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Our Mission

The mission of the California Academy of Eye Physicians and Surgeons is to serve the total visual health care needs of the people of California through public and professional education, membership services, and legislative advocacy. The California Academy of Eye Physicians and Surgeons is dedicated to the public's direct access to an ophthalmologist's care.

Our Vision

The California Academy of Eye Physicians and Surgeons is the leader in promoting visual health and accessible, affordable, quality total eye care for Californians.

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Headquarters
1201 J Street, Suite 200
Sacramento, CA 95814

Correspondence and Accounting
425 Market Street, Suite 2275
San Francisco, CA 94105

Phone: (415) 777-3937
Fax: (415) 777-1082
CaEyeMDs@aol.com

AGS, CMA, and CAEPS call for Review of Blinded Veterans Cases Prior to Further Implementation of Glaucoma Certification Standards for Optometrists

UPDATE: Based on comments from the Department of Consumer Affairs, the Administrative Petition has been revised and clarifies that the action requested related to the regulatory process is the withdrawal of the Department of Consumer Affairs' "Findings and Recommendations" that were provided to the State Board of Optometry. The petition also better outlines concerns about potential bias of the consultant selected to reconcile the reports of the ophthalmologists and optometrists on the Glaucoma Treatment and Advisory Committee formed to recommend revised standards for optometrists seeking certification to treat certain types of glaucoma.

The American Glaucoma Society, the California Medical Association, and the California Academy of Eye Physicians and Surgeons are calling for an investigation into the blinding of seven veterans being treated at a VA hospital in Palo Alto while under the care of two optometrists licensed by the State.

According to published reports (see article that follows), the US Department of Veteran Affairs Hospital in Palo Alto discovered in January of this year that eight veterans (an additional one has been identified since initial reports) had suffered varying degrees of blindness, another 16 had "progressive vision loss," and 87 more were at high risk of losing their sight.

Veterans Affairs policy, which the two optometrists apparently violated, requires that when optometrists suspect glaucoma in a patient they must consult with an ophthalmologist, a physician who specializes in eye care. The requirements recognize the fact that optometrists complete only four years of optometry school, while ophthalmologists have eight years of training: four years of medical school, a one-year internship and a three year residency.

Prior to passage of SB 1406 (Correa, 2008) California law required that optometrists who wanted to treat glaucoma to be certified in a process that required stringent, "hands on" clinical training under the supervision of an ophthalmologist. Significantly, the two optometrists at the VA Hospital, although licensed by the state, had not been certified to treat glaucoma.

This information first became available as California was in the final stages of reconsidering standards in place since 2000 that, had they been followed, might have protected the VA patients.

SB 1406 sponsored by the California Optometric Association eliminated the clinical training requirements that had been in place for almost a decade, and authorized the Department of Consumer Affairs (DCA) to establish replacement standards. As part of the regulatory proceedings, a former President of the California Optometric Association (who, of note, was not himself certified to treat glaucoma in California) had been hired to make the key recommendations for implementation of the bill. Not surprisingly, the former head of the optometrists’ group recommended a drastic reduction in the requirements previously in place. Of particular concern is the fact that these can actually be fulfulled without the candidate for certification ever having treated/managed a glaucoma patient him- or herself.

"The VA tragedy could well hold lessons about the wisdom of allowing inadequately trained healthcare providers to treat an eye disease like glaucoma," said James B. Ruben, MD, President of the California Academy of Eye Physicians and Surgeons. "Can you imagine licensing an airline pilot who had only passed a written exam but never flown an airliner before to fly 200 passengers from Sacramento to Los Angeles?"

In light of the VA Hospital blindness cases, an Administrative Petition [Updated 10/11/09; see above] has been filed with the DCA calling on its new director to reconsider those decisions.

The petition asks the DCA to call on the resources and expertise of the Medical Board of California, the State Board of Optometry, and the California Department of Veterans Affairs in conducting an investigation that would seek to determine whether any state or federal laws have been violated. And while the investigation is ongoing, the petition asks that the current regulatory proceedings under SB 1406 be suspended. It further asks that at the conclusion of the VA hospital investigation, any further regulatory proceedings should utilize the records obtained during that process and incorporate any recommendations or conclusions its final regulatory decision.

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Glaucoma Care by Optometrists Scrutinized at Palo Alto VA Medical Center

On July 22, 2009 the San Jose Mercury News reported that the Department of Veterans Affairs’ Palo Alto Medical Center (PAVAMC) has put the chief of optometry on administrative leave and reassigned another optometrist during an ongoing investigation of the treatment of hundreds of glaucoma patients, some of whom allegedly experienced significant vision loss (and even total blindness) under the Department’s care. At issue is whether the optometry section failed to follow PAVAMC policy requiring it to consult with ophthalmologists on glaucoma cases. Of note, the chief was not glaucoma certified in California; however, because he is also licensed in Washington state (where the basic license grants glaucoma privileges), VA rules allowed him to treat under the aforementioned supervision. (Of course with such licensure he could currently be treating glaucoma independently in Washington state without any oversight.) The California Optometric Association has been reported to be supporting the optometric chief. While CAEPS has no access to the specifics of the individual cases because of patient privacy laws, we support appropriate review of the circumstances reported to ensure that our Veterans receive the highest possible quality of care.

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Glaucoma Certification Recommendations Adopted by Board of Optometry

As required by SB 1406, which mandated development of new certification requirements for optometrists to medically treat primary open-angle, exfoliative, and pigmentary glaucoma, the State Board of Optometry adopted a set of recommendations from the Office of Professional Examination Services (OPES) of the Department of Consumer Affairs for such standards on July 16, 2009.

The recommendations were a reconciliation of those in separate reports produced by the ophthalmologist and optometrist members of the Glaucoma Diagnosis and Treatment Advisory Committee (GDTAC) of the Board after the entire Committee deadlocked on the "Case Management" requirements. The ophthalmologists supported maintaining the standards developed eight years ago (which involved following and treating 50 patients prospectively in a supervised fashion over two years) with specific changes to streamline the practicality of the process, while the optometrists felt a 16-hour classroom course (without any prospective treatment of patients) was adequate.

OPES, utilizing an optometrist consultant who is a faculty member at the Southern California College of Optometry (and whose potential bias has been formally challenged by both CAEPS and the California Medical Association), ultimately "split the baby," reducing the 50 patient requirement to 25 "prospectively treated over 1 year." However, because 15 patients of this requirement can be satisfied by a course similar to the one suggested by the optometrists’ report, and the remaining 10 can be fulfilled by completing a course utilizing live patients presented in a "grand rounds" fashion with undefined "follow-up," CAEPS agrees with the American Glaucoma Society (which stated in a letter to the Board) that these standards "both disrespect the complexity of the disease and the patients who suffer from it."

We also have significant concerns with the recommendation that no additional training be required for graduates after May 1, 2008, which could have been imposed by the Committee "after reviewing training programs for representative graduates." The committee’s optometrists members refused to provide data for such a review, forcing the ophthalmologist committee members to presume the training was inadequate.

CAEPS is assessing how and if recent revelations regarding glaucoma treatment at the Palo Alto VA Medical Center (see article above) may impact this issue and is working closely with the AAO and the CMA to explore all avenues to ensure the public safety is adequately protected with regard to glaucoma treatment for Californians.

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Senate Bill 1406 Stripped of All Surgery

Huge "Win" for Patient Safety

A bill that would have allowed optometrists to perform surgery, SB 1406, has been severely limited by amendment to allow only changes to the process by which optometrists are certified to treat glaucoma, certain non-surgical procedures and testing, and some additions to the limited formulary they are permitted to prescribe, as well as other minor changes.

Thanks to strong work on the part of a coalition of CAEPS, the California Medical Association (CMA), the American Academy of Ophthalmology (AAO), and the California Educators of Ophthalmology for Quality Care (Department Chairs of California university training programs), patient safety has come first in this process. The coalition was a formidable obstacle to organized optometry, forcing them to come to the table and negotiate.

Without our efforts, the bill could have let optometrists:

• Perform ALL EYE SURGERY;
• Perform injections, likely including intravitreal injections;
• Order ANY Diagnostic Test; and
• Treat nearly ALL types of glaucoma after only graduation from optometry school (or very limited undefined additional training).

In addition, the meaningless "oversight" mechanism originally proposed to "comment" on standards for the revised glaucoma certification process has been significantly strengthened to require the Board of Optometry to adopt the committee's recommendations (subject to amendment by the Office of Examination Resources to meet certain standards), and the nominees of CAEPS and the CMA must occupy the physician and surgeon positions on the committee, which make up half the appointments. This process was recently completed (see above article).

As with any negotiation process, certain other things like additions to the formulary, some diagnostic testing, various modifications of referral requirements, and minor non-surgical procedures were authorized without specific educational standards. CAEPS worked with the Board of Optometry to attempt to establish such standards through the regulatory process.

Because of the changes to the bill, all the involved groups dropped their opposition to the legislation, which has now passed both the Assembly and the Senate, was signed into law, and went into effect on January 1, 2009.

 

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Compromise Helps Maintain Access to Avastin for
Eye Disease

The California Academy of Eye Physicians and Surgeons (CAEPS) believes that Genentech’s recent decision to halt sales of Avastin® (bevacizumab) to compounding pharmacies would have have had a negative impact on the care of patients with age-related macular degeneration (AMD) and other conditions with potentially blinding complications. It therefore responded to that action by issuing a Press Release and introducing an Emergency Resolution that was approved by both the Houses of Delegates of the California Medical Association (CMA) and the American Medical Association (AMA) calling for those organizations to join in opposition to this move on the part of Genentech in late October and early November. It also called upon its members and the public to put pressure on Genentech to reconsider.

"We understand [Genentech’s] need to provide a reasonable return to [its] shareholders. However, we believe that need must be balanced by the needs of society, particularly patient access to appropriate off-label uses of medications based on an individual physician’s well-established ability to weigh the risks, benefits, and available evidence of a specific use as part of the ‘practice of medicine,’" wrote Howard R. Krauss, MD, CAEPS 2007 President, in a letter to Arthur D. Levinson, PhD, Genentech Inc.’s Chairman and Chief Executive Officer.

CAEPS is therefore pleased that the American Academy of Ophthalmology and the American Society of Retina Specialists were able to conclude with Genentech that physicians would be able to purchase the medication from an authorized distributor (known are AmerisourceBergen, McKesson Specialty Pharmaceutical, and Morris & Dickson) and provide it to a compounding pharmacy.

It should be noted, however, that direct availability to compounding pharmacies remains the most likely approach to both maximize patient access as well as minimize waste and inefficiency (and therefore cost), and CAEPS is monitoring ongoing activities of the US Senate Committee on Aging (which has an open investigation on this issue). However, the arrived at compromise will better assure patients retain the option of Avastin [vs. having access solely to Lucentis® (ranibizumab), which is far more expensive ($1500-2000/dose vs. $50-100/dose for Avastin)].

CAEPS is seeking a ruling from the state Board of Pharmacy as to the acceptability of the described practice and will report additional details as available.

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July is UV Safety Month

Exposure to the sun can cause damage to not only your skin, but also your eyes. Use of appropriate sunglasses and other protective devices can reduce this risk.

Read more about this important topic from EyeCare America by clicking here.