Eyeworld

EW NEWS & OPINION 18 Ophthalmologists look back at how optometry scope of practice was widened, how other states can avoid the same O phthalmologists across the U.S. were stunned in February when the gover- nor of Kentucky signed a controversial bill into law that allows optometrists there to perform laser and scalpel proce- dures, as well as injections. "We were completely blind- sided," said Brock K. Bakewell, M.D., clinical assistant professor of ophthalmology, University of Utah, Salt Lake City, and chair of the ASCRS government relations com- mittee. Senate Bill 110 grants op- tometrists in Kentucky authority to perform laser procedures, including laser trabeculoplasty, peripheral iri- dotomy, iridoplasty, and capsulo- tomy, YAG capsulotomies, LASEK, and laser "only" clear-lens extrac- tion. The bill, which is scheduled to go into effect on June 29, will also allow optometrists to perform some scalpel procedures and administer pharmaceutical agents, including by injection into the vitreous. Kentucky is the second state, be- hind Oklahoma, to widen the opto- metric scope of practice to include surgery. Ian Benjamin Gaddie, O.D., a Louisville optometrist and presi- dent-elect of the Kentucky Optomet- ric Association, said that the new law offers Kentuckians better access to eyecare. "We're not going to be doing retinal lasers or corrective eye surger- ies," Dr. Gaddie said on a local tele- vision program called Pure Politics. "The laser surgery procedures are mainly to take care of some post-op- erative cataract problems and some glaucoma issues." Instead of bracing for similar stories in other states, 25 of which have already rejected similar legisla- tion, some ophthalmologists are considering the Kentucky move as a call to action. "Ophthalmologists need to get more politically active," Dr. Bakewell said. "They can't sit back on their laurels and think their domain isn't going to be threatened because or- ganized optometry isn't going to stop until they have all the surgical privileges that we have." Woodford Van Meter, M.D., president, Kentucky Academy of Eye Physicians and Surgeons, and profes- sor of ophthalmology, University of Kentucky, Lexington, said there were several conditions that led to the bill being passed in Kentucky, and oph- thalmologists can move forward by studying and learning from those. First, organized optometry in the state was well funded and highly organized. "Optometrists have made sub- stantial donations over the last 3 years to the state legislature, to the tune of roughly $450,000," Dr. Van Meter said. "Not only do they give a lot of money, but they interact fre- quently with their legislators. We know that almost every optometrist took his or her legislator out for meals. They presented the checks to them personally." Next, manpower, both at the capitol and within the state organi- zation, was lacking. The Kentucky Academy of Ophthalmology em- ploys two part-time lobbyists, com- pared to the Kentucky Optometric Association's lobbying force of 18 at the capitol for that session. Also, "one-third of the 150 oph- thalmologists practicing in Kentucky are not members of the state organi- zation," Dr. Van Meter said. "Out of those 104 ophthalmologists, there are only 25 who give to the state po- litical action committee, whereas the optometry number is close to 100%." EW June 2011 by Jena Passut EyeWorld Staff Writer Lessons learned from Kentucky Stabilizing the IOL A bent 26-gauge needle is used to create a scleral tunnel at the edge of the scleral flap. This is created intra- sclerally parallel to the limbus and is done toward the direction of the ex- teriorized haptic on either side. It is actually better to do this in the be- ginning of the surgery when one creates the sclerotomy. Also a marker pen can be put on the needle while creating this so that one knows ex- actly where the tunnel is created. If the location of the tunnel becomes lost, one can recreate the tunnel or use a simple rod to pass through the tunnel and check its location. The haptic is then tucked into the scleral pocket created. This se- cure tuck of the haptic within the pocket prevents any kind of move- ment of the IOL and provides great stability to the IOL. At this stage, the degree of cen- tration of the IOL is assessed and if decentration is noted, it is corrected. This is done simply by varying the degree of tuck of either haptic into the scleral pockets created on oppo- site sides. Gluing the IOL The infusion is then removed and the AC filled with air. This way the area of the sclerotomy where the haptics are is dry as now there is no fluid coming out. Also, the air in the AC prevents any collapse of the chamber and any hypotony in the post-op period.The scleral bed is dried with a Weck-Cel sponge. Fibrin glue is then applied to the undersur- face of the flap and the flap is glued down. The conjunctiva is also closed with glue and the corneal wound is hydrated. A suture may be applied if required. Corneal incisions can be glued down using the same glue. One can perform the glued IOL in the vertical (suggested first by Jeevan Ladi from India) meridian (12 to 6 o'clock). If the white-to- white diameter is too much in the horizontal meridian, it will be shorter in the vertical as the corneal diameter is shorter vertically. One should always measure the white-to- white length so that one has enough haptic to tuck and glue when exteri- orized. EW Editors' note: Dr. Agarwal has no financial interests related to his com- ments. Contact information Agarwal: + 91 44 2811 6233, dragarwal@vsnl.com the entire haptic or IOL within a closed globe system. While the first haptic is held by an assistant, the tip of the trailing haptic is grasped by forceps and is flexed gently into the eye and out through the second sclerotomy. The leading haptic held by the assistant should not be released during this maneuver. Once both haptics are ex- teriorized on to the scleral surface, they can be released. At this stage, the IOL remains firmly on the scleral surface without falling into the vitre- ous cavity. Vitrectomy is performed over the sclerotomy sites to remove any vitreous that may have prolapsed out through the sclerotomy. This is done by turning the cutting port to- ward the scleral surface. A step continued from page 17 continued on page 21 Brock K. Bakewell, M.D. Woodford Van Meter, M.D.

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