Remember the end of the millennium and the frightful predictions about the Y2K bug? Computer networks would fail. Power grids would go dark. Financial institutions would collapse. Anarchy would ensue, and civilization would fall apart.

But somehow the bug was swatted. And although the world has since seen chaos and tragedies, none of them came from crashing computers.

Those fin de sicle fears also unsettled the eye care world. Would LASIK make eyeglasses and contact lenses obsolete? Would comanagement come to an end? Would eye exams become a requirement for all school children? Would optometry ever get full prescriptive authority in every state?

Here, well look at some of the predictions made back at the turn of the millennium. Some have come to pass. Some havent. And some turned out in ways you may not have predicted.

Then: In September 2000, Review of Optometry published an article (Doctor, Do You Still Need Glasses?) that asked if optometrists would abandon their traditional bread-and-butter business of eyeglasses in favor of medical eye care. The article concluded that, in the future, patients will still have plenty of need to visit the dispensary.

Now: Fortunately, eyeglass sales have not tumbled. However, the number of Americans who wear prescription eyewear appears to be eroding slightly. Specifically, about 146 million Americans wear eyeglasses in 2005, according to the VisionWatch Eyewear U.S. Study, a recent survey by Jobson Research and Vision Council of America. That number is down from 149 million in 2002, a dip of about 2%.

In short, dont knock down your dispensary just yet. Indeed, the dollar amount spent in the U.S. market on frames and spectacle lenses exceeded $15 billion this year, according to the VisionWatch survey, which is roughly the same as in 2000.

Contact Lenses
Then: In November 2001, the FDA approved Bausch & Lombs PureVision lens, the first of the high-Dk silicone hydrogel lenses, for 30-day continuous wear. This was good news for contact lens patients and their optometrists.

But at that time, O.D.s began to seriously worry if LASIK would take away their contact lens patients. Or maybe the Internet contact lens discounters would snatch their patients.

Now: Thanks in large part to silicone hydrogels, the overall contact lens market is growing, not shrinking. As of June 2005, 40 million Americans wear contacts. Thats an increase of 20% since the end of 1998 when the U.S. had about 33.2 million contact lens wearers. 

One thing that some people were predicting was that the market would shift into just two types of lenses, either 30-day extended wear or daily disposable, says Carmen F. Castellano, O.D., a past president of the American Optometric Associations Contact Lens and Cornea Section. But this prediction didnt materialize. There is certainly a significant market for each of those, but they have not taken over the overwhelming majority of the market, he says.

Another significant development for the contact lens market: the passage of the Fairness to Contact Lens Consumers Act. Before it was enacted in December 2003, some people were saying that contact lenses were a dead end for private practice because ultimately all contact lenses would be sold over the Internet or at grocery stores, Dr. Castellano says. Now, under the act, a good number of people still purchase lenses [online and in chain stores], but at least its done with some restrictions. It certainly hasnt been the end of life as we know it for private practice contact lens care. (For more on the current state of the contact lens market, see articleCultivate Your Contact Lens Care.)

Live Poll
To what extent has your office gone paperless?
Completely automated and paperless: 13%
Many systems paperless: 18%
Halfway to paperless: 22%
One or two tasks are automated: 25%
Still in the Stone Age: 22%

The Paperless Office
In 2000, only 6% of O.D.s called their practices paperless, according to a Review of Optometry survey. Compare that with 14% of practices today.

Why havent even more practitioners jumped on the paperless bandwagon? A lot of doctors dont want to invest the time or money or do the work involved to get their staff up to snuff, says Thomas J. Overberg, of Fremont, Ohio.

Dr. Overberg, whose office has been paperless since 1997, says the investment pays for itself. A recent study bears this out: Initial costs for an electronic health records (EHR) system averaged $44,000 per provider, and ongoing costs averaged $8,500 per provider per year. But the average practice paid for its EHR costs in 2.5 years and profited handsomely after that.3

I used to have 11 people on my payroll. Now I have six, and we accomplish more with six than we ever did with 11, Dr. Overberg says. And everybodys happier.

Optometric Workforce
Then: The American Optometric Association commissioned a study, Workforce Projections for Optometry, published in May 2000.1 The study predicted an oversupply of O.D.s through 2020. Still, a 1% increase in demand for eye exams would eliminate the oversupply and result in a shortage of O.D.s by 2013, the study said.

Now: If you want to know the weather, just stick your head out the window. Likewise, if you want to know whether theres an oversupply of O.D.s, take a look at the holes in your appointment book, says optometrist Roger Filips, of Hartington, Neb. Dr. Filips led an online petition against the opening of a new school of optometry proposed at the Pembroke campus of the University of North Carolina.

Not only is the number of optometrists growing, Dr. Filips says, but optometric productivity has greatly increased. Back then, eight exams a day was a big day. Now insurance reimbursements are down and everybodys increasing productivity, but there arent any more patients to pick up the slack, he says. So it takes fewer optometrists [to serve the] population.

That could be true in certain areas, but its impossible to say if there is currently an oversupply (or an undersupply) on a nationwide basis, says Mort Soroka, Ph.D., of the Center for Vision Care Policy at the SUNY State College of Optometry. And the workforce study didnt provide the answer since the data used for the study were outdated and fraught with errors, he says. (Dr. Soroka and his team are currently studying how to create an up-to-date and accurate workforce database of optometrists.)

Not only did the database have problems, Dr. Soroka says, but the ratio of optometrists-per-population used in the workforce study was more of a rough guess than a clear snapshot. (The ratio used in that study was one O.D. per population of 7,000. But coming up with an exact ratio is almost impossible on a nationwide basis, Dr. Soroka says. Too many factors are involved.)

I dont think we have an oversupply by any stretch of the imagination, Dr. Soroka says.

In that regard, a number of other factors now affect the demand for optometrists and the utilization of optometric eye care, says optometrist Larry Davis, president of the Association of Schools and Colleges of Optometry and dean of the University of Missouri at St. Louis College of Optometry:

Optometric scope of care has expanded, so optometrists can see and treat a broader range of patients.

Patients are living longer and, as a result, require more eye care. Also, the large baby boom population is entering its senior years, a time when patients need more care.

Specialty vision care needs, such as in pediatrics and low vision, continue to be unmet.

Minority communities in many parts of the country lack access and utilization of quality eye care.

There are many unmet needs in the community, Dr. Davis says. From that point of view, you could argue that there are too few optometrists.

Childrens Vision
Then: In July 2000, Kentucky became the first state to pass a law mandating that all children entering school have an eye exam.

Now: From that auspicious beginning, several states have enhanced their childrens vision legislation. Right now, steam is building in Congress in support of a bill (H.R. 2238) that aims to boost funds and publicize the need for childrens eye exams. Sounds like significant progress in just five years, right?

It could be much better, says Darlene Eakin, executive director of the Kentucky Optometric Association. She points out that almost all of the state laws lack the teeth of the Kentucky law. Only North Carolinas law mirrors Kentuckys in mandating a comprehensive exam by an eye doctor. The rest settle for mandated vision screenings or simply encourage eye exams, she says. And several states still do not mandate any kind of vision screening before kids enter school.

It doesnt make sense that more states havent followed Kentuckys lead, Ms. Eakin says, especially because its law has been so well received. Parents, school administrators, educators and health care providers relate story after story about children who were found to have vision problems that no one suspected.

Furthermore, the dire predictions made about the Kentucky law have not come to pass. For one, the financial impact has not proven to be a problem, Ms. Eakin says. Parents havent complained to their legislators about the cost of the exam, she says, and a well-publicized fund set aside for needy families has remained nearly untouched. For another, there hasnt been a lack of providers able to perform exams.

So why havent other states achieved legislation that mandates eye exams for kids? Turf battles, Ms. Eakin says.

Im very disappointed that ophthalmologists and pediatricians have failed to support something that is so clearly beneficial to children and have actively tried to prevent these laws from being passed, she says. If you care about children, you want them to be able to see and be successful learners. What physician would say that its not a best practice to have a true comprehensive eye exam?

Then: In the spring of 2000, the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) issued a joint position paper that said comanagement should be the exception, not the norm. Would this policy irreparably change the relationships between M.D.s and O.D.s?

Now: Nothing has changed much, says optometrist Paul C. Ajamian, center director of Omni Eye Services in Atlanta and editor of Review of Optometrys Comanagement Q&A column. Organized ophthalmologys policy paper didnt seem to affect the tried-and-true relationships between individual M.D.s and O.D.s, Dr. Ajamian says.

The high-volume surgeons, who have the best surgical results, are confident enough in their abilities and in the skills of the referring O.D.s that they are happy to comanage, he says. They know that if there is a complication or problem, optometrists have a stellar reputation for erring on the conservative side and sending the patient back to the surgeon for an opinion. The bottom line is that everything is patient driven. Optometrists and eye surgeons who comanage do so because it is in the best interest of their patients.

Dr. Ajamian does foresee one emerging problem: Refractive surgery centers that are looking to branch into clear lens replacement with multifocal IOLs. In my experience thus far, these surgeons may be dangerous because they are interested in promoting the newest technologies without having the experience that high-volume cataract surgeons have, he says. Its no different than a cataract specialist waking up one day and deciding that he is going to do LASIK.

One change in comanagment: Refractive surgeons are comanaging fewer patients with optometrists. This too appears to be a patient-driven decision rather than a problem with comanagement between O.D.s and M.D.s. For more, see the following.

Scope of Practice Keeps Expanding

Here are just few highlights in prescriptive authority in the past five years:
California. Added topical steroids in certain circumstances, topical anti-glaucoma drugs in certain patients, topical antiviral drugs, oral antihistamines, oral non-steroidal anti-inflammatories, many additional classes of oral antibiotics, oral codeine and hydrocodone compounds, and the use of an injection to counter anaphylaxis. Also added lacrimal irrigation and dilation and the use of punctal plugs to treat conditions. Repealed the Therapeutic Pharmaceutical Agent Advisory Committee (October 2000).

New Hampshire. Added treatment of glaucoma with topical agents (orals in an emergency). Also added topical steroids, topical antivirals and oral antihistamines. Removed the prohibition on treatment of the lacrimal drainage system (January 2003).

Pennsylvania. Added prescription of steroids and treatment of glaucoma with topical legend drugs (January 2003).

Oklahoma. Legislation clarified that non-laser surgery procedures, in addition to laser surgery procedures, are included in the scope of practice (December 2004).

Maryland. Added topical steroids. With the enactment of this law, optometrists in all 51 jurisdictions have the authority to prescribe topical steroids (May 2005).

Source: AOA State Government Relations Center.

Refractive Surgery
Then: Refractive surgery hit its stride in 2000. That year, surgeons performed more than 1.4 million procedures on 793,000 patients, according to MarketScope, a consulting firm that tracks trends in refractive surgery. Also at that time, a few LASIK discounters began lowballing their prices (some advertised as low as $499 an eye). This caused referring doctors to worry whether procedure prices would drop too low to allow reasonable fees, excluding them from the comanagement equation.

An additional concern: Would the increase in LASIK allow more and more patients to throw away their glassesas well as their optometristfor good?

By 2010, fewer optometrists will comanage refractive surgery, but those who do will continue to grow their practices, said one optometrist in Review of Optometrys October 2000 cover story, LASIK in 2010: Will You Be There?

Now: Refractive surgery, although as popular as ever, has not made glasses and contact lenses obsolete. The number of refractive surgery procedures has remained steady, with an estimated 1.45 million to be performed in 2005, according to MarketScope.

Notably, patients are paying more per procedure, says optometrist Jeffrey Augustine, national director of optometric clinical services for Clear Choice Laser Eye Centers, in Brecksville, Ohio, and president of the Optometric Refractive Surgery Society. Were experiencing an increase in fees secondary to new technologies, Dr. Augustine says. Patients are now offered more advanced technology, such as IntraLase and wavefront, often on a tiered pricing scale or an a la carte menu, he says. For an example of the increase in pricing, the average LASIK procedure in 2002 was close to $1,600, MarketScope reported. In the second quarter of 2005, it was $1,965.

This increase in fees in combination with newer technologies has knocked the lowballers out of the market, Dr. Augustine says. At the same time, a minority of surgeons performs the majority of procedures.

On the down side, comanagement is declining. In 2004, fewer than half (42%) of surgeons participated in comanagement while three out of four surgeons comanaged their refractive surgery patients in 2000.2 Patients are now going directly to refractive surgery centers, bypassing referring O.D.s, Dr. Augustine says. This is likely due to a few factors: the centers word of mouth, the management of the patient, the centers results and the image that the refractive surgery center puts forth. By contrast, refractive surgery takes a back seat to glasses and contact lenses showcased in the O.D.s office, he says.

Also, the comanagement role of the O.D. has changed dramatically, Dr. Augustine says. We have to adopt new technology in order to stay at the forefront of comanagement. For example, pachymetry, topography, wavefront and pupillometry should all be standard care in the comanaging doctors office. At the same time, this means that the procedures are getting more refined, and patients are more likely to obtain a better outcome, he says.

If these developments indicate anything, its this: Hope springs eternal. Despite changes in the ophthalmic market, optometrists continue to survive, prosper and await an even brighter future.

Take the advancements in prescriptive authority, for example. (See Scope of Practice Keeps Expanding.) I am confident that all states will finish up their scope legislation within the next five to 10 years, says Dr. Ajamian, a past president of the Georgia Optometric Association. In Georgia we have a great bill, with unrestricted glaucoma treatment and oral narcotics, but we are stuck on the oral antibiotics. It is only a matter of time.

1. White AJ, Doksum T, White C. Workforce projections for optometry. Optometry 2000 May;71(5):284-300.
2. Duffey RJ, Leaming R. US Trends in Refractive Surgery: The 2004 ISRS/AAO Survey. Paper presented at ISRS/AAO Meeting, October 22, 2004; New Orleans, La.
3. Miller RH, West C, Brown TM, et al. The value of electronic health records in solo or small group practices. Health Aff (Millwood) 2005 Sep-Oct;24(5):1127-37.

Vol. No: 142:11Issue: 11/15/2005