It behooves us to both know where our patients’ needs lie and provide the comprehensive care that is within our scope of practice. Performing advanced laser procedures can significantly help not only patients but the entire healthcare system. I’ll detail these and other innovative clinical options you may not have considered. Be sure to consult with your state board on which surgeries would be within your scope of practice.
Typical Advanced Procedures
Ten states allow for laser procedures such as selective laser trabeculoplasty (SLT), laser peripheral iridotomy (LPI) and YAG laser capsulotomy. Surgical privileges in these states include injections and removing non-cancerous lesions, lumps and bumps.
SLT can lower IOP by 25% to 30% and is relatively non-invasive, quick and easy to perform, highly efficient, repeatable and cost-effective. LPI can be administered in narrow-angle glaucoma patients.
Another glaucoma option is the bimatoprost sustained-release implant known as Durysta (Allergan), which can often be performed at the slit lamp. Insert a speculum and prep the ocular surface with anesthetic, antibiotic or aseptic drops. The special-designed inserter is a combination of a 28-gauge needle with a push-button release mechanism, much like that of a punctal plug. The inserter is placed just inside the limbus around 4:00 and inserted at least two bevel lengths aiming toward the inferior angle—away from the iris and pupil. It’s best to hold the inserter with two fingers behind and two in front (with one of them on the press release button). Once released, gravity takes the pellet to the lower anterior chamber. The needle should then be removed very slowly. The pellet remains in the inferior angle for two to four months, although studies show that 28% to 40% of patients sustained lower IOP one to two years after implantation.1
Corneal Crosslinking (CXL)
These systems are typically too expensive for most optometric practices, even though the vast majority of keratoconus patients are followed and managed by an optometrist. A company called TecLens is developing a CXL technology that involves a scleral lens with a built-in transducer that can be placed on a patient’s eye with riboflavin in the bowl. The UV light is applied, and after 15 to 30 minutes, CXL is complete.
Another technology not far from potential approval is the EpiSmart system (CXL Ophthalmics), which has shown promise in being able to perform an epithelium-on CXL and would simplify the procedure.
Light Delivery Service
One of the most innovative technologies I’ve experienced, which achieves the highest percentage of 20/20 or better post-cataract surgery outcomes of any cataract implant, is the Light Adjustable Lens (RxSight). With this technology, the cataract surgeon obtains a basic measurement and selects an IOL. If the post-cataract refraction needs tweaking or the patient prefers monovision, for example, the lens can be adjusted with a light delivery device (LDD) in one to two minutes. The majority of postoperative measurements to determine the ideal correction for the LDD are taken by optometrists, which is not a big surprise; however, the LDD procedures are also performed by a sizable percentage of optometrists. LDD adjustments are great procedures that can help lessen the burden on cataract surgeons.
Your Surgical Future
Ophthalmic surgery performed by optometrists serves a key role in the healthcare system, from patient access in rural areas and communities with few ophthalmologists to slowing the backlog of patients who need cataract and other advanced surgeries. As in the case of the Light Adjustable Lens, for every cataract surgery there are at least three postoperative visits and often two to three LDD procedures, which back up the system.
Optometrists performing these procedures can greatly help their patients, the ocular surface and the healthcare system, just to name a few. It becomes incumbent on optometry, in states where they are licensed to perform these surgeries, to do so.
Dr. Karpecki is the director of Cornea and External Disease for Kentucky Eye Institute, associate professor at KYCO and medical director for the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.
1. Craven ER, Walters T, Christie WC, et al. 24-month phase I/II clinical trial of bimatoprost sustained-release implant (bimatoprost SR) in glaucoma patients. Drugs. 2020;80(2):167-79.