Access to health care in rural America is a persistent challenge, and eye care is no exception. Patients often drive hours to see an ophthalmologist, while a large workforce of optometrists remains legally barred from performing routine, medically necessary procedures.
Scope-of-Practice Reform Gains Momentum
A policy brief from the Pacific Legal Foundation, released this week, argues that expanding optometrists’ scope of practice to include YAG laser capsulotomies—a simple, in-office treatment for secondary cataracts—could dramatically improve access. The procedure, which clears cloudy vision after cataract surgery, is performed on over half a million elderly Americans annually and has an excellent safety record. Yet in most states, only ophthalmologists are allowed to do it.
The brief, authored by West Virginia University researchers Kihwan Bae and Liam Sigaud, finds that Medicare patients in states that expanded optometrist scope-of-practice between 2013 and 2023 received 19 percent more YAG procedures than those in restrictive states. In states that expanded before 2013, the rate was nearly 42 percent higher. The effects were even more pronounced in non-metropolitan areas, suggesting that rural patients—who face the most severe access barriers—would benefit most.
Workforce Imbalance
The U.S. has roughly three times as many optometrists as ophthalmologists, and more than 99 percent of Americans live in a county with an optometrist. Ophthalmologists tend to cluster in urban centers. This imbalance means patients needing YAG procedures often face long wait times and high travel costs. Allowing optometrists to perform the procedure could reduce those burdens, the authors argue.
Safety concerns have historically been a barrier to reform. But the evidence suggests those fears are overblown. A review of nearly 150,000 laser procedures performed by optometrists found only 0.001 percent resulted in negative outcomes. Optometrists complete four years of doctoral training in eye care, and many programs already include YAG surgery in the curriculum. In the U.K. and New Zealand, optometrists have safely performed these procedures for years.
Political and Professional Pushback
Organized ophthalmology groups are expected to oppose the reforms, citing patient safety and professional turf. But the authors argue the debate should center on what’s best for patients, not who controls the procedure. “Professional turf battles are as old as medicine itself,” they write.
The broader trend in health policy has been toward expanding scope-of-practice for non-physician providers, including nurse practitioners and physician assistants. Evidence from those expansions shows improved access, lower costs, and a more resilient health care system. The researchers say optometry should follow suit.
As the U.S. population ages, the demand for eye care will only grow. The ophthalmologist shortage is expected to deepen, particularly in underserved communities. “If we want to reduce care delays, especially in underserved communities, we need to use every tool available,” the authors concluded. “Letting optometrists do more is one of the easiest and most effective steps we can take.”
For more on how policy changes affect access, see the analysis on the Texas voter poll on election integrity and ballot access, and the bipartisan push to boost clinical trial access for underserved groups.
