTICE OF OPTOMETRY\nAS FOUND IN STATE LAWS AND BOARD REGULATIONS\nBased upon provisions of State optometric practice acts and\nboard regulations outlining the equipment which an optometrist\nmust have, a chart of functions/procedures has been compiled.\nIn most cases, only the functions expressly authorized in the\nlaws or regulations appear on the chart for a given State.\nHowever, where specific functions were not detailed, an analysis\nof the provision could often uncover implied functions. For\nexample, the Delaware licensing law authorizes optometrists to\n\"employ any objective or subjective means or methods for the\npurpose of determining the refractive powers of the human eyes\nand/or any visual, muscular or anatomical anomalies of the human\neyes and their appendages; or any ocular deficiency\". On the\nbasis of this definition, the chart for Delaware was composed to\nreflect the following procedures: external and internal examin-\nation, visual fields, visual acuity, refraction, and sensory\nmotor testing. The definition may in fact be broad enough to\nencompass all of the functions on the chart. If a provision\nempowers an optometrist to measure visual powers or visual range,\nthe chart will reflect visual acuity and visual fields. If the\nprovision defines \"optometry\" as the \"measurement\" or \"diagnosis\"\nof the human eye, it may be inferred that the authority to examine\nthe eye is granted.\nWhen both the express and implied functions are tabularized, the\nfollowing patterns appear. In each State, optometrists may or\nmust perform external and internal examinations of the eye.\nVisual acuity testing is either part of the required minimum\nexamination of each patient or a function expressly or impliedly\npermitted in the laws and regulations of 34 States. Visual fields\nmeaurement is required or permitted in 33 jurisdictions. Twenty-\nseven States direct optometrists to keep patient histories for\nvarying periods of time.\nTwenty-four States mention refraction or measurement of refractive\npowers among the permitted or required functions of an optometrist.\nThe measurement of muscular anomolies or muscle balance falls\nwithin the practice of optometrists in 22 jurisdictions.\nEighteen States define the functions of an optometrist to include\nmeasurement of the amplitude of convergence and accommodation.\nIn eighteen jurisdictions, one of two situations occurred:\nFORD & LIBRARY GERALD\n79\neither the retinoscope was required equipment or the optometrist\nwas expressly authorized to perform a retinoscopy.\nPhoria and duction appeared 13 times among lists of conditions\nfor which each patient must be tested. In 13 States, either the\nkeratometer is required equipment or the measurement of corneal\nor curves is expressly within the scope of. practice of an optom-\netrist. Color testing and steropsis appeared 8 times each on\nthe minimum requirements lists for patient examination.\n\"Subjective findings far and near\" appears on six lists of\nconditions which must be tested as part of a minimum patient\nexam, while \"trial case\" appears on five lists. Only three States\ninclude consultation with the patient, advice, or follow through\non lists of required procedures.\nTo date only 10 States expressly require, by statute or regulation,\nthat an optometrist refer patients in need of other professional\ncare to the appropriate professions. On this chart, the following\nabbreviations were used to indicate the location of the referral\nprovision:\nD\n- Definition section\nDisc.\n- Disciplinary provision (Suspension and revocation)\nM.E.\n- Minimum Examination of Patients provision\nPol\n- Statement of policy\nRec\n- Records provision\nFORD & LIBRARY GERALD\nSPECIFIC PROVISIONS FOR THE PRACTICE OF OPTOMETRY, 1975\nPATIENT HISTORY\nEXTERNAL EXAM OF THE\nINTERNAL OPTH. EXAM\nSENSORY MOTOR/MUSCLE\nEYE 1\nBALANCE\nVISUAL FIELDS\nREFRACTION\nVISUAL ACUITY\nTONOMETRY\nCOLOR TESTING\nSUBJECTIVE FINDINGS\nNEUROLOGICAL ASSESS-\nMENT\nPHORIA AND DUCTION\nTRIAL CASE\nCONSULTATION. ADVICE\nFOLLOW-THROUGH\nCORNEAL CURVATURE\nMEASUREMENTS\nRETINOSCOPY\nFUSION\nSTEREOPSIS\nAMPLITUDE OF CONVER-\nGENCE & ACCOMODATION\nREFERRALS\na. SECTION\nb. CITES\nGERALD\nFORD & LIBRARY\n15\n=\nI.\na\nX\nX X X\n4\n4\n5\na\nX\nX\nX\ns\n5\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\n4\nX\n41\n4\nF.\nX\nX\n'1\nX\nX XX X X XIX\nif\n4\nXIX\nX 1 X X\n4\nX\nX\nX\nX\nX\nColorado\nX\nX\nX\nA\nis\nX\nX\n2\nc/s\n2-40-125\n=\n1.6.\nX\nX\nX\nX\nX\nX X\n4 4\nXIX\nVIX\nX\nX\nX\nX\n--\nre\nX\nX\nX\nXIX\nX\nX X\nX\nX\nX\nX\nG\nX\nX\n1\nX\nX\nX\nin\n's\nX\n14\nX\nXXIX\nX\nX\nX\nX\n\",\nX\nX\nX\nX\nDi\nX\nX\nX\nof\nyy\nX X4 X\nC/R\nXIV P 18\nX\nX\nX\nX\nX\nX\nX\nX\nX\nis\nas\nX\n4\nX\nx4\nY.\nX\nX\nX\nX\nX\nD\nReg\n65-6-6\nX\nX\nXIX\nX\nX\nX\nX\nX\nX\nX\nX X XIX\nXXX\nX\nX\nX\nX\nM\n1\n/3\n$2567\nX\n:\nX\ne\n=\nS\n2\nX\nX\nX\nX\nX\nX\nX\nX\n=.\nX X X X\nX\nX\nX XM\nX\nIntende\nXMX\n$ '1\nX\nXIX\nX X\nX\nY.\nX\nX\nD\n338.291\n=\nX\nX\n4\nX\nX X X\nReg\n-\nReg\n/Reg\nOpt. 3\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nM.L\nLi\nales 1E & 21\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\n4\nit\nX\nX\nX X\nX\nX\n4\nX\nX\nX\n:\nI\nX\nV\nw\nX X X\nX\nX\nX\nX\nX\nX\nX\nM\nCO\nX\nis\nX\nX\nYork\nX\n\"2\nX\n*\n0\nNorth Carolina\nX\nX\n\"1\nX\nX\nr\nX\n80\nSPECIFIC PROVISIONS FOR THE PRACTICE OF OPTOMETRY, 1975 (CONTINUED)\nPATIENT HISTORY\nEXTERNAL EXAM OF THE\nINTERNAL OPTH. EXAM\nSENSORY MOTOR/MUSCLE\nEYE\nBALANCE\nVISUAL FIELDS\nREFRACTION\nVISUAL ACUITY\nTONOMETRY\nCOLOR TESTING\nSUBJECTIVE FINDINGS\nNEUROLOGICAL ASSESS-\nMENT\nPHORIA AND DUCTION\nTRIAL CASE\nCONSULTATION, ADVICE,\nFOLLOW-THROUGH\nCORNEAL CURVATURE\nMEASUREMENTS\nRETINOSCOPY\nFUSION\nSTEREOPSIS\nAMPLITUDE OF CONVER-\nGENCE & ACCOMODATION\nREFERRALS\na. SECTION\nD. CITES\nNorth Dekota\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nChin\nX\nX\nChichenn\nX\nX\nX\nX\nX\nX\nCrecon\nX\nX\nX\nX\nX\nX\nX\"\nX\nX\nRec/Reque 10-045\nX\nX\nX\nX\nX\nX\nX\nX X\nX\nX\nX\nX\nX\nX\nD\n63 8231\nPhode\nX\nX\nX\nX\nX\nX\nX\nX\nX\nSouth Carolina\nX\"\nit\nX\"\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\"\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nPol\nReg 4\nVircinia\nX\nX\nX\nX4\nX\ny.4\nX\nX\nX\nX\nX\nMost\nX\nX\nX4\nX\nX4\nX\nWisconsin\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX4\nX4\nX4\nX\nX+\nX\nDistrict of\nColumbia\nX\nX\nlVisual fields (confrontation) and visual fields central (after age 40).\n?Including presbyonic findings if prescribed for.\n3Performed on patients after age 40 unless contra-indicated.\n4By implication/analysis.\nGERALD\n?\nFORD\nLIBRARY\n81\n82\nATTACHMENT B\nLAWS AND REGULATIONS RESPECTING THE\nUSE OF DRUGS BY OPTOMETRISTS, 1976\nDelaware optometrists may employ \"topical ophthalmic drugs for\ndiagnostic purposes only.\" The drugs for such diagnosis will be\nlimited to: topical anesthetics, mydriatics, cycloplegics, and\nmyotics. Each new applicant for licensure in Delaware will be\nexamined on the subject of pharmacology as it relates to optometry.\nPracticing optometrists must complete a refresher course in pharma-\ncology as it relates to optometry before employing these drugs.\nThis course must be given by an institution recognized by the\nNational Commission on Accreditation or the Delaware State Board\nof Examiners in Optometry.\nLouisiana permits optometrists to use \"topical ocular diagnostic\npharmaceutical agents.\" In the initial examination for licensure,\napplicants will be tested on \"general pharmacology and ocular\npharmacology as it applies to optometry with emphasis on the\ntopical use of diagnostic pharmaceutical agents to the eye.\"\nLouisiana defines diagnostic pharmaceutical agent as \"any chemical\nin solution, suspension emulsion, or ointment base other than a\nnarcotic which when applied topically to the eye, results in physio-\nlogical changes which permit more efficient or otherwise facilitates\nexamination of the external eye or its adnexa or the evaluation of\nvision or which is necessary to determine normal physiological\nfunction as part of an examination regimen.\"\nPrior to the employment of topical ocular diagnostic pharmaceutical\nagents by a licensed optometrist, that licensed optometrist must\nsubmit to the Louisiana State Board of Optometry Examiners satis-\nfactory evidence that the optometrist has successfully completed\ncourses, approved by the board, in pharmacology as they apply to\noptometry, with particular emphasis on topical application of\ndiagnostic pharmaceutical agents to the eye.\nOptometrists in Maine may use diagnostic drugs solely for \"the\npurpose of detecting any pathological condition or functional\nabnormality to the eye.\" Prior to employing these drugs, practic-\ning optometrists must obtain a diagnostic drug license by complet-\ning \"a course in general and ocular pharmacology as it applied to\noptometry approved by the board.\" Furthermore, \"each use of a\ndiagnostic drug shall be noted in writing and shall be made part\nof the record of each examination and placed on file.\" Licensure\nFORD & LIBRARY GERALD\n83\nexaminations for all new applicants will include the \"subject of\ngeneral and ocular pharmacology as it relates to optometry and\nthe use of topically applied diagnostic drugs.\nEvery individual desiring to commence the practice of optometry\nin Oregon after January 1, 1976, or to use diagnostic drugs in\nhis practice shall have satisfactorily completed \"a course in\npharmacology as it applies to optometry, by an institution accred-\nited by a regional or professional accreditation organization\nwhich is recognized or approved by the National Commission on\nAccrediting or the United States Commissioner of Education with a\nparticular emphasis on the topical application of diagnostic\nagents to the eye for the purpose of examination of the human eye\nand the analysis of ocular functions.\" The Oregon Board of\nExaminers must designate those diagnostic pharmaceutical agents\nwhich may be used in practice of optometry. Categories for\nselecting such drugs shall be cycloplegics, mydriatics, topical\nanesthetics, dyes such as fluorescein and, for emergency use only,\nmiotics.\nIn Pennsylvania, the Secretary of Health shall determine the\nspecific agents optometrists may use. The determination shall be\nmade from the following categories: cycloplegics, mydriatics,\ntopical anesthetics and miotics which are applied topically.\nLicensed optometrists may employ these agents only after complet-\ning \"a course in pharmacology as it applies to optometry, by an\ninstitution accredited by a regional or professional accreditation\norganization which is recognized or approved by the National\nCommission on Accrediting or the United States Commissioner of\nEducation with particular emphasis on the topical application of\ndiagnostic pharmaceutical agents to the eye for the purpose of\nexamination of the human eye and the analysis of ocular functions.\"\nThe examination for licensure will include the subject of pharma-\ncology as it applies to optometry.\nIn Rhode Island, only those presently licensed optometrists who\nhave \"(i) satisfactorily completed a course in pharmacology, as\nit applies to optometry, at an institution accredited by a\nregional or professional accreditation organization which is\nrecognized by the National Commission on Accreditation, with\nparticular emphasis on drugs to the eye for the purpose of detect-\ning any diseased or pathological condition of the eye, approved\nby the Board of Examiners in optometry and the chief of pharmacy\nin the Department of Health, and (ii) have successfully completed\nan examination given by the Board of Examiners in conjunction\nwith the Chief of Pharmacy of the Department of Health, shall be\npermitted to apply drugs topically to the eye. Said Chief of\nPharmacy shall consult and advise the Board of Examiners in\noptometry with respect to that portion of the examination dealing\nFORD & LIBRARY GERALD\n84\nwith pharmacology. The standard examination for licensure in\noptometry shall also include pharmacology as it applies to\noptometry with particular emphasis on the topical application of\ndiagnostic drugs.\nIn order to employ diagnostic drugs in their practice of optometry,\noptometrists in Tennessee must demonstrate \"professional competence\nand transcript credit of at least six (6) quarter hours in a course\nor courses in general and ocular pharmacology with particular\nemphasis on diagnostic pharmaceutical agents applied topically to\nthe eye, from a college or university accredited by a regional or\nprofessional accreditation organization which is recognized or\napproved by the National Commission on Accrediting or the United\nStates Commissioner of Education. It specifies, further that\n\"the optometrists so qualified are authorized to utilize in con-\nnection therewith diagnostic pharmaceutical agents (miotics,\nmydriatics, cycloplegics and anesthetics), applied topically only.\"\nWest Virginia now defines optometry as \"the examination of the\nhuman eye, with or without the use of drugs prescribable for the\nhuman eye, which drugs may be used for diagnostic or therapeutic\npurposes for topical application to the anterior segment of the\nhuman eye only and, by any method other than surgery, to diagnose,\ntreat or refer for consultation or treatment any abnormal condi-\ntion of the human eye or its appendages.\"\nOnly two of these, Maine and Rhode Island, expressly state that\nthe diagnostic drug shall be used only for detecting any diseased\nor functional abnormality of the eye. All laws prohibit the use\nof ocular drugs or pharmaceutical agents in \"treatment\" of\ndisease.\nThe optometric practice acts of three States amended the definition\nof optometry to extend the scope of vision care without the use of\ndrugs. Alabama enlarged the practice of optometry to \"(a) ascer-\ntaining the status of the human visual system, including the\nrefractive and functional abilities thereof; or (b) ascertaining\nthe presence of ocular disease or ocular manifestations of\nsystemic disease and any other departure from the normal which\nmay require referral to other health care practitioners.\"\nIdaho permits optometrists to \"employ in the examination, diagnosis,\nor treatment of another, any means for the measurement, improvement,\nor development of any or all functions of human vision or the\nassistance of the powers of range of human vision or the determin-\nation of the accommodative or refractive status of human vision or\nthe scope of its functions in general. 11\nNew Mexico enacted legislation in 1973 to define practice of\noptometry to prohibit the use of drugs.\nBERALD FORD\n85\nThe State of Washington, in its definition of the practice of\noptometry, permits the use of any \"diagnostic instruments or\ndevices for the examination or analysis of the human vision\nsystem.\" It is doubtful that these four provisions extend to\ndiagnostic pharmaceutical agents.\nOther legislative authorities have addressed these changes in\ndefinition. The Rhode Island State Supreme Court Decision upheld\nthe constitutionality of the Rhode Island amendment which was\npassed in 1971. This decision of Marcy 27, 1974, remitted the\ncase to the Superior Court, where no further action was taken,\nthus ending the matter. Optometrists in the State of Rhode\nIsland have utilized pharmaceutical agents for diagnostic purposes\nsince 1974.\nA recent Louisiana Attorney General's opinion held that the new\nlaw \"does not illegally encroach upon the practice of medicine.\"\nAlso opinions of State Attorneys General in Florida, Indiana,\nNevada, and New Jersey state that there is no statutory prohibi-\ntion in those States which preclude the utilization of pharmaceut-\nical agents for diagnostic purposes by optometrists.\nFORD LIBRAR if GERALD\n1\nVIOI in\nColorado\nCalifornia\nAlaska )\nAlabama\nLIBRARY OROF BERALD\n)\nG\n5\n)\nHV\na\nG\n11\n',\nX\nX\nX\nX\nX\n:-\nX\nGeometric Optics\nX\n:-\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\n:-:\nX\nX\nOcular Anatomy\nX\n:-:\nX\nX\nX\nX\n:-\nX\nX\nX\nX\nX\nX\nX\nOcular Pathology\nX\nX\nX\nX\n:-\nX\n:\nX\n:-\n:-:\nX\nX\nOcular Physiology\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nTheoretical Optics\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nPractical Optics.\nX\nX\nX\nX\nX\n,\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nPhysiological Optics\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nTheoretical Optometry\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nA\nX\nX\nPractical Optometry\nX\nX\nX\nHygiene\nX\nX\nX\nX\nPsychology\nOptical Laboratory\nX\nX\n& Clinical Work\nX\nX\nX\nX\nX\nX\n%\nX\nX\nVisual Training/\nOrthoptics\nX\nX\nX\nX\nX\nX\nX\nContact Lenses\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nGeneral Anatomy\nX\nX X X\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nPsysiology\nX\nX\nX\nX\nX\nX\nPathology\nMathematics (as\nX\nX\nX\nrelated to 0)\nX\nX\nX\nPhysics\nX\nX\nX\nX\nX\nX\nX\nOptics\nSUBJECT MATTER MASTERY REQUIRED FOR INITIAL STATE LICENSURE OF OPTOMETRISTS\nX\nX\nOcular Examination\nX\nX\nX\nX\nX\nRefraction\nCase Analysis\nX\nX\nPrescribing &\nX\nX\nX\nFitting\nDuplication\nX\nX\nX\nX\nClinical Optometry\nX\nX\nX\nX\nX\nPharmacology\nX\nX\nPhysical Optics\nX\nX\nMechanical Optics\nX\nX\nX\nPsychological Optics\nX\n:-:\nTonometry\n:<\nOcular Myology\n98\nX\nOcular Neurology\nSUBJECT MATTER MASTERY REQUIRED FOR INITIAL STATE LICENSURE OF OPTOMETRISTS 4 (CONTINUED)\nGeometrics Optics\nOcular Anatomy\nOcular Pathology\nOcular Physiology\nTheoretical Optics\nPractical Optics\nPhysiological Optics\nTheoretical Optometry\nPractical Optometry\nHygiene\nPsychology\nOptical Laboratory\n& Clinical Work\nVisual Training/\nOrthoptics\nContact Lenses\nGeneral Anatomy\nPsysiology\nPathology\nMathematics (as\nrelated to 0)\nPhysics\nOptics\nOcular Examination\nRefraction\nCase Analysis\nPrescribing &\nFitting\nDuplication\nClinical Optometry\nPharmacology\nPhysical Optics\nMechanical Optics\nPsychological Optics\nTonometry\nDcular Myology\nOcular Neurology\nNorth Dakota 5\nOhio:\nX\nX\n!\nX\nX\nX\nX\nX\nX\nOklahoma\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX X\nOregonl,2\nX\nX\nX\nPennsylvania2\nX\nX\nX\nX\nX\nX\nX\nX\nX\nPhode Island\nX\nX\nX\nX\nX\nX\nX\nX\ny\nSouth Carolina\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nSouth Paketal\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nTennesseet\nX\nX\nX\n:\nX\nX\nX\nX\nX\nX\nX\nTennsit\nX\nX\nX\nX\nX\nX\nUtahi\nX\nX\nX\nX\nX\nX\n5\nVirginia++\nX\nX\nX\nWashington\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX X\nXX\nWest Virginia\nX\nX\nX\nX\nX\nX\nX\nWisconsin-\nX\nX\nX\nX\nWyoming\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nDistrict of\nX\nX\nX\nX\nX\nX\nX\nX\nX\nX\nColumbia\n1 Plus those courses the Board may require.\n2 Accepts National Board Exam.\nActual course requirements.\n5 Except as specified, indicates subject/matter required to be covered in an examination\nFORD s LUBRARY GLARD\nNot specified\n87\nBERALD FORD LIBRARY\nREQUIREMENTS FOR INITIAL STATE LICENSURE OF OPTOMETRISTS\nPersonal Qualifications\nEducation\nExamination\nCood\nNumber of time\nState\nAge\nCitizenship\nCharacter\nOther\nPreliminary Professional Experience\nWritten Oral Practical Proficiency Candidate may\nbe reexamined\nAlabama\n21\nX\nX\nH.S.\nX\n3 mos.\nX\nX\nAlaska\n21\nX\nH.S.\nX\nX\nX\nX\nArizona\nX\nH.S.\n(1)\nX\n75%\nArkansas\n21\nX\nX\nx⁷\nx⁷\nCalifornia\n18\nX\nH.S./60 hrs. 2800 hrs.\nx5\nX\n75%\n32\nCollege\nColorado\n21\nX\nX\nX\nX\nX\nX\n75%\nConnecticut\n18\nX\nH.S.\n4 yrs.\nx5\nX\nDelaware\nX\nII.S./2 yrs.\n4 yrs. 3\n6 mos.\nx5\nX\nX\n75%\nCollege\nFlorida\n18\nx4\nX\n4 yrs.\nx11\nGeorgia\n21\nX\nH.S./2 yrs.\n3 yrs.\nX\n75%\nCollege\nHawaii\n18\nX\nH.S.\nX\nX\nX\n75%\nIdaho\n21\nX\nX\nx5\nX\nX\nIllinois\n21\nX\nX\nH.S./1 yr.\n3 or 4 yrs.\nx5\nX\nX\n75-60%\n8\n32\nIndiana\n18\nX\n2 yrs. Coll.\n4 yrs.\nX\nIowa\nH.S.\n4 yrs.\nx5\nX\nX\n75-65%\n8\n2\nKansas\nX\nX\nH.S.\n4 yrs.\nX\nX\nKentucky\n18\nX\nX\nH.S.\n5 yrs.\nx5\nX\n12\n75-60%\n8\nx2\nLouisiana\nX\nX\nH.S.\nX\nX\nMaine\n18\nX\nX\nX\nX\nMaryland\n18\nX\nH.S./2 yrs.\n4 yrs.\nX\nX\nX\nCollege\nMassachusetts\n18\nX\nH.S.\n3 yrs.\nX\nX\n70%\nx2\nMichigan\n18\nX\nH.S./2 yrs.\n4 yrs.\nX\n75%\nCollege\nMinnesota\nX\n2 yrs. Coll.\nX\nx5\nX\n2⁶\nATTACHMENT D\nMississippi\n21.\nX\nH.S.\nX\nx9\nX\nMissouri\n21\nX,\nH.S./x¹³\nx¹³\nX\nX\nX\nMontana\n18\nX\nX\nH.S.\n4 yrs.\nx5\nX\nX\n75%\nNebraska\n21\nX\nX\nH.S./2 yrs.\n3 yrs.\nX\n75-60%\nCollege\nNevada\n21\nX\nX\nH.S./2yrs.\n4 yrs.\nX\nX\n75%\nCollege\nFORD & LIBRARY GERALD\nREQUIREMENTS FOR INITIAL LICENSURE OF OPTOMETRISTS (CONTINUED)\nPersonal Qualifications\nEducation\nExamination\nGood\nNumber of time\nState\nAge\nCitizenship\nCharacter\nOther\nPreliminary\nProfessional\nExperience\nWritten\nOral\nPractical\nProficiency\nCandidate may\nbe reexamined\nNew Hampshire\n18\nX\n2 yrs. Coll.\n4 yrs.\nx3,5\nX\nX\nNew Jersey\n21\nX\nX\nResidency\nH.S./2 yrs.\n4 yrs.\nCollege\nx5\nX\nNew Mexico\n18\nx4\nX\nH.S./College\nX\nX\nx7\nX\n75%\nNew York\n21\nX\nX\nX\nX\n75-60%8\nNorth Carolina\n21\nX\n4 yrs.\nX 10\nx5\nX\nX\n75-60%\nNorth Dakota\n18\nX\nH.S.\nX\nX\nx⁷\nChio\n21\nX\nX\n2 yrs. Coll.\n3 yrs.\nX\n75%\n4\nOklahoma\n21\nX\nH.S.\nX\nX\n75%\n12\nOregon\n18\nX\n4 yrs.\n1 yr.(I)\nx5\nPennsylvania\n21\nX\nX\nX\n75%\nRhode Island\n21\nX\nH.S./2 yrs.\n4 yrs.\n6 mos.\nX\nX.\nSouth Carolina\n21\nX\n2 yrs. Coll\n4 yrs.\nX\nX\nX\nSouth Dakota\n18\nX\nH.S.\nX\nx5\nX\n70%\nTennessee\n18\nX\nX\nH.S.\n4 yrs.\nx12\nx12\n75%\nTexas\n21\nX\nX\nH.S./2 yrs.\n4 yrs.\nX⁷\nX7\nx⁷\n75-70%\nUtah\n21\nX\nH.S.\n2000 hrs.\nX\nX\n75-60%\n8\nVermont\n18\nX\nH.S./2 yrs.\n4 yrs.\nx5\nX\nX\nCollege\nVirginia\n18\nH.S.\nX\nx5\nWashington\nX\nH.S.\nX\nXs\nWest Virginia\n18\nX\nH.S.\n2000 hrs.\nX\nWisconsin\n18\nX\nH.S./2 yrs.\n3 yrs.\nxs\nX\n75-70%\n8\nx6\nCollege\nWyoming\n19\nX\n4 yrs.\nX\n75%\nDistrict of\nColumbia\n21\nX\n2 yrs. H.S.\n5 yrs.\n1. 2 alternate methods (a) 5 year course in optometry (b) 3 year optometry course with 60 hours of college work\n2. Reexamined in failed area\n3. 6 month internship required after written examination and before any practical examination or receiving certificate to practice\n4. Or declared intent to become a citizen\n5. National Board accepted for written examination\n11. Exam required, form not specified\n6. Further education may be required after failure\n12. Either written or oral, not both\n7. At boards discretion\n13. Must graduate from an approved school of optometry. The school must\nS. Minimum in any one subject\nrequire for graduation a minimum of 5 terms of pre-optometric training\n68\n9. Applicant must pass a second exam after 1 year's practice\nin not less than 5 years.\n10. 2 week practice orientation\nGERALD FORD FIBRARY\nRENEWAL OF LICENSES AND CONTINUED EDUCATION FOR OPTOMETRISTS\nRenewal\nContinuing Education\nState\nPeriod\nRequired\nType\nDuration\n(yrs.)\nAlabama\n1\nX\n25 hours/yr.\nAlaska\n1\n2\nX\n(3)\n24 hours/2 yrs.\nArizona\n1\nArkansas\n1\nX\n(3)\n2days/yr.\nCalifornia\n1\nX\n1\n(2)\nColorado!\n1\nX\n24 hours/yr.\nConnecticut\n1\nX\n8 hours/yr.\nDelaware\n1\nX\n(3)\n12 hours/2 yrs.\nFlorida\n1\nX\n(3)\n24 hours/yr.\nGeorgia\n1\nX\n(3)\n10 hours/yr.\nHawaii\n1\nX\n(3)\n8 hours/yr.\nIdaho\n1\nX\n(3)\n12 hours/yr.\nIllinois\n1\nX\n6\n(5)\n(5)\nIndiana\n1\nX\n(3)\n12 hours/yr.\nIowa\n1\nX\n(3)\n12 hours/yr.\nKansas\n1\nX\n(3)\n2 days/yr.\nKentucky!\n1\nX\n(3)\n8 hours/yr.\nLouisiana\n1\nX\n(3)\n12 hours/yr.\nMaine\n1\nX\n(3)\n20 hours/yr.\nMaryland\n1\nX\n(3)\n25 hours/yr.\nMassachusetts\n1\nX\n(4)\n(4)\nMichigan\n1\nX\n(3)\n12 hours/yr.\nMinnesota\n1\nX4\n(4)\n12 hours/yr.\nMississippi\n1\nX\n(4)\n20 hours/yr.\nMissouri\n1\nX\n(3)\n8 hours/yr.\nMontana\n1\nX\n(3)\n12 hours/yr.\n3 ATTORMENT\nNebraska\n1\nX\n(3)\n16 hours/yr.\nNevada\n1\nX\n24 hours/yr.\nNew Hampshire\n1\nX\n(3)\n25 hours/yr.\nNew Jersey\n1\nX\n(3)\n50 hours/2 yrs.\nNew Mexico\n1\nX\n(3)\n2 days/yr.\nNew York.\n2\n06\nNorth Carolina\n1\nX\n(3)\n10 hours/yr.\nFORD i LIBRARY GERALD\nRENEWAL OF LICENSES AND CONTINUED EDUCATION FOR OPTOMETRISTS\nRenewal\nContinuing Education\nState\nPeriod\nRequired\nType\nDuration\n(yrs.)\nNorth Dakota\n1\nX\n(3)\n18 hours/3 yrs.\nOhio\n1\nX\n(3)\n12 hours/yr.\nOklahoma\n1\nX\n(3)\n2 days/yr.\nOregon\n1\nX\n(3)\n12 hours/2 yrs.\nPennsylvania\n2\nRhode Island\n1\nSouth Carolina\n1\nX\n(3)\n6 hours/yr.\nSouth Dakota\n1\nX\n(3)\n8 hours/yr.\nTennessee\n1\nX\n(3)\n18 hours/yr.\nTexas\n1\nX\n(3)\n12 hours/yr.\nUtah\n1\nVermont\n1\n1\n7\nVirginia\nX\n(3)\nNot to exceed 16 hours/yr.\nWashington'\n1\nWest Virginia\n1\nX\n(3)\n8 hours/yr.\nWisconsin\n1\nX\n(3)\n10 hours/yr.\nWyoming\n1\nX\n(3)\n25 hours/yr.\nDistrict of Columbia\n1. Board regulations being developed.\n2. Requires satisfactory proof that licensee has stayed abreast of present developments by means\nof Continuing Education.\n3. Optometric or other scientific education, lecture, symposium or course approved by board and\npostgraduate study at school of optometry or course given by Optometric Association.\n4.\nSet by board\n5. Determined by examining committee\n6. Effective May 1977.\n91\n7. Effective August 1976.\n92\nSECTION II-C\nOPTOMETRIC EDUCATION\nCompiled by\nDavid B. Hoover, M.P.H.*\nThe responsibilities and function of health professionals are to a\nlarge extent defined by the basic occupational preparation for the\nprofession. The organization of health care is such that personnel\ntend to be utilized to the limit of their capacities, especially in\ninstitutional settings and subject to limits and sometimes vague\nconstraints in law. Typically, legal or other formal recognition\nof a responsibility or function of a particular health occupation\nfollows its adoption by some practitioners and its incorporation\ninto educational objectives and philosophy.\nAn examination of how optometrists are educated therefore contributes\nat least as much to understanding their functions and capabilities\nas does analysis of the legal basis for practice or the data that\nare available about practice itself.\nThere are thirteen schools of optometry in the United States. The\noldest was established in 1870, the youngest in 1975. Seven are\nschools or colleges within public universities (or in one case\nwithin a State college). Five are private and independent insti-\ntutions, and one is a school within a private university. All meet\nthe accreditation standards of the council on education and pro-\nfessional guidance of the American Optometric Association.\nAdmission to a school of optometry requires at least two years of\ncollege study\nThe optometry professional curriculum itself is\nfour years long, leading to the degree of Doctor of Optometry (O.D.).\nSeven schools also have graduate programs which grant a Master of\nScience degree, and six have programs leading to a Ph.D. in\nphysiological optics. Enrollment in optometry schools ranges from\n85 to 566, with an average of about 300; a class size is about\none-fourth of this. A list of schools and their enrollments is\nfound as attachment A to this section.\nThe Development of Optometric Education\nEducation for the health professions has evolved from informal\napprenticeship in on-the-job types of training to the present\n*Associate Director for Program Planning and Evaluation, Division of\nAssociated Health Professions, Bureau of Health Manpower, Health\nResources Administration, Department of Health, Education, and Welfare.\nFORD & LIBRARY GERALD\n93\nelaborate, formal, and controlled systems found in medicine,\ndentistry, optometry, pharmacy, and other diciplines. Organized\noptometric education dates from the nineteenth century, beginning\nwith schools in which students served a formal apprenticeship under\na successful practitioner. Specialized educational institutions\nemerged rapidly as, in the latter half of the century, there were\nmany advances in optics and in the application of optical principles\nto the correction of vision 2/ Ohio State University dates its\neducation in optometry from 1870, and the independent Illinois\nCollege of Optometry from 1872.\nA university program (now defunct) was established at Columbia\nUniversity in 1910, and full four-year programs leading to the O.D.\ndegree at Ohio and the University of California at Berkeley. These\nearly university courses were usually conceived of as a division\nwithin the general study of Physics. In time, however, the emphasis\nin optometry shifted toward the physiological aspects of vision and\nthe programs became distinct from physical optics\n3/\nAs optometry began to be recognized as an appropriate subject for\nuniversity education, there was a corresponding movement within the\nprofession to standardize the qualifications for optometric schooling\nand actual course offerings at the various colleges. The 1912\nconvention of the American Optometric Association adopted a resolution\nconcerning educational standards of qualification for practice. The\nstandardization and upgrading of education has continued to the present\nday, stimulated by new knowledge of vision disorders, technological\nadvances in diagnosis, treatment, and rehabilitation, obvious unmet\nneeds for optometric services, and more stringent requirements for\nlicensure and educational program accreditation.\nDevelopment of the Accreditation Process\nThe International Association of Boards of Examiners in Optometry,\n(IAB) was created in 1922. At a \"Conference to Establish Optometric\nStandards\" held in St. Louis that same year, it was resolved that\nthe process of accreditation should include adoption of a uniform\nsyllabus by all the schools\n4/\nDuring 1925 and 1926 the accreditation process, which involved on-\nsite inspections by a committee of the IAB, was commenced.\nAccrediting procedures were continually refined, with the AOA's\nCouncil on Education and Professional Guidance eventually taking\nover the function of the IAB in this area by 1941.*\n*The Council is recognized by the Commissioner, U.S. Office of\nEducation, as the official accrediting agency for schools of\noptometry.\nFORD & LIBRARY GERALD\n94\nAt a 1936 meeting of representatives from the AOA, IAB, American\nAcademy of Optometry and most of the schools and colleges, it was\nfirst proposed that a four year curriculum be implemented by all\nthe educational institutions 5/ The Council on Education and\nProfessional Guidance produced in 1941 a manual of accrediting which\nis now in its eighth (1975) edition.\nThe Association of Schools and Colleges of Optometry.\nThe Association of Schools and Colleges of Optometry was organized\nin 1941, with the goal of \"aid in the advancement of optometry by\ngiving attention to the problems of the education of optometrists,\nand by formulating and supporting desirable educational standards\nand policies. Today the Association represents the thirteen\nschools and colleges of optometry in the United States and two\nprograms in Canada, with nearly 4,000 optometric students. The\nAssociation incorporated in 1972 and established a staffed national\noffice in 1974, which publishes a monthly newsletter, the ASCO\nEDUCATOR, and a quarterly JOURNAL OF OPTOMETRIC EDUCATION (JOE).\nASCO maintains standing Councils in three major educational areas;\nAcademic Affairs, Student Affairs, and Institutional Affairs. The\nCouncil on Academic Affairs is currently working on a major policy\nstatement concerning curricular standards for optometry programs.\nThe effort began in 1973 and a preliminary curriculum model was\nrecently presented to the Board of Directors and published in the\nJournal of Optometric Education. The same Council has developed\nguidelines for optometric residency programs and post-graduate\npharmacology training. Currently, the Council is developing a\nproposal to study the feasibility of conducting an organized and\nstructured national program of continuing education for practicing\noptometrists, using the schools and colleges as a base.\nThe Council on Student Affairs has developed and produced the\nOptometry College Admissions Test. The test is administered to\nover 4,000 applicants yearly throughout the U.S. and Canada, and is\nrequired as part of the admissions process at each member institution.\nNational Board Examinations\nIf there is large variation from State to State in the subject matter\nin which a candidate is examined for licensure, and especially if\nsome of the subjects are no longer relevant to proficiency in\npractice, educational programs for that occupation are faced with\na dilemma. Training the student to master all of the subjects on\nwhich he may be examined becomes difficult or impossible as well\nas undesirable. The examinations will not represent, collectively,\na suitable set of educational objectives. Optometry found itself in\nthis position in the 1940's, with the additional complication that\nrapid advances in optometric knowledge were quickly making exam-\ninations obsolete. A uniform national examination that could be\nGERALD FORD LIBRARY\n95\nadopted by States as a licensing examination seemed in order.\nBoth the IAB and ASCO constituted committee in 1950 to formulate\nproposals for a National Examining Board of Optometry, and estab-\nlished the National Board of Examiners in Optometry in 1951.\nCurrently the national examination is administered over a two day\nperiod in April and involves approximately nineteen hours of\ntesting. It serves as the written examination for licensure in 18\nStates currently. Candidates are examined in the areas listed\nbelow:\nVisual Science\nOcular Pathology\nTheory and Practice of Optometry\nTheoretical Optics\nOphthalmic Optics\nOcular Anatomy\nSocial, Legal, Ethical, Economic and Professional\nAspects of Optometry\nOcular Pharmacology\nDuring the 1950's, most of the schools adopted first a five and\nthen a six year program of studies, including four years of pro-\nfessional instruction leading to a doctor of optometry degree.\n\"The move from a two year to a four year professional course over\nthe past 25 years has resulted in much more clinical experience\nfor the optometry student, now commencing in the second year and\nexpanding until, in the fourth year, he devotes at least half-time\nto work under supervision in the clinic. He gains experience in\nsuch areas as contact lenses, low vision, children's vision and\nvision therapy, in addition to basic visual analysis and the pres-\ncription of lenses\n8/\nThe sixties had witnessed a sharp rise in the number of applicants\nseeking admission to colleges of optometry. As a step toward\nsecuring highly qualified candidates as potential optometrists,\nASCO explored the feasibility of instituting a national entrance\nexamination for all prospective optometry students. The first\nOptometry College Admissions Test (OCAT) was administered in 1971,\nand by 1972 the test was offered using approximately the same\nformat in existence today 9/\nEducational Philosophy and Objectives\nAlthough each of the individual schools and colleges has developed\nits own philosophy and objectives for optometric education, certain\nprinciples are stated by all of the institutions. Chief among these\nare: providing a high quality educational program intended to\nFORD & LIBRARY GERALD\n96\nprepare each graduate to conduct a practice which is competent,\nservice oriented and ethical and; stimulating any research which\nwill further existing knowledge in the visual sciences, usually\nthrough the medium of graduate programs.\nIn 1971 an eighteen month study was undertaken by the National\nCommission on Accrediting which examined all aspects of optometric\neducation. Under the direction of Robert J. Havighurst, Professor\nof Education and Human Development at the University of Chicago,\na report was prepared and subsequently published in 1973.\n\"Optometric Education, A Summary Report\" dealt with current trends\nand future goals of the professions under such topics as Manpower\nNeeds, The Scope of Optometry, and Financing Optometric Education.\nThe Commission recommended an ongoing review process in optometric\neducation, a recommendation which has received endorsement from\nthe optometric community.\nOptometric education has reflected the expanding role of the\noptometrist as a provider of primary health care. In the last\ntwenty-five years major modifications have taken place in the\neducational process. They can be measured both in additions to\nthe curricula of the schools and in the continuing revision of\nthe NBEO.\nAmong the courses that evidence the direction of optometric edu-\ncation are Pennsylvania College of Optometry's Environmental\nOptometry\" and Illinois Learning Disabilities of Children\", which\ncarry the following descriptions:\nEnvironmental Optometry\nThe student will be taught the application of standard\noptometric techniques as well as new and innovative\nprocedures for the detection. and correction of visual\nproblems resulting from changes and alterations in\nman's environment. Special problems of illumination;\nseeing under condition of movement, especially high\nspeed transport; reactions of the eye to smog and\npollutants; problems of vision in the industrial set-\nting; and classroom design to assist vision in the\neducational institution. This will serve to prepare\nthe future practitioner for the role of consultant on\nsuch matters. A concurrent laboratory will give the\nstudent exposure to experiences of working in these\nareas in the college building as well as external\ntraining centers (schools, factories, etc. )11/\nLearning Disabilities of Children\nThis seminar provides students with the opportunity\nof indepth discussions of issues in the complex field\nFORD & LIBRARY GERALD\n97\nof children's learning disabilities. The multidis-\nciplinary approach is considered in an analysis of the\ncontributions of several professional disciplines to\nthe overall optometric evaluation of treatment of the\nlearning-disabled child. 12/\nAdvanced Degrees\nOhio State was the first of the optometry schools to offer a master's\ndegree and later a Ph.D. in physiological optics, beginning its\nprogram in 1936. At the end of Work War II, the University of\nCalifornia at Berkeley initiated its own graduate curriculum. A\nfew years after its founding, Indiana conferred advanced degrees,\nwhile the College of Optometry at the University of Houston secured\napproval for a Master's program in 1971 and admitted students for\nPh.D. study in 1975. The University of Alabama and the State\nUniversity of New York are the schools with the newest programs for\nGraduate Study in Optometry. The schools which currently award the\nM.S. and Ph.D. degrees are seeking to develop qualified persons to\nbe primarily employed in teaching and research in vision science.\nThe graduate degree in physiological optics is available not only\nto O.D.s, but also to others with professional scientific back-\ngrounds. Also, a program at the Massachusetts College of Optometry\nprovides individuals who presently hold a Ph.D. degree with an\nopportunity to receive their O.D. in only two years. In the\nacademic year 1974-75 sixty-six students were enrolled in graduate\nprograms.\nEducation For Care of the Cataract and Aphakic Patient\nThe proper care of the cataract and aphakic patient requires specific\nknowledge, skills, and attitudes by the practicing optometrist, but\nno anomaly can be evaluated and treated as a separate entity.\nFurther, patients with aphakia or cataract, whether congenital,\ntraumatic, or degenerative, are subject to a high probability that\nother visual, ocular, or systemic anomalies will be present. The\nproper optometric care of any patient whether they have cataract,\naphakia, or other anomaly requires a full evaluation and analysis\nfollowed by a selection of treatment based on all of the anomalies\npresent, the needs and characteristics of the patient, the prognosis,\nand the possible interrelated effects of the proposed treatment\nprocedures. To provide this full scope of care the optometrist\nshould not only be trained in the care of cataract and aphakic\nproblems, but just as importantly he must be educated and trained\nto be concerned about all aspects of health care that may fall\nwithin his purview, and specifically to detect and manage visual\nand ocular problems and to enhance visual performance.\nAll optometry schools share certain basic curricular elements which\nfollow at least two years (and for the majority of students four years)\nFORD\n&\nGERALD\nLIBRARY\n98\nof undergraduate studies, predominately in the biological sciences.\nThe basic elements include:\n- A biological science component.\nThis includes gross and microscopic human anatomy,\ngeneral human physiology, biochemistry, and pharma-\ncological principles, all presented with emphasis on\nthe visual system and related structures.\n- Physiological optics.\nVision processes, visual stimuli, accommodation\nmechanisms, neurophysiological mechanism, ocular\nmotility, binocular perception.\n- Pathology\nEssentials of bacteriology and virology, principles\nof health and disease, tissue changes in pathology,\nocular diseases and abnomalities, ocular manifestations\nof systemic disease.\n- Optics\nLight, lenses, optical systems, ophthalmic materials.\n- Professional orientation (health practice)\nEpidemiological procedures, the epidemiology of specific\ndisorders, health care organization, public health,\ninterpersonal relations, management of practice.\n- Clinical skills\nPatient history, refraction, visual performance\nmeasurement, detection and diagnosis of visual anomalies\nand visually-related learning and perceptual disturbances,\nlow vision rehabilitation, care of the aging patient,\ncontact lens fitting.\nA more complete listing of this common subject matter is found in\nattachment B to this Section. The catalogues of the schools provide\nstill more detail.\nSome areas of the optometric curriculum have more information on or\nare directed more toward the care of the patient with cataract or\naphakia than others, but elements of the whole curriculum are\ninvolved in preparing the optometrist to care for such patients.\nThe understanding of the functioning and anomalies of the body as\nwell as the eye are involved. Elements of optics, pharmacology,\nand visual perception, understanding of the aging process, health\ncare delivery systems and the problems of the partially-sighted, as\nwell as patient care skills and experience, are involved in providing\ncare for the patient with cataract or aphakia. The entire optometric\ncurriculum fosters the broad range of knowledge, skills and attitudes\nnecessary to provide the needed optometric care for patients with a\n&\nFORD\nGERALD\nLIBRARY\n99\ndeveloping cataract, a clinical cataract, and with the problems of\naphakia.\n1. Geratric consideration: The patient with cataract or aphakia\nis generally elderly, and consequently the care of such patients\nnecessitates an understanding of the physiological, psycho-\nlogical, and sociological changes associated with aging. The\ndecrease in mobility and activity, the increase in illness and\naccidents, and the psycho-social problems of the elderly pose\nspecial problems to those providing health care to such patients.\n2. Low vision consideration: If the patient is a surgical high\nrisk patient and the cataractous lens is left in place, attempts\nare made to improve the visual performance with the use of low\nvision devices and/or modification of the visual environment.\nIn some patients (7% to 16%) who have the crystalline lens\nremoved, the corrected visual acuity is reduced, due to prior\nproblems or surgical complications. Low vision services may\nbe helpful to these patients, and therefore are often utilized\nin the care of patients with cataract or aphakia. Optometry\nspecializesin low vision aids, and all students are taught to\nunderstand their function and application and to recognize\nsituations in which they will be of benefit.\n3. Pathology consideration: Patients with cataract or aphakia are\ngenerally elderly and have a high incidence of systemic and\nocular pathological conditions with much use of therapeutic\ndrugs. The association of systemic disease and cataract\n(diabetic cataract, thyroid cataract, tetany cataract) and of\nocular disease and cataract (irodocyclitis, intraocular tumor,\nglaucoma) and the cataractogenic character of some drugs\n(steriods, miotics, antimitotics) needs to be understood by the\npractitioner for assistance in the early detection and care of\nsuch patients, and these subjects have received emphasis in\nthe optometric curriculum and in supervised clinical experience.\nAn understanding of ocular pathology, its causes, symptoms and\ndetection, and treatment is provided students to enable them to\nmake early detection of and prompt referral for complications\nof cataracts and cataract surgery such as secondary glaucoma,\ncorneal edema, retinal detachment, and the like. Effective\noptometric practice in this area requires integration and\nsynthesis of many basic elements in the optometric curriculum,\nthrough supervised clinical training.\n4. Optical consideration: Optometrists must be skilled in the\nfitting of contact lenses and ophthalmic lenses (spectacles) on\npatients with aphakia, who present special problems. The pres-\ncription of ophthalmic lenses induces several optical complications\nsuch as ring scotoma, increased peripheral prismatic effects and\nFORD & LIBRARY GERALD\n100\naberrations, increased magnification of the field, decreased\nfield, decreased field of view, thick lenses, convergence\nproblems, etc. If there is a unilateral aphakia there is the\nadditional problem of aniseikonia (a difference in image size\nbetween the two eyes). The capability of the elderly patient\nfor the physical management of contact lenses must be a factor\nin prescribing. Students call upon knowledge of basic optical\nprinciples, physiologic optics, and optical anatomy, among\nother subjects, to deal with these problems. An objective of\neducation and training is to have the practitioner skilled in\nthe fitting of contact lenses and ophthalmic lenses on patients\nwith aphakia, understanding the sources of the optical problems,\nand able to select the most appropriate lens design.\n5. Visual performance consideration: The ultimate aid of visual\nrehabilitation is to maximize visually-dependent functions,\nnot merely to obtain a particular correction of refractive\nerror. Visual performance is dependent upon many factors other\nthan acuity. For providing service to elderly and, especially,\naphakic patients the optometry student is taught this broad\nview of rehabilitation and the underlying concepts of health\nand health services.\nThe use of vision to relate the patient to his environment is\ndirectly related to the characteristics of the patient's\nretinal images. When an elderly patient has had good clear\nvision for several years, followed by a period of dim catar-\nactous vision, and then suddenly following cataract surgery\nhas clear but magnified and somewhat distorted retinal images,\nsignificant consequences can occur in his visual performance.\nOlder patients often have mobility problems, and the change in\ntheir perception of space brought about by the magnification\nand other optical problems of aphakic lenses can aggravate the\nmobility problem and produce a significant obstacle to their\nmoving about effectively in their environment. Since falling\nis the major cause of accidents in the elderly, and most of\nthem are aware of it, this changed perception of space can have\na profound impact on their activity. A visual rehabilitation\nto the new visual system must occur before the patient can\nreturn to somewhat near his pre-cataractous life style. Opto-\nmetry students obtain understanding of visual perception,\nvisual performance, lens design, and the problems of aging so\nthey will be equipped to design the best correction lens and\nto assist the patient with the necessary rehabilitation.\nFaculty\nThe nature of the faculty is recognized as a principal determinant\nof educational experience in the health professions. In Schools of\nOptometry the great majority of faculty are optometrists, as is to\nbe expected. Many of these advanced degrees are in optometry or other\nFORD is LIBRARY GERALD\n101\nfields. At the University of Alabama, for example, among 33 faculty\n20 hold higher degrees other than or in addition to the O.D.s\nincluding 12 Ph.D.s (7 in physiological optics, two in neuro-\nphysiology, and one each in biomedical science, physics, and\nexperimental psychology). Three faculty hold degrees in public\nhealth. At the Illinois College of Optometry, 21 faculty have\nadvanced degrees other than the O.D., including 10 Ph.D.s (psy-\nchology, pharmacology, microbiology, and biochemistry), 2 M.D.s\n(ophthalmology and anatomy), and 2 Ed.D.s.\nAt the Pennsylvania College of Optometry 30 faculty members hold\nadvanced degrees other than the O.D., including 18 Ph.D.s, 8\nMaster's degrees excluding the M. Opt., and 2 M.D.s. The Ph.D. in\nphysiological optics is becoming recognized as an appropriate point\nof entry into optometric education, but the faculty of the schools\nshows a diversification that is consonant with the broad range of\nsubject matter taught.\nOptometrists are primary providers of health care and as such are\nresponsible for determining whether the problem of the patient is\nwithin his scope of treatment or whether the patient should be\nreferred to another health provider. Optometric education includes\nspecific curriculum and clinical training related to the detection\nand diagnosis of ocular disease and ocular manifestation of\nsystemic disease. All schools include on their faculty and in\ntheir clinical programs physicians, and particularly ophthalmologists,\nin the training of optometric students. Particular attention is\npaid to the detection and diagnosis of cataract, the complications\nfollowing cataract surgery and the procedures for the selection of\ntherapy, management and proper followup of aphakic patients.\nOptometry students in their clinical training rotate through\naffiliated clinics in hospitals, nursing homes, and other community\nhealth facilities. Here they examine patients with cataract and\naphakia, and detect and diagnose ocular diseases related to these\nconditions as well as other ocular abnormalities.\nOn the basis of this educational and clinical experience the\noptometric student must demonstrate a mastery of the skills and\nknowledge necessary for the diagnosis and management of the cataract\nand aphakic patient for both graduation and licensure.\nThe training provides the capability to diagnose complications of\ncataract surgery such as shallow anterior chamber, secondary\nglaucoma, cystoid maculopathy, intraocular infection, Elschnig\nPearls, etc.; and the appropriate use of techniques such as bio-\nmicroscopy, gonisoscopy, tonometry, direct and indirect ophthal-\nmoscopy perimetry, etc., as well as the skilled use of standard\noptometric techniques applicable to patients with cataract or\naphakia (Such knowledge and skills on the part of optometrists\nare recognized by ophthalmologists in the regular referral patterns\nbetween individual optometrists and ophthalmologists in the care of\ncataract and aphakic patients.).\nFORD\nGERALD\nLIBRARY\n102\nFootnotes and Bibliography\n1/ According to The Association of Schools and Colleges of Optometry,\n53% of the 1975 entering class had baccalaureate degrees, and\nan additional 6% had a higher degree. Of applicants to optometry\nschools, 15% have also applied to medical schools and 14% to\ndental schools, and 16% and 15% have taken the respective admis-\nsions tests for these schools.\n2/ Hofstetter, Henry W., Optometry: Professional, Economic and\nLegal Aspects. St. Louis: The C.V. Mosby Company, 1948, P. 295.\n3/ Gregg, James R., American Optometric Association: A History.\nSt. Louis: American Optometric Association, 1972, PP. 51-52.\n4/ Hofstetter, Henry W., Optometry: Professional, Economic and\nLegal Aspects, P. 298.\n5/ National Academy of Sciences, Report of a Study: Costs of\nEducation in the Health Professions, Parts I and II, Washington:\nDepartment of Health, Education, and Welfare, 1974.\n6/ Carter, Darrell B. and Uglum, John R., \"The History, Activities\nand Present Status of the National Board of Examiners in\nOptometry,\" Journal of the American Optometric Association.\n37:2 (February, 1966) pp. 130-131.\n71 National Board of Examiners in Optometry, Topical Outline, 1976\nRevision. New York: NBEO, 1976.\n8/ Havighurst, Robert J., Optometric Education: A Summary Report.\nWashington: National Commission on Accrediting, 1973, P. 32.\n9/ Optometry College Admission Test, Handbook. New York: The\nPsychological Corporation, 1974, P. 1.\n10/ Havighurst, Robert J. (Op. Cit.)\n11/ Pennsylvania College of Optometry 1975/1976, Philadelphia:\nPennsylvania College of Optometry, 1975, PP. 50-51.\n12/ Illinois College of Optometry Catalog 1973-1975, Chicago:\nIllinois College of Optometry, 1973, P. 61.\nGERALD FORD LIBRARY\nCurrently Active Professional Programs in Optometry\nSchool or\nPublic/\nYear\nDegree (s)\nTotal\n1\nCollege Name\nCity\nState\nIndepen.\nEstab.\nOffered\nEnrollment\nICO\nChicago\nIllinois\nIndepen.\n18722\nO.D.\n532\nIU\nBloomington\nIndiana\nPublic\n1951\nO.D.,M.S.,Ph.D.\n266\nMCO\nBoston\nMass.\nIndepen.\n18943\nO.D.\n285\nPCO\nPhiladelphia\nPenn.\nIndepen.\n1919\nO.D.\n533\nPU\nPrivate\n1921\n4\nForest Grove\nOregon\nO.D.,M.S.\n294\nSCCO\nFullerton\nCal.\nIndepen.\n19045\nO.D.\n307\n6\nSCO\nMemphis\nTenn.\nIndepen.\n1932\nO.D.\n566\nSUNY\nNew York\nNY\nPublic\n1970\nO.D.,M.S.,Ph.D.\n85\nTOSU\nColumbus\nOhio\nPublic\n18707\nO.D.,M.S.,Ph.D.\n218\nUAB\nBirmingham\nAlabama\nPublic\n1969\nO.D.,M.S.,Ph.D.\n98\nUCB\nBerkeley\nCal.\nPublic\n19238\nO.D.,M.S.,Ph.D.\n231\nUH\nHouston\nTexas\nPublic\n19529\nO.D.,M.S.,Ph.D.\n264\n10\nFerris State\nBig Rapids\nMichigan\nPublic\n1975\nO.D.\n20\n1\n1974-75 Annual Survey of Optometric Institutions, Council on Optometric Education, American\nOptometric Association.\n2\nBegan as Northern Illinois College of Ophthalmology and Otology, later the Northern Illinois\nCollege of Optometry.\n3\nBegan as Klein School of Optics, adopted the name Massachusetts College of Optometry in 1909,\nwill change to New England College of Optometry in 1976.\n4\nOperated as North Pacific College until 1945, when its charter was transferred to Pacific University.\n5 Founded in 1904 under the name Los Angeles College of Optometry, the present name was adopted in 1972.\n6 Founded by J.J. Horton, changed to non-profit status in 1944.\n7\nFirst established as a division of the Physics Department, became a separate school in 1952.\n8\nFounded as a division of the Physics Department. In 1941 a separate school was established.\nAttachment A\n9\nOriginally a private school, the school became state supported in 1963.\n10\nPresently only the first year class is enrolled.\n*\nSee attached page for full names.\nFORD is GERALD LIBRARY\n103\n104\nAttachment\nICO - Illinois College of Optometry\nIU - Indiana University, School of Optometry\nMCO - Massachusetts College of Optometry\nPCO - Pennsylvania College of Optometry\nPU - Pacific University, College of Optometry\nSCCO - Southern California College of Optometry\nSCO - Southern College of Optometry\nSUNY - State University of New York, College of Optometry\nTOSU - The Ohio State University, College of Optometry\nUAB - University of Alabama in Birmingham, School of Optometry\nUCB - University of California, Berkeley, School of Optometry\nUH - University of Houston, College cf Optometry\nFerris State - Ferris State College, College of Optometry\nFORD in GERALD LIBRARY\n105\nATTACHMENT B\nBASIC ELEMENTS OF THE CURRICULUM OF SCHOOLS OF OPTOMETRY\n1. Biological science knowledge base.\na. Gross human anatomy and microscopic anatomy, with emphasis\non head, neck, and thorax.\nb. Embryology, gross and microscopic anatomy of the human\nnervous system - concentrating on the central nervous\nsystem.\nc. General human physiology, including the study of the funda-\nmental organ systems and the mechanisms which regulate body\nfunction. Emphasis is on the sensory, motor and cardio-\nvascular systems.\nd. Basic concepts of general and cellular biochemistry, with\nstudy of nomenclature, structure, and reactions of organic\nmolecules. Emphasis is on the visual system - tears, intra-\nocular fluids, lens, retinal photochemistry, and actions of\ndrugs upon these.\ne. Concepts of human genetics and genetic disorders, including\nthe frequency and distribution of genetic disease, inheri-\ntance patterns, polygenic inheritance, chromosomal abber-\nration syndromes, multifactorial genetics, and principles\nof genetic counseling.\nf. Gross and microscopic anatomy of the lids, orbit, orbital\ncontent, globe, muscles, nerves, and vessels, and embryology\nof the eye.\ng. Vegetative physiology of the eye, extraocular and intra-\nocular fluids, corneal and lens metabolism, ocular circula-\ntion, retina and optic nerve metabolism.\nh. General pharmacological principles, methods of administration,\nvarious systemic drugs and their pharmacological action and\nside effects with emphasis on those that affect the visual\nsystem, such as cataractogenic and glaucoma producing drugs.\ni. Pharmacology; uses, doses, contraindications, and adverse\neffect of drugs producing miosis, mydriasis, cycloplegia,\naccommodation, and ocular anesthesia. The pharmacology, use\ncontraindications, and adverse effect of drugs commonly used\nin treating visual and ocular problems.\nFORD & LIBRARY GERALD\n106\n2. Physiological optics knowledge base:\na. Introduction and orientation to physiological optics,\nanatomical and physiological processes associated with\nresponses to light; vision and the processes of vision.\nb. Measurement and specification of visual stimuli, light\nsources, radiometry, photometry, colorimetry. The eye\nas an image forming mechanism, the optical role of the\npupil, the retinal image and its evaluation. Nature,\nclassification, and etiology of ametropia. Physiological\nmechanism and optical aspects of accommodation.\nc. Monocular sensory mechanism of vision, photoreception and\nretinocortical transmission, spatial and temporal inter-\naction and resolution, adaptation, brightness discrimina-\ntion, color vision and their possible neurophysiological\nmechanisms.\nd. Ocular motility. Intra- and extra-ocular muscle systems\nwith regard to their anatomy, physiology, pharmocology, and\nneurology. Measurement, characteristics, and control of\nocular movements.\ne. Binocular vision and space perception. Visual direction,\ntheory of correspondence, mapping of ninocular space.\nModifications of space perception. Binocular eye move-\nments, fusion, rivalry, ocular dominance, steropsis.\nNeurophysiological mechanisms.\nf. Perception and information processing. Theories of per-\nception. The perception of time, size, shape, distance,\nmotion. Perceptual and sensory deprivation, and percep-\ntual adaptations.\n3. Pathology knowledge and skills base:\na. The essentials of bacteriology, virology, and immunology\nand the biological properties of micro-organisms, processes\nof infection and chemotherapy. Flora of the anterior\nsegment of the eye and adnexa and the anatomical and\nphysiological features which favor or inhibit their activity.\nb. Principles of health and disease. A survey of disease,\ndisease processes, and disease manifestations. A study\nof tissue changes in inflammation, tumor formation, al-\nlergies, disturbances of metabolism and circulation, and\ninjuries.\nFORD is LIBRARY GERALD\n107\nc. The etiology, epidemiology, symptoms, signs, and course\nsequelae of ocular disease and anomalies. Disease and\nanomalies of lids, orbit, conjunctiva, cornea, sclera,\niris, ciliary body, lens, vitreous, retina, choroid, and\noptic nerve.\nd. Ocular manifestations of systemic disease and anomalies.\nThe etiology, epidemiology, symptoms, signs and course\nsequelae of visual and ocular neurological anomalies, lid\nand pupillary anomalies, paralytic strabismus, and visual\nfield problems.\ne. The etiology, epidemiology, symptoms, signs and course\nsequelae of the major and/or more common health problems\nin the U.S.A.. Principles of emergency care.\n4. Optics knowledge and skills base:\na. Light and light rays, the formation of images, reflection,\nspherical mirrors, refraction, spherical refracting sur-\nfaces, thick lenses, thin lenses, cenrered systems, theory\nof stops, fields of view.\nb. Cylindrical lenses, prisms, aberrations, aspherical mirrors\nand lenses, magnification, microscopes, telescopes.\nNature of light, interference, diffraction, polarization,\nresolving power, dispersion, spectra, thin films. Princi-\nples of optical systems, optics of keratometer, lensometer,\nradioscope, retinoscope, ophthalmoscope, slit-lamp, NCT\ntonometer, tropscope, eikonometer, stereoscopes, fundus\ncamera.\nC. History of ophthalmic materials; physical characteristics\nof lenses, lens aberrations, lens design; ophthalmic\nprisms, multifocal lenses, lens specifications; physical\ncharacteristics of frames; lens and frame specification,\nelements of a prescription, lens and frame inspection and\nverification; fitting and dispensing concepts.\nd. Special lenses and frames, protective eyewear, unique\ndesigns, low-vision aids, aniseikonic lenses, fitting\nand dispensing. Optics and design of contact lenses,\ncontact lens specification, fabrication, verification,\nand modification of contact lenses.\nFORD is LIBRARY GERALD\n108\n5. Professional orientation knowledge and skills base:\na. National, State and local development of the optometric\nprofession. Opportunities available in the eye care and\nvision research fields.\nb. A review of descriptive statistics, probability, sampling,\ncorrelation, prediction, and their use in optometry and\nvision research. The essentials of epidemiological study\nprocedures and their significance in health care. Epidemi-\nology of major systemic disorders and disorders of the\nvisual system.\nc. Introduction to health care. Health care and sick care.\nHealth care systems. Health care professions, their\nnumbers and distribution. Role of optometry in health\ncare. What an optometrist is and what he does.\nd. Principles of human interpersonal relationships. The\ndevelopment of patient-doctor, technician-doctor, staff-\ndoctor, and community-doctor relationships. Emphasis\nis\non preparing the student to understand and deal\nwith the many human interpersonal relationships necessary\nin the practice of optometry.\ne. History of public health, sociological aspects of health\ncare, the financing of health care, organizations of\nhealth care. Methods of payment. Evaluating an optometric\npractice.\nf. Local, State, Federal organizations involved in health\ncare, comprehensive health planning and new trends in\nhealth care delivery, health and patient-community educa-\ntion, organization of health services.\ng. The development and management of an optometric practice\nfrom a patient and community service point of view--\noffice design, office routine, patient care administration,\npersonnel management, recall systems, developing patient\nand interprofessional relationships through effective\ncommunication.\nh. The establishment, development, and management of an opto-\nmetric practice from a business point of view. Legal\ndevelopment, governmental relationships, legislation and\nthe legislative process, licensing procedures, State\nboards and laws, malpractice, professional ethics, taxes,\nfee structures, insurance, and accounting methods.\nFORD i LIBRARY GERALD\n109\n6. Clinical patient care knowledge and skills base:\na. Introductory clinical optometry, patient orientation,\nessentials of case history, clinical testing of inter-\npupillary distance, versions, accommodation, and pupillary\nreflexes.\nb. Development of clinical skills necessary for patient care\nin the areas of refraction, ocular motility, binocular\nintergration, and visual performance.\nc. Correlation, evaluation and analysis of optometric data.\nThe process of patient care-diagnosis, prognosis, therapy--\nrelating to the needs of the patient. Preview discussion\nof optometric specialty areas.\nd. Historical development of the contact lens and its use.\nBasis theories and methods of fitting. Contraindications\nfor fitting. Fitting of hard and soft contact lenses and\ntheir modification, post fitting care and problems, care\nand treatment of contact lenses. Contact lens solutions.\ne. Advanced contact lens fitting, theories and clinical\nmethods for meridional, prism segment, bifocal contact\nlenses. Fitting keratoconus, astigmatic corneas, aphakic\neyes, and high refractive errors. Use and fitting of\nhaptic lenses, cosmetic shells, and prosthetic eyes.\nf. The etiology, epidemiology, symptoms, signs, and course\nsequelae of the obstacles of binocular vision sensory,\nintegrative, motor--and the detection, diagnosis, prog-\nnosis, and orthoptic treatment of such anomalies. Clinical\ncare of aniseikonia.\ng. The etiology, epidemiology, sysmptoms, signs, and course\nsequelae of learning, perceptual--motor, and other vision\nperformance problems, and their detection, diagnosis,\nprognosis, and therapy. Study of the psychology, unique\nexamination procedures, and care of pediatric patients\nand their problems and needs.\nh. The etiology, epidemiology, symptoms, signs and course\nsequelae of low vision. Methods of testing, prognosis,\nand selection of therapy, design of environmental and\noptical aids, problems of rehabilitation. Agencies, laws,\npublic and social assistance for the partially sighted\nand blind.\nFORD & LIBRARY GERALD\n110\ni. The physiological, psychological, and sociological changes\nwith age. Disease and aging. Visual and ocular problems\nof the elderly. Unique examination procedures and care\nof the geriatric patients.\nj. The principles of efficient illumination, vision require-\nments in homes, schools, business, industry, and vision\nsafety in the environment. Vision screening in schools,\nindustry, community, motor vehicle examinations. Visual\naspects of job analysis, the relationship between vision\nand vocational and avocational efficiency. The roles of\npatient care and human engineering in maximum visual\nperformance.\nk. Presentation and discussion of interesting clinical patients.\nAdditional clinical testing techniques and concepts. Further\ndiscussion of patient data analysis--the process of deter-\nmining diagnosis, prognosis, and therapy. Further dis-\ncussions in the optometric specialties. Recent informa-\ntion that relates to the process of vision and the clini-\ncal practice of optometry.\n7. Patient care experience:\na. The clinical examination and care of patients in the\ngeneral optometry clinic, along with the design, fitting,\nevaluation, and dispensing of opthalmic lenses and frames.\nb. The clinical examination and care of special patient popu-\nlations in hospitals, nursing homes, schools for blind,\nvisual screening, etc.\nc. The clinical examination and care of patients in the opto-\nmetric specialty areas--contact lenses, low vision, ani-\nseikonia, analysis, etc.\nFORD & LIBRARY GERALD\n111\nSECTION II-D\nSUPPLY AND DISTRIBUTION CONSIDERATIONS: ACCESS\nCompiled by\nStuart Bernstein, B.A. *\nIn 1973, there were 10,496 active ophthalmologists and 19,265\nactive optometrists in the United States, a ratio of nearly one\nto two.\nSources of Data\nThe data on ophthalmologists are from the records of the American\nMedical Association 1/,2/,3/ The AMA defines ophthalmologists as\nany physician in practice who declares ophthalmology as a primary\nspecialty. This includes ophthalmologists in private practice as\nwell as those active in clinics, hospitals or other institutions.\nHowever, this self declaration implies neither board certification\nin ophthalmology nor full time commitment to the practice of oph-\nthalmology. Any physician reporting practicing ophthalmology as\na secondary or tertiary specialty is also, therefore, not included\nin the number of ophthalmologists reported by AMA.\nData on active optometrists are from the 1972-73 inventory of\noptometrists conducted by the American Optometric Association\nthrough State Licensure Boards and with the cooperation of the\nInternational Association of Boards of Examiners in Optometry 4/\nThe inventory supported by the Bureau of Health Manpower, HRA,\ntook place between October 1972 and December 1973, following the\nlicensure renewal cycle of the Boards.\nOf the total number of active ophthalmologists, 9,568, or 91 per-\ncent are classified by the AMA as non-Federal practitioners in\npatient care activities. About 95 percent or 18,300 of the\nactive optometrists are comparably classified as being non-Federal\npractitioners in patient care activities.\nA count of Board Certified Ophthalmologists from the 1974-75\nDirectory of Medical Specialists indicated that 6,600 or about\nthree-fifths of all ophthalmologists are Board Certified. 6/\n*Statistician, Manpower Analysis Branch, Office of the Director,\nBureau of Health Manpower, Health Resources Administration, DHEW.\nFORD is LIBRARY 038470\n112\nDifferences Between States\nIn terms of the medicare eligible population, age 65 and over,\nthere were 45 active non-Federal ophthalmologists and 90 active\noptometrists per 100,000 resident population in 1973. Table 1\nshows the number of active non-Federal opthalmologists and optom-\netrists in each State and geographic division as well as the ratio\nto 100, resident population age 65 and over. Although the same\ntwo States, California and New York, have the largest numbers of\nboth ophthalmologists and optometrists, careful examination of the\ntable will show that in the Nation, as a whole, there is no appar-\nent correlation between the ratios of ophthalmologists and optom-\netrists to the medicare eligible population in a given State.\nThis has been demonstrated by other studies as well. On a\nregional basis, it can be said that in the Pacific States for both\nophthalmologists and optometrists the highest ratios of practi-\ntioners to the over 65 population occur. Conversely, the lowest\nratios for both disciplines occur in the East South Central States:\nThe relationship between optometrists and ophthalmologists that\nexists on a national basis (2 to 1) is exceeded or approximated\nin most States. However, notable exceptions exist. Only in\nMaryland and the District of Columbia does the number of active\nophthalmologists actually exceed the number of active optometrists.\nLouisiana has only 20 percent more optometrists than ophthalmol-\nogists and New York, Florida and Utah have fewer than 50 percent\nmore optometrists than ophthalmologists. In seven States, (Maine,\nRhode Island, Indiana, Illinois, North Dakota, South Dakota, and\nNebraska) there were greater than three times as many optometrists\nas ophthalmologists. It should be noted that, proportionately,\nthe distribution of all active ophthalmologists by State approxi-\nmates the State Distribution of Board Certified Ophthalmologists.\nDifferences Between Metropolitan and Non-Metropolitan Areas\nThe major concern as related to access of the medicare eligible\npopulation to the services of ophthalmologists and optometrists\nis the gross difference in distribution of the two disciplines\nwithin States, namely between metropolitan and non-metropolitan\nareas.\nTable 2 shows that in metropolitan areas of the United States,\nthere were approximately 1.7 optometrists for every ophthalmol-\nogists, while in non-metropolitan areas the ratio was two and\na half times as great, 4.2 optometrists for every ophthalmolo-\ngist. In terms of persons 65 and over with medical insurance\ncoverage, 97 there were 55 ophthalmologists and 99 optometrists\nper 100,000 persons in metropolitan areas while there were 19\nophthalmologists and 79 optometrists in non-metropolitan areas.\nClearly, the medicare eligible population in non-metropolitan\nareas has greater access to the service of optometrists in that\napproximately 27 percent of the optometrists and 13 percent of\nFORD & LIBRARY GERALD\n113\nthe ophthalmologists are in non-metropolitan areas potentially\nserving 32 percent of the medicare eligible population. Within\nmetropolitan areas, available data indicate that there are a\nsomewhat higher ratio of both ophthalmologists and optometrists\nto medicare eligible population in areas of 500,000 population\nor more than in smaller metropolitan areas.\nOnly 6 of the 69 metropolitan areas of 500,000 or more population\nhad more active ophthalmologists than optometrists in 1973.\nThe largest of these metropolitan areas were Baltimore and New\nOrleans. The Chicago metropolitan area had the greatest difference,\nmore than three times as many optometrists than ophthalmologists.\nThe distribution of ophthalmologists and optometrists between metro-\npolitan and non-metropolitan areas differs throughout the Geographic\nDivisions of the United States (Table 3). In non-metropolitan\nareas of the North Central States there are between six and seven\noptometrists for every ophthalmologist. In non-metropolitan areas\nof the South (South Atlantic, East South Central and West South\nCentral Divisions) there are between four and five optometrists\nfor every ophthalmologist. The remainder of the non-metropolitan\nareas of the Nation has approximately three optometrists for every\nophthalmologist.\nThere is substantially less difference between the numbers of\noptometrists and ophthalmologists in metropolitan areas of the\nUnited States than non-metropolitan areas. Only in the New\nEngland East North Central Divisions are there more than two\noptometrists for every ophthalmologist. In the remainder of the\nmetropolitan areas of the Nation, there are approximately 1.6\noptometrists for every ophthalmologist.\nThe highest ratio of ophthalmologists to 100,000 medicare eligible\npopulation is in the metropolitan areas of the Mountain States;\nthe lowest ratio is in non-metropolitan areas of the West South\nCentral States. The highest ratio of optometrists to 100,000\nmedicare eligible population is in the metropolitan areas of the\nPacific States; the lowest ratio is in non-metropolitan areas of\nthe East South Central States.\nDistribution Within Counties\nThe most recent data on the distribution of ophthalmologists within\ncounties of the United States is from the 1968 Survey of Ophthalmol-\nogists condicted by the National Center for Health Statistics.\n10)\nHowever, more recent data in a number of States indicate that there\nhas been little change in the number of counties with and without\nthe services of ophthalmologists since this time. In 1968, only\none-third of the counties in the United States had active ophthalmol-\nogists.\nThis is in sharp contrast to the fact that two-thirds\nof the counties in the United States in 1973 had the services of\noptometrists. The proportion of counties with and without the\nFORD & LIBRARY GERALD\n114\nservices of ophthalmologists and optometrists varies in the\ndifferent regions of the Nation.\nIn the Northeast (New England and Middle Atlantic States) in\ncontrast to the Nation as a whole, four-fifths of the counties had\nactive ophthalmologists in 1968. One-half of the counties in the\nPacific States had active ophthalmologists. In contrast, five of\nthe six remaining Divisions in the United States had fewer than\n30 percent of the counties with active ophthalmologists in 1968.\nTo substantiate this, a study by the Southern Regional Education\nBoard showed that there were only 19 percent of the counties 117 of\nthe South with Board Certified Ophthalmologists in 1973.\nAlso, data used in a study by the Institute of Medicine, National\nAcademy of Sciences 127 showed that in the States of Georgia,\nMichigan and Oregon there was little difference in the number\nof counties with ophthalmologists in 1974 as compared to 1968.\nOnly four States ( Massachusetts, New Hampshire, Rhode Island\nand New Jersey) had fewer counties without ophthalmologists than\nwithout optometrists. Broken out by region, the following table\nillustrates the proportion of counties without the services of\nophthalmologists in 1968 or without optometrists in 1973.\nCounties Without\nCounties Without\nOphthalmologists\nOptometrists\nUnited States\n67%\n32%\nNortheast\n19\n13\nSouth\n73\n38\nNorth Central\n69\n26\nWest\n65\n37\nIt should be noted that in the non-metropolitan counties with the\nsmallest population, a far greater proportion of optometrists are\nlocated than are ophthalmologists 57 Eleven percent of ophthalmolo-\ngists are located in counties with total population of under 25,000\nin contrast to 22 percent of optometrists in the same county size\ngroup. Fewer than 1,000 ophthalmologists were located in such\ncounties in contrast to nearly 4,200 optometrists, a number more\nthan four times as great.\nIn comparing 1968 ophthalmologist data with 1973 optometrist data\nby county, 1,251 or 40 percent of the counties have one or more\noptometrists but no ophthalmologists, 33 or 1 percent have one or\nmore ophthalmologists but no optometrists, 1,009 or 32 percent of\nthe counties have both optometrists and ophthalmologists and 851\nor 27 percent have neither optometrists nor ophthalmologists.\nFORD & LIBRARY GERALD\n115\nOn a regional basis, the break-out follows:\nAll\nOptometrists Ophthalmologists\nCounties\nOnly\nOnly\nBoth Neither\nNortheast\n100%\n16%\n1%\n80%\n3%\nSouth\n100%\n39%\n2%\n26%\n33%\nNorth Central\n100%\n48%\n1%\n30%\n21%\nWest\n100%\n32%\n1%\n34%\n33%\nFuture Supply and Other Considerations\nBetween 1968 and 1973, active non-Federal ophthalmologists in\npatient care grew from 8,300 to 9,600, an annual growth rate of\n2.8 percent compounded. At the same time, active optometrists\ngrew from 18,400 to 19,300, an annual growth rate of 0.9 percent\ncompounded. The Bureau of Health Manpower projects the number of\nactive ophthalmologists in the United States to grow from 13,300\nin 1980 to 18,400 in 1990. 5/ The number of active optometrists\nare projected to grow to 22,000 in 1980 and 28,200 in 1990.\nThe proportion of ophthalmologists as a percent of total professional\nvision care manpower is projected to grow from 137 35 percent in 1973\nto 38 percent in 1980 and 39 percent in 1990.\nThe number of active ophthalmologists per 100,000 population age\n65 and over is projected to grow from 49 in 1973 to 54 in 1980\nand 64 in 1990. The number of active optometrists per 100,000 pop-\nulation age 65 and over is projected to be about level at 90 between\n1973 and 1980 and grow to 97 in 1990.\nThe greatest growth in the number of active ophthalmologists over\nthe period from 1968 to 1973 was in the South. However, during\nthe same period the greatest growth in ophthalmology residencies as\nreported by AMA was in the West. 14/ No data exists relating place\nof ophthalmology residency to place of eventual practice. However,\na study published by AMA indicated that for interns and residents\nwho were 1960 graduates of medical schools, 51.7 percent were\npracticing in the same State in 1975 as the final year of graduate\ntraining\n15,\nThe same study showed that 42.7 percent were practicing\nin the same State in 1975 as where they graduated from Medical\nSchool in 1960. However, no conclusions can be drawn as to whether\nophthalmologists in practice followed a similar pattern.\nOptometrists experienced a much smaller growth than did ophthalmol-\nogists between 1968 and 1973. 16/ However, it is notable that the\nSouth and West experienced a far greater growth in optometrists in\nthis time interval than did the Northeast and North Central States.\nMore than four out of five optometrists under age 45 practicing\nin States where Schools of Optometry are located are graduates\nfrom the school (s) within their State. Little difference in this\nstatistic exists between metropolitan and non-metropolitan areas.\nFORD & LIBRARY GERALD\n116\nIn States with long-standing Schools of Optometry, the relationship\nis even more marked. The proportion of all active optometrists\nwho are graduates from schools within their State of practice are\nmore than 92 percent in Illinois, 86 percent in Pennsylvania, 81\npercent in California and 77 percent in Massachusetts.\nIt should be noted that in two States where there has been a\nsubstantial growth in the over 65 population, Florida and Arizona,\nalso show substantial growth in the numbers of both ophthalmolo-\ngists and optometrists between 1968 and 1973. In neither of these\nStates is located a School of Optometry.\nIn regard to the relationship between location of school and State\nof Practice, it is notable that in Illinois which has the greatest\nconcentration of optometrists also has the most prolific School of\nOptometry. (Illinois College of Optometry and its predecessors,\nthe Northern Illinois College of Optometry and Chicago Monroe\nCollege of Optometry), accounting for nearly one-third of all active\noptometrists in the United States.\nThe American Medical Association in its \"Directory of Approved\nResidencies\" reports that only 2.3 percent of the approved resi-\ndencies offered in ophthalmology in 1975-76 were located in non-\nmetropolitan areas. Little change in this statistic is evident\nover the last decade as three percent of the approved residencies\nin 1964 and two percent of the approved residencies in ophthalmol-\nogy in 1969 were located in non-metropolitan areas. There have\nbeen no studies relating metropolitan status of residency location\nto metropolitan status of practice location for ophthalmologists.\nHowever, several studies support the thesis that hometown size and\nspecialty choice are interrelated predictors of the community in\nwhich physicians practice. 17/ Physicians with non-metropolitan\nbackgrounds were two to three times as likely to select non-metro-\npolitan practice as physicians with urban backgrounds.\nOverall, 27.4 percent of the active optometrists in the United\nStates are located in non-metropolitan areas. This statistic\nvaries somewhat by age of the optometrist. Older optometrists,\nthose age 55 and over, are somewhat less likely to be practicing\nin non-metropolitan areas than those under age 45.\nData from the most recent inventory of optometrists show that\nschools of optometry make a varied contribution of optometrists\nto non-metropolitan areas. Two schools, the Southern College of\nOptometry and the Pacific University College of Optometry have\ncontributed 48 and 43 percent of their graduates to non-metropolitan\nareas, respectively. Three other schools have contributed more than\n30 percent of their graduates to these areas - (Illinois, Houston,\nand Indiana). Together, these schools account for three out of\nfour optometrists practicing in non-metropolitan areas.\nFORD is LIBRARY GERALD\n117\nBased upon existing trends and without other intervention, little\nchange in the proportion of either ophthalmologists or optometrists\npracticing in non-metropolitan areas can be expected. The propor-\ntion of recent graduates from schools of optometry, age 30 and\nyounger, practicing in non-metropolitan areas is about the same or\nslightly lower for nine out of ten established optometry schools\nas compared to the proportion of total graduates practicing in\nthese areas. In comparing 1968 to 1972 data, a lower proportion\nof ophthalmologists were practicing in non-metropolitan areas in\n1972. While 16 percent of ophthalmologists were practicing in\nnon-metropolitan areas in 1938, only 13 percent were practicing\nin such areas in 1972.\nVolume of Services\nIf reimbursement coverage under Part B of Medicare were extended\nto optometrists, the workload of practicing optometrists may\nincrease. This is especially true in sections of the country\nwhere the medicare eligible population has not had access to the\nservices of an ophthalmologist but may now be eligible for reim-\nbursement of optometric services. To get an understanding of\npossible increases in volume of services rendered by optometrists,\none must look at existing data on productivity of optometrists.\nOne such measure for which data are available relates to vision\nanalyses performed by optometrists in 1973. Such data shows little\noverall difference between metropolitan and non-metropolitan areas\nin average vision analyses per optometrist.\nHowever, within non-metropolitan areas for optometrists practicing\nin very small communities, there is a sharp drop off in this\nstatistic.\nThis data becomes more significant when one relates utilization of\nfull time auxiliary personnel, other than secretaries or reception-\nists, to the average number of vision analyses performed by optom-\netrists. While non-metropolitan optometrists showed a somewhat\ngreater average number of vision analyses than did optometrists in\nnon-metropolitan areas utilizing auxiliaries. In fact, within non-\nmetropolitan areas, for these optometrists utilizing full time\nauxiliaries, there was also a sharp drop in average vision analyses\nin the very smaller communities. The data show that in all areas,\noptometrists employing full time auxiliaries were able to perform\nabout 28 percent more vision analyses, on the average, than were\noptometrists not utilizing auxiliaries.\nGiven the potential of expanded reimbursement coverage for\noptometrists under Part B of Medicare, it could be expected that\nthe effects in terms of increased demands for vision care services\nwould be felt, particularly, in areas served by optometrists but\nnot by ophthalmologists. This chapter has sought to demonstrate\nthat a substantial part of the country, particularly in non-metro-\npolitan areas, is being served by optometrists only. Such optom-\netrists, as the data have shown, by a basic measure of productivity,\nFORD & LIBRARY GERALD\n118\nmay be seeing fewer patients on the average than optometrists\nnot in these areas. Yet, the data have also shown that the use of\nfull time auxiliary personnel may potentially relate directly to\ngrowth in productivity. In fact, on a national basis, a U.S.\nDepartment of Labor survey has demonstrated that more than 9 out\nof 10 optometric practices have room for additional growth and\nthat optometrists can care for 30 percent or more patients under\ntheir present structure 18/ Particularly, in areas where the\ngrowth in demand for vision care services may be the greatest is\nthere potential for additional growth in optometric practice\nthrough the increased use of auxiliaries or by other means.\nFORD & LIBRARY GERALD\nGERALD FORD LIBRARY\nTable 1 Number of Active Ophthalmologists and Optometrists and Ratio to 100,000\nResident Population Age 65 and Over by Division and State: 1973\nOphthalmologists\nOptometrists\nDivision\nActive\nResident\nper 100,000\nper 100,000\nand\nNon-Federal\nActive\nPopulation 65+\nResident Population\nResident Population\nState\nOphthalmologists\nOptometrists\n(000's)\n65+\n65+\nU.S. Total\n9,568\n19,265\n21,329\n45\n90\nDivision\nNew England\n625\n1,381\n1,322\n47\n105\nMaine\n39\n124\n121\n32\n102\nNew Hampshire\n32\n72\n84\n38\n86\nVermont\n18\n44\n50\n36\n88\nMassachusetts\n333\n749\n652\n51\n115\nRhode Island\n36\n126\n109\n33\n116\nConnecticut\n167\n266\n306\n55\n87\nMiddle Atlantic\n2,065\n3,393\n4,044\n51\n84\nNew York\n1,132\n1,590\n1,987\n57\n80\nNew Jersey\n342\n675\n734\n47\n92\nPennsylvania\n591\n1,128\n1,323\n45\n83\nEast North Central\n1,555\n4,262\n3,967\n39\n107\nOhio\n396\n974\n1,037\n38\n94\nIndiana\n180\n538\n523\n34\n101\nIllinois\n438\n1,569\n1,125\n39\n139\nMichigan\n340\n745\n787\n43\n95\nWisconsin\n201\n436\n495\n41\n88\n119\nTable 1 (Cont'd.) - Number of Active Ophthalmologists and Optometrists and Ratio to 100,000\nResident Population Age 65 and Over by Division and State: 1973 (Con't)\nOphthalmologists\nOptometrists\nDivision\nActive\nResident\nper 100,000\nper 100,000\nand\nNon-Federal\nActive\nPopulation 65+\nResident Population\nResident Population\nState\nOphthalmologists\nOptometrists\n(000's)\n65+\n65+\nWest North Central\n689\n1,654\n1,984\n35\n83\nMinnesota\n188\n361\n425\n44\n85\nIowa\n114\n314\n357\n32\n88\nMissouri\n222\n422\n583\n38\n72\nNorth Dakota\n17\n74\n70\n24\n106\nSouth Dakota\n15\n87\n83\n18\n105\nNebraska\n50\n149\n189\n26\n79\nKansas\n83\n247\n277\n30\n89\nSouth Atlantic\n1,422\n2,204\n3,306\n43\n67\nDelaware\n20\n38\n47\n43\n81\nMaryland\n227\n210\n326\n70\n64\nDistrict of Columbia\n77\n68\n71\n109\n96\nVirginia\n198\n326\n398\n50\n82\nWest Virginia\n59\n135\n204\n29\n66\nNorth Carolina\n183\n336\n456\n40\n74\nSouth Carolina\n84\n179\n212\n40\n84\nGeorgia\n158\n291\n402\n39\n72\nFlorida\n416\n621\n1,190\n35\n52\nEast South Central\n436\n893\n1,368\n32\nFORD & LIBRARY GERALD\n65\nKentucky\n112\n225\n355\n32\n63\nTennessee\n154\n363\n414\n37\n88\n120\nAlabama\n104\n181\n357\n29\n51\nMississippi\n66\n124\n242\n27\n51\nTable 1 (Cont'd.) - Number of Active Ophthalmologists and Optometrists and Ratio to 100,000\nResident Population Age 65 and Over by Division and State: 1973 (Con't)\nOphthalmologists\nOptometrists\nDivision\nActive\nResident\nper 100,000\nper 100,000\nand\nNon-Federal\nActive\nPopulation 65+\nResident Population\nResident Populatic\nState\nOphthalmologists\nOptometrists\n(000's)\n65+\n65+\nWest South Central\n816\n1,489\n1,992\n41\n75\nArkansas\n67\n163\n258\n26\n63\nLouisiana\n182\n225\n329\n55\n68\nOklahoma\n95\n273\n321\n30\n85\nTexas\n472\n828\n1,084\n44\n76\nMountain\n437\n786\n778\n56\n101\nMontana\n35\n101\n71\n49\n142\nIdaho\n33\n85\n74\n45\n115\nWyoming\n18\n40\n32\n56\n125\nColorado\n136\n208\n200\n68\n104\nNew Mexico\n42\n80\n82\n51\n98\nArizona\n97\n149\n196\n49\n76\nUtah\n51\n75\n85\n60\n88\nNevada\n25\n48\n38\n66\n126\nPacific\n1,523\n3,203\n2,577\n59\n124\nWashington\n167\n385\n344\n49\n112\nOregon\n131\n305\n245\n53\nCalifornia\n1,169\n2,421\n1,929\n61\nAlaska\n12\n18\n8\n150\nGERALOR FORD LIBRARY 126 124\n225\nHawaii\n44\n74\n51\n86\n145\nSources: American Medical Association, Distribution of Physicians in the U.S., 1972, Volume 2\n12\nOptometric Association\nBureau of Health Manpower, 1972-73 Inventory of Licensed Optometrists conducted under contract by American\nBureau of the Census Current Population Reports, Series P-25, No. 518, June 1974\nTABLE 2- NUMBER OF ACTIVE OPHTHALMOLOGISTS AND OPTOMETRISTS\nAND RATIOS TO.100,000 PERSONS 65 AND OVER COVERED UNDER MEDICARE\nMEDICAL INSURANCE: 1973\nPersons 65+\nOphthalmologists\nOptometrists\nActive\nWith Medical\nper 100,000\nper 100,000\nNon-Federal\nActive\nInsur. Coverage\nPersons 65+\nPersons 65+\nOphthalmologists\nOptometrists\n(100,000's)\nCovered\nCovered\nUNITED STATES\n9,510\n19,265\n207.8\n45.8\n92.7\nMetropolitan, Total\n8,270\n13,987\n141.0\n58.7\n99.2\nMetro 500,000 or More\n6,152\n10,527\n103.8\n59.2\n101.4\nMetro - Less than 500,000\n2,118\n3,460\n37.2\n57.0\n93.0\nNon-Metropolitan\n1,240\n5,278\n66.8\n18.6\n79.0\n1/ 1972 estimate of active ophthalmologists in patient care. 1973 estimate - 9,568\nSource: AMA Distribution of Physicians in the United States, 1972, Volume 2\nBureau of Health Manpower, 1972-73 Inventory of Licensed Optometrists\nDHEW, Social Security Administration, Medicare 1973, Section 2 - Enrollment, 1975\nFORD i LIBRARY GERALD\n122\nTable 3\nDistribution of Active Ophthalmologists and Optometrists for Metropolitan and\nNon-Metropolitan Areas and Ratios of Practitioners to 100,000\nPopulation 65 and Over Covered Under Medical Insurance Program of Medicare\nBy Geographic Division: 1973\nActive\nActive\nOphthalmologists\nOptometrists\nOphthalmologists\nOptometrists\nRatio to 100,000\nRatio to 100,000\nGeographic\nMetro\nNon-Metro\nMetro\nNon-Metro\n65+ Medicare Eligible Pop.\n65+ Medicare Eligible Pc\nDivision\n(1972)\n(1973)\nMetro\nNon-Metro\nMetro\nNon-Metro\nUnited States\n8,270\n1,240\n13,987\n5,278\n59\n19\n99\n79\nNew England\n531\n75\n1,141\n240\n52\n26\n112\n83\nMiddle Atlantic\n1,954\n147\n2,963\n430\n58\n26\n87\n76\nSouth Atlantic\n1,147\n225\n1,484\n720\n57\n20\n74\n83\nEast South Central\n331\n104\n442\n451\n56\n14\n75\n60\nWest South Central\n669\n113\n968\n521\n62\n13\n90\n61\nEast North Central\n1,417\n163\n3,159\n1,103\n52\n14\n115\n97\nWest North Central\n507\n170\n643\n1,010\n63\n15\n80\n87\nMountain\n304\n120\n412\n374\n74\n34\nPacific\n1,410\n123\n2,774\n429\n66\nGERALD FORD LIBRARY\n100\n108\n33\n129\n115\nNOTE: Entries may not add to totals due to rounding in computational process\nSources: Bureau of Health Manpower 1972-73 Inventory of Optometrists conducted under contract by American Optometri\nAssociation\nAmerican Medical Association, Distribution of Physicians in the United States, 1972\nDHEW, Social Security Administration, Medicare: Health Insurance for the Aged and Disabled, 1973. Section 2 -\nPersons Enrolled\n124\nBIBLIOGRAPHY\n1. American Medical Association, Center for Health Services\nResearch and Development, Distribution of Physicians in the\nUnited States, 1972 - Volume 1/Regional, State, County, 1973\n2. American Medical Association, Center for Health Services\nResearch and Development, Distribution of Physicians in the\nUnited States, 1972 - Volume 2/Metropolitan Areas, 1973\n3. American Medical Association, Center for Health Services\nResearch and Development, Distribution of Physicians in the\nUnited States, 1973, 1974\n4. DHEW, Bureau of Health Manpower Inventory of Optometrists in\nthe United States (Data collected 1972-73 by the American\nOptometric Association), 1973 (unpublished)\n5. HRA, Bureau of Health Manpower, Manpower Analysis Branch,\nGeographic Distribution of Optometrists and Ophthalmologists -\nA Statistical Summary, Report No. 76-100, Mar. 1976\n6. Marquis Co., Directory of Medical Specialists, 16th Edition,\n1974-75, Chicago, Illinois\n7. Department of Commerce, Bureau of the Census, Current Population\nReports, Population Estimates and Projections, Series P-25,\nNo. 418, June 1974\n8. Hayes, S. and Randall, G., \"Geographic Distribution of Ophthal-\nmologists and Optometrists\", Arch Ophthalmol, Volume 92,\nNovember 1974\n9. DHEW, Social Security Administration Medicare: Health Insurance\nfor the Aged and Disabled, 1973, Section 2: Persons enrolled\nin the Health Insurance Program, June 1975\n10. DHEW, HSMHA, National Center for Health Statistics, Ophthalmol-\nogy Manpower: A General Profile - United States - 1968, Series\n14, No. 5, December 1972\n11. Dorn, W., Mou, T. and Peters, H., A Proposed Regional Plan for\nthe Expansion of Optometric Education in the South, Southern\nRegional Education Board, Dec. 1974\n12. National Academy of Sciences, Institute of Medicine, unpub-\nlished data on county distribution of Ophthalmologists obtained\nfrom States of Georgia, Michigan and Oregon\n13. DHEW, HRA, BHRD, Supply of Health Manpower: 1970 Profiles and\nProjections to 1990 (Dec. '74) - Modifications of estimates in\nthis publication were made\nFORD & LIBRARY GERALD\n125\n14. American Medical Association, Directory of Approved Residencies:\n1974-75, 1975 (also previous editions)\n15. Mason, H., \"Medical School, Residency and Eventual Practice\nLocation\", JAMA, Volume 233, No.1, July 7, 1975\n16. DHEW, HSMHA, National Center for Health Statistics, Optometrists\nEmployed in Health Services: United States - 1968, Series 14,\nNo. 8, March 1973\n17. Cullison, S., Reid, C., and Colwill, J., \"Medical School\nAdmissions, Specialty Selection and Distribution of Physicians\",\nJAMA, Volume 235, No. 5, February 2, 1976\n18. Eger, M. J., \"Manpower Strategy U.S. Underutilization\", JAOA,\nVolume 43, No. 1, January 1972\nFORD is LIBRARY GERALD\n126\nSECTION II-E\nCOST IMPLICATIONS\nCompiled by Larry W. Lacy, M.A.*\nIssues and Difficulties\nIn judging the question of whether optometrists should be reimbursed\nfor the services they provide to cataract and aphakic enrollees\nunder Part B of Medicare, consideration must be given to how much\nsuch an extension of coverage would increase Medicare program costs.\nThe estimate of this cost increase can then be compared with the\nbenefits provided Medicare enrollees. Extension would benefit\nthose enrollees who now use an optometrist and who would, under\nextension of coverage enjoy greater security from high health costs\nas well as those who are now deterred from seeking diagnosis of\ntheir clinically significant cataracts by the cost of optometric\nservices.\nA lack of reliable information on the current use of optometrists\nby enrollees, uncertainty of how much enrollees would increase their\nutilization of optometric services after coverage extension, and\nuncertainty of what would be the exact rules for reimbursement under\nextension, prevent exact estimation of the costs to the Medicare\nprogram of the proposed coverage change. Therefore, the results of\nthe calculations below can only be illustrative of the actual amounts\nlikely to be realized. Under the assumptions of this section's\nanalysis, it is estimated that extension of Medicare coverage for\nthe services in question would result in Medicare payments for\noptometrists' services of from $2 million to $5 million a year.\nThis excludes any higher payments to surgeons and hospitals from\na possibly higher rate of cataract surgery resulting from greater\nnumbers of diagnoses of cataracts after extension.\nMethod of Analysis\nThere are three basic steps in the estimation of the cost to the\nMedicare program of extending coverage to include services provided\nby optometrists to enrollees with cataracts or aphakia First was\nestimation of the existing volume of such services. Second was\ndetermination of what would be the probable charge to the Medicare\nprogram for both a single diagnostic visit and the volume of services\nestimated in the previous step. The last step was an attempt to\njudge the possible magnitude of the increase in the use of optometrist\n*Economist, Manpower Analysis Branch, Office of the Director, Bureau\nof Health Manpower, Health Resources Administration, DHEW.\nFORD i LIBRARY GERALD\n127\nservices which might follow coverage extension as well as the\nadded charge to the program for these visits 2/ Because the first\nand third steps suffered from a lack of reliable information, two\ndifferent estimates of the possible cost increase were made. The\ncalculations below use 1975 as the base year. To aid understanding,\nthe flow chart which follows outlines the 3 steps of the analysis.\nDerivation of Estimate of Cost to the Medicare Program of Coverage\nof Optometrists' Services Provided to Cataract and Aphakic Enrollees\nStep 1: Estimation of the current volume of optometric services\nwhich would be reimbursable under extension of coverage.\nA. Estimated number of Medicare reimbursed cataract operations\nin 1975 -\n245,000\nB. American Optometric Association estimate of the fraction of\nsurgical cases originally referred by optometrists - 2/3\nC. Study advisor's estimate -\n1/3\nD. High estimate of current number of reimbursable pre-surgical\ndiagnostic visits to optometrists (A X B) -\n163,000\nE. Low estimate (A X C) -\n82,000\nF. American Optometric Association estimate of the fraction of\nsurgical cases returning to optometrists for care - 1/3\nG. Estimate of current number of reimbursable post-surgical\ndiagnostic visits to optometrists (A X F) -\n82,000\nStep 2: Estimation of the cost to the Medicare program of providing\ncoverage for the current volume of reimbursable optometric\nservices only.\nH. Estimate of average charge to Medicare program of single\ndiagnostic visit to optometrist under extension -\n$14\nI. High estimate of the cost to Medicare program of current\nvolume of reimbursable visits ((D + G) X H) - $3,400,000\nJ. Low estimate ((E + G) X H) -\n$2,300,000\nStep 3: Estimation of the additional cost to the Medicare program\nof an increase in the number of reimbursable visits after\ncoverage extension.\nK. High estimate of the increase in the number of reimbursable\nvisits to optometrists which might occur after cover\nextension -\n82,000\nGERALD FORD LIBRARY\n128\nL. Low estimate -\n0\nM. Added cost to Medicare program of high estimate of increase\nin volume of reimbursable visits (K X H) -\n$1,100,000\nN. High estimate of total cost to Medicare program for current\nand expanded volume of reimbursable visits (I + M) -\n$4,500,000\n0. Low estimate -\n$2,300,000\nStep 1\nLittle data exist on the current number of visits by enrollees with\ncataracts or aphakia to optometrists' offices. Even more uncertain\nis the number of these examinations which would be labelled \"routine\"\nand hence would not be covered under the Supplementary Medical\nInsurance program. Several sources of information, however, do\noffer some help in this regard.\nThe first is the 1975 American Optometric Association Senior Citizens\nSurvey. Based on results from a national sample of about 3,000\nrespondents, AOA staff inferred that \"optometrists initially refer\nto the ophthalmologist two-thirds of those persons for whom cataract\nsurgery is performed, although such surgery may not be performed\nfor several years after referral. 113/ The AOA also found that about\none-third of those over 65 who have had cataract surgery went to an\noptometrist for the last diagnostic examination they had before the\ntime of the survey. If it is assumed that (1) only visits for\ncataracts which are severe enough to warrant an operation are of\na nonroutine nature and hence would be reimbursable under extension\nand (2) only one pre-surgical and one post-surgical examination by\nan optometrist would be reimbursable for a single patient, these\nfractions (2/3 for pre-surgical and 1/3 for post-surgical) can be\nmultiplied by the estimated number of Medicare reimbursed cataract\noperations in 1975 to obtain a very rough measure of the current\nvolume of optometrist services that would be reimbursable under the\nproposed extension. Since probably some cataracts would be judged\nnonroutine but would not be surgically removed, the resultant\nestimate would probably be somewhat smaller than what would\nactually be reimbursed under extension.\nUnfortunately, the AOA did not obtain a random sample of the entire\nover-65 U.S. population. Probably underrepresented are the poor,\nminority groups, and residents of rural areas. Such problems may\nreduce the reliability of the survey's results. Also, study advisors\nindicated that probably considerably fewer than two-thirds of Medicare\npatients who have cataract operations were referred by optometrists.\nThe advisors felt that one-third corresponds more closely to the\ntrue figure.\nFORD & LIBRARY GERALD\n129\nThe next part of Step 1 was to estimate the number of Medicare\nreimbursed operations in 1975. On the basis of claims gathered by\nthe various Medicare intermediaries, the Social Security Adminis-\ntration has provided for this study unpublished estimates of the\nnumbers of Medicare reimbursed cataract operations for the years\n1967 through 1972.\nCalendar Year\nNumber of Medicare Reimbursed Cataract Operations\n1967\n155,000\n1968\n159,000\n1969\n161,000\n1970\n172,000\n1971\n172,000\n1972\n202,000\nThe upward trend of the SSA figures suggest a 1975 total of from\n220,000 to 245,000 cataract operations. Other sources indicate\nthat the higher number may be more accurate. In unpublished data\nthe National Eye Institute estimates there were 332,000 annual\noperations for cataracts for people of all ages in 1972. According\nto unpublished data from the 1971 National Health Interview Survey,\n74 percent or 245,000 of all cataracts occur in the over 65 popula-\ntion. Therefore, this latter figure will be used as a rough estimate\nof 1975 cataract operations reimbursed by Medicare.\nApplying the AOA inference that two-thirds of cataract surgical cases\nfor those over 65 were initially referred by optometrists to the\n245,000 figure yields high estimate of 163,000 (2/3 X 245,000)\npre-surgical visits to optometrists which would have been reimburs-\nable under the stated assumptions. For purposes of obtaining a\nlower estimate, the study advisors' suggestion of one-third referrals\nfrom optometrists to ophthalmologists is multiplied by 245,000 which\nreduces the estimate of pre-surgical covered visits to 82,000\n(1/3 X 245,000). If one-third of all those enrollees who have a\ncataract operation, upon recovery, seek the services of an optometrist,\nthere would have been 82,000 (1/3 X 245,000) post-surgical visits to\noptometrists which would have been covered under extension. Addition\nof this amount to the first result above produces 245,000 (163,000 +\n82,000) as a high estimate of pre- and post- surgical examinations\nwhich would have been covered under extension. The corresponding\nlow estimate is 163,000 (82,000 + 82,000 with correction for rounding).\nStep 2\nTo obtain the cost to the Medicare program for these two volumes of\ncovered visits, each must be multiplied by the average charge to\nthe Medicare program for each such examination. Unfortunately, the\nAmerican Optometric Association does not collect data on the average\nfees charged by its members, and neither does the Bureau of Labor\nFORD & LIBRARY GERALD\n130\nStatistics collect the needed information. Several other sources\nincluding the California Medical Program, the National Eye Institute,\nand a survey for the Optical Manufacturers Association suggest that\nthe average fee for an office visit to an optometrist is from\n$20.00 to $26.00.5/ For the purposes of the calculations below,\n$23.00 serves as the average fee. Not all of this fee, however,\nwould be chargeable to the Medicare program under extension of\ncoverage. First, 20 percent must be deducted to reflect enrollee\ncost-sharing under Supplementary Medical Insurance regulations which\nalso require that a second 20 percent must be deducted for the non-\nreimbursable refraction portion of an examination. This leaves\nabout $14 (60% X $23) as the average charge to the Medicare program\nper visit.\nMultiplying this by 245,000 yields $3,400,000 (245,000 X $14) as a\nrough high estimate of the cost of covering only the existing (1975)\nvolume of services of optometrists which would be reimbursable\nunder extension. Multiplying by 163,000 produces $2,300,000\n(163,000 X $14) as a rough low estimate.\nStep 3\nIt is probable that an extension of coverage would change the extent\nand nature of cataract care of the over 65 population. For instance,\nif Medicare enrollees who had cataract operations in 1975 had been\ncovered for services of optometrists, a larger proportion of those\noriginally referred by an optometrist might have returned to one\nimmediately after recovery from their operations. The AOA Senior\nCitizens Survey suggests that one-third of those who have had\ncataracts surgically removed use their optometrists for diagnostic\nexaminations and glasses. If this fraction rose to two-thirds --\nthe estimated proportion originally referred by optometrists\naccording to the AOA -- it would have meant perhaps 82,000\n(1/3 X 245,000) additional reimbursable visits to the optometrist\nin 1975. This would have added about $1,100,000 (82,000 X $14)\nto Medicare program costs. This would raise total costs of\nreimbursement extension to $4,500,000 ($1,100,000 + $3,400,000)\nusing the high cost figure above. If no additional enrollees\nreturned to optometrists after surgery, program payments would\nremain at the levels estimated for the existing (1975) volume of\nservices only.\nThe most unpredictable and potentially most important effect on\nMedical program costs would be an increase in the number of enrollees\nwho seek diagnosis of cataracts by optometrists, who subsequently\nhave surgery, but would not otherwise have obtained any services.\nThese would primarily be people with limited access to an\nophthalmologist and who would not have been willing to pay the\nfull cost of service by an optometrist. This is probably a small\ngroup because it means that its members would be deterred from\nFORD & LIBRARY GERALD\n131\nobtaining services by the relatively small cost of an optometrist's\nvisit. The members of this group would also have to be well\ninformed of Medicare reimbursement policies, otherwise their\nbehavior would not change.\nEven if this group is very small, it could have large effects\non Medicare program costs. Unpublished figures provided for this\nreport by the National Eye Institute give a basis for estimating\nthe current average reimbursable cost to the program of a single\noperation for cataracts to be about $1,500.6/ If there are 3,000\nadditional operations as a result of reimbursement extension,\nMedicare program costs would .rise $4,500,000. Ten thousand\nadditional operations would mean $15,000,000 in increased costs.\nIt seems possible, therefore, that the chief cause of higher\ncharges to the program would be a rise in surgical rates. It\nshould be noted that nearly all of such increased payments resulting\nfrom surgery would not be for optometrists services but for surgical\nand hospital services.\nRelation to Medicaid Program\nA small portion, perhaps 5-10 percent of the Medicare program cost\nincreases would be offset by a decrease in Federal Medicaid pay-\nments. Thirty-two States, with perhaps 80 percent of the U.S.\npopulation, provide Medicaid coverage for optometrists' services\nwith the Federal government assuming about 60 percent of total\npayments. About 17 percent of all Medicare enrollees are also\neligible for Medicaid benefits. Multiplying all these percentages\ntogether produces 8 percent as a rough estimate of the Medicare\ncost increase which would be offset by a reduction in Federal\nMedicaid payments\nPayments to Ophthalmologists\nUnder prevailing medical billing practice there would have been no\noff-setting decrease in charges for ophthalmologic services. Since\nophthalmologists generally include the cost of post-surgical care\nin their surgical fee, there is generally no separate charge for\npost-surgical examination and prescription of lenses.\nOptometric Malpractice Insurance\nIt has been suggested that an extension of coverage would change\nthe nature of optometric practice sufficiently to raise the cost of\nmalpractice insurance for optometrists. This seems improbable\nbecause the over 65 are only a fraction of an optometrist's\npractice and cataract services constitute only a part of the vision\ncare of enrollees. Also, optometrists would still not perform\nsurgery, the major source of malpractice claims. Conversations\nwith the Chairman of the AOA Committee on Insurance and an associate\nFORD & LIBRARY GERALD\n132\nof the major carrier of malpractice insurance for optometrists\nsupport the conclusion that no significant effects on insurance\nrates would result from extension.\nSummary of Findings\nThe following chart summarizes this section's cost analysis. As\nexplained above, these figures are only illustrative due to the\nlack of reliable information. The results indicate that extension\nof coverage would result in annual Medicare payments for optome-\ntrists' services of from $2 million to $5 million. A potentially\nlarger cost to the Medicare program would result if some enrollees,\nwho under existing reimbursement policy would not receive any\ncataract care, react to extension by going to optometrists for\ndiagnoses which would in turn lead to increased rates of surgery.\nOn average, each of these surgical procedures would add $1,500\nto Medicare expenses. A lack of information prevents estimating\nthe number, if any, of additional operations which would result\nfrom such extension.\nSummary of the Estimated Cost to the Medicare Program of Coverage\nof Optometrists' Services Provided to Cataract and Aphakic Enrollees\n/\nA. Number of visits to optometrists which would be reimbursable\nunder proposed reimbursement change if enrollees do not increase\nrate of visits\nLow estimate\n163,000\nHigh estimate\n245,000\nB. Additional number of visits to optometrists which would be\nreimbursable under proposed reimbursement change if enrollees\nincrease rate of visits\nLow estimate\n-0-\nHigh estimate\n82,000\nC. Total number of visits to optometrists which would be reimburs-\nable under proposed reimbursement change (A + B)\nLow estimate\n163,000\nHigh estimate\n327,000\nD. Estimated average charge to Medicare program for each reimburs-\nable visit to an optometrist - $14\nE. Estimated annual total increase in Medicare program cost (D X c)⁹/\nLow estimate\n$2,300,000\nHigh estimate\n$4,500,000\nFORD & LIBRARY GERALD\n133\nSuggestions for Further Study\nThe calculations reported above rest upon many simplifying\nassumptions. The first is that only diagnostic visits associated\nwith surgery would be covered. Another is that only one visit to\nan optometrist before surgery and only one after would be covered.\nA third assumption is that the AOA Senior Citizens Survey produced\ndata representative of all enrollees. It was also assumed that\nMedicare enrollees under 65 years of age would not have cataract\noperations. Still another assumption is that all people who have\ncataract operations have met the SMI deductible and have not\nexceeded hospital day limitations of the Hospital Insurance program.\nThese assumptions, which were necessary to produce a rough estimate\nof program costs implications under time constraints, make the\nresults of the calculations only illustrative.\nSources:\nMany people and organizations were consulted during the preparation\nof this section of the report. In particular, an unsuccessful\nattempt was made to find a source with useful economic analysis\nof the demand for vision services. Those organizations that\nprovided the unpublished data on which this section is based are\nlisted as follows:\n-- American Optometric Association\n- California State Department of Health\n--- National Center for Health Statistics, DHEW\n---- National Eye Institute, DHEW\n-- Social and Rehabilitation Service, DHEW\n-- Social Security Administration, DHEW\nFORD & LIBRARY GERALD\n134\nFootnotes and Bibliography\n1/ This section will deal only with those enrollees 65 years of\nage or older.\n2/ If the increase in the use of optometric and ophthalmologic\nservices were much broader, it could contribute to rises in\nthe unit price of vision care. Consideration of this last\nquestion, however, lies outside the scope of this paper.\n3/ Internal American Optometric Association memorandum of March 1,\n1976.\n4/ Source: unpublished SSA figures based on 5 percent samples of\nbeneficiaries.\n5/ California and NEI data are unpublished. The Optical Manufacturers\nAssociation figures are from \"The Impact of National Health Insur-\nance on the Use and Spending for Sight Correction Service,\" 11\nGordon R. Trapnell, Consulting Actuaries, 1976.\n6/ This includes an initial diagnostic visit to an optometrist plus\na total ophthalmologist fee of $580. Of this total, $480 would\nbe reimbursable. Fully reimbursable would be five days in the\nhospital at $840. Deducting 20 percent for cost-sharing leaves\nabout $120 as the charge to the Medicare program for post-\nsurgical examination by an optometrist, prescription, and\nprovision of lenses ($14 + $480 + $840 + $120 = $1,454).\n7/ .8 X .6 X .17 = .081\n8/ Numbers refer to 1975 data.\n9/ Excludes possible higher payments to physicians and hospitals\nresulting from increasing rates of cataract surgery.\nFORD & LIBRARY GERALD"
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