Intravitreal injections by optometrists?

Our profession has had to fight for the privilege of caring for our patients with ocular disease. With optometry as a legislated profession, these battles have occurred in every state and, as a result, optometric practice acts vary widely. Ophthalmology does not have to endure such travails. Ophthalmologists can do pretty much whatever is in their purview, as is their right. 

Much has been made of the possible shortage of healthcare providers due to changes in healthcare delivery, and as a consequence, some policy makers are looking to “physician extenders” to fill the perceived gap. One possible use of physician extenders caught the eye of an optometrist friend of mine, and he enlightened me.

The article, “Implementation of a Nurse-Delivered Intravitreal Injection Service” was published in the June 2014 issue of Eye. The purpose of this study was “to introduce nurse-delivered intravitreal injections to increase medical retina treatment capacity in the United Kingdom.”¹ A “rigorous training schedule” was developed that included “mandatory attendance at a full (one) day intravitreal injection (IVI) course, including practical training on pig eyes in a wet lab.” Following the completion of this one-day course, the nurse observed and shadowed the consultant ophthalmologist for 20 injections. Then the nurse performed 20 injections under the supervision of an ophthalmologist.  At the end of the training period of 100 injections, the nurse was graded and deemed competent.

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Over 4,000 nurse-delivered IVIs were followed over a two-year period. The only complication seen was subconjunctival hemorrhages in 5.7 percent of patients. The authors concluded, “Our preliminary results of a series of 4,000 nurse-delivered injections associated without serious vision-threatening complication is indicative that this procedure can be safely administered by a nurse.” No cases of post-intravitreal anti-VEGF endophthalmitis occurred in this study.

Age-related macular degeneration is the most common cause of visual loss and blindness in patients over 50 years of age in the developed world.² As the population ages, the need for therapeutic intervention with this disease will only increase. Some states currently allow some form of ocular injections in their practice acts, but the regulations are restrictive and rare. The results of this study clearly show that nurses, with appropriate training and supervision, can administer this procedure safely and effectively. The question readily follows: why can’t optometrists? The answer surely is we can. We have far more training in ocular anatomy and physiology than do nurses, and optometrists are more familiar with AMD, as we see the condition in our offices daily.

And in areas where retinal specialists are widely distributed geographically, it would make even more sense. Optometrists would need to be trained in the procedure, and the U.K. training model appears to be a good one. You can’t argue with their results. With the changing U.S. healthcare landscape, perhaps it is time for ophthalmology and optometry to work together to provide contiguous care in this area, much as we now comanage cataract procedures. It would be a nice change to cooperate and find common ground with ophthalmology instead of undertaking a protracted, costly legislative battle. No one wins in those situations, least of all our patients, and our patients are truly our only concern.ODT

References

1. DaCosta J, Hamilton R, Nago J, et al. Implementation of a Nurse-Delivered Intravitreal Injection Service. Eye. 2014;28(6):734-40.

2. Augood CA, Vingerling JR, de Jong PT, et al. Prevalence of age-related maculopathy in older Europeans: the European Eye Study (EUREYE). Arch Ophthalmol. 2006;124:529–35.