December 1998
TO: 1999 Kansas Legislature
Interprofessional Advisory
Committee
The Kansas State Board of Examiners in Optometry accepts the Interprofessional Advisory Committee Legislative Report. The KSBEO thanks the IAC for its many hours of work on both glaucoma co-management and the oral pharmaceutical report. The KSBEO agrees with the conclusions of the report.
In addition to the IAC report, the KSBEO would like to make its own observations.
The interaction between ophthalmology and optometry has enhanced patient care in Kansas. The ongoing dialogue between ophthalmology and optometry will have a lasting, positive effect on Kansas vision care.
On the negative side, the process has generated an immense paperwork burden for the IAC & KSBEO. Over 4,900 forms have been processed to date. With the prospect of glaucoma co-management lasting several more years, the clerical requirements loom large.
KSBEO has no reports or pending actions against optometrists for the improper use of glaucoma medications during the first thirty months of glaucoma co-management.
The KSBEO adds the following information to the oral pharmaceutical issue. The KSBEO conducted a survey of all state boards in optometry during the summer of 1998. Boards were contacted by mail, e-mail and phone. Those not responding to the first survey were contacted on at least two additional follow-ups.
Twenty-seven states responded including all states surrounding Kansas. Twenty-two of the twenty-seven responding states allow optometrists to treat glaucoma. Those responding, report no board complaints or actions pending against optometrists’ improper use of glaucoma medications. Twenty-two of the twenty-seven responding states allow some oral pharmaceuticals use. Those responding report a single (a) incident of improper use of oral pharmaceuticals with no other pending actions.
(a) Louisiana – optometrist cited for prescribing a non-allowed diet pill.
The KSBEO concludes from the survey, that glaucoma and oral pharmaceutical authority has had minimal effect on official board actions in other states. In states that allow optometrists glaucoma and oral pharmaceutical prescription authority, it appears that optometrists have demonstrated competency and responsibility, with or with out a co-management period.
The Kansas State Board of Examiners in Optometry concludes that glaucoma co-management and eventual glaucoma treatment by optometrists, is beneficial to the visual welfare of the citizens of Kansas. As a next step, we endorse giving oral pharmaceutical authority to qualified optometrists in Kansas.
Many hours of unpaid work were needed to complete this legislative
report. The KSBEO again thanks the IAC, the Kansas Optometric Association
and Kansas State Ophthalmological Society for their research and editing of this
report.
December 1998
FORWARD
Pursuant to the requirements of S.B. 684 passed in 1996, the Kansas State Board of Examiners in Optometry and the Interprofessional Advisory Committee were required to prepare a report to the 1999 Kansas Legislature about the results of glaucoma co-management between optometrists and ophthalmologists and the advisability of expanding the scope of optometrists to prescribe, administer and dispense oral pharmaceutical drugs.
The Kansas State Board of Examiners in Optometry wishes to acknowledge the hard work and many hours of public service provided by the members of the Interprofessional Advisory Committee in this process. Our heartfelt thanks go to IAC members: Dave Amos, OD, Pete Brungardt, OD, Bill Clifford, MD, Mike Stiles, MD, Paul Reimer, OD, Mike Reynolds, MD and the late Les Nesmith, MD. Dr. Nesmith was instrumental in the early IAC work in 1996-97. He resigned from the committee in 1998 several months before his tragic death in November 1998.
As President of the Kansas State Board of Examiners in Optometry, I want to recognize the State Board of Examiners in Optometry members who have also worked hard in reviewing the glaucoma cases and preparing this report: Diana Carriger, OD, Sharon Michel, OD, John Page, OD, Warren Thomas, OD and Mr. Tom Lemon. Our secretary Marshella Woods has done an outstanding job in handling the paperwork involved in this process.
The cooperation and assistance of the Kansas Medical Society, Kansas Optometric Association and Kansas State Ophthalmological Society was extremely helpful in facilitating this process.
Respectfully submitted,
Dr. Larry Stoppel, President, Kansas State Board of Examiners in Optometry
Chair, Interprofessional Advisory Committee
This report is divided into two major sections to address the statutory
requirements outlined in S.B. 684 (Appendix A) passed in 1996. In the
first section, the Interprofessional Advisory Committee (IAC)1 and the State
Board of Examiners in Optometry (SBEO)2 have prepared an analysis of the results
and requirements of glaucoma co-management. The IAC is composed of three
optometrists and three ophthalmologists with meetings chaired by a member of the
SBEO. The State Board of Examiners in Optometry is the licensing board for
Kansas optometrists. It is composed of four optometrists and a public
member appointed by the Governor. The second section reviews the
educational and clinical prerequisites of optometrists to use oral
pharmaceutical drugs; identifies classes of oral drugs which are effective
treatments for ocular conditions; and the advisability of expanding the scope of
practice to prescribe, administer and dispense oral drugs.
S.B. 684 allowed optometrists to co-manage glaucoma patients in
cooperation with a consulting ophthalmologist prior to independent
treatment. This process was designed to encourage a cooperative clinical
learning experience for the optometrists with consulting
ophthalmologists. The glaucoma co-management process has been a
positive one. Not
all the eligible optometrists or ophthalmologists
chose to participate but the numbers are impressive.
Since 1996, almost three hundred of the 360 Kansas optometrists have filed an
intent to
co-manage glaucoma form (Appendix B). This indicates a
significant interest in this process. Over 320 optometrists have taken the
approved glaucoma education course since 1996. Interested ophthalmologists
were welcome to attend and participate in the educational programs as
well. Over 60 ophthalmologists participated by co-managing with interested
optometrists. Over 4,000 Kansas glaucoma patients have been treated and
monitored. Each case is reviewed by the Interprofessional Advisory
Committee and the State Board of Examiners in Optometry.
Prior to December 15, 1998, 48 optometrists had completed all the educational
and
clinical requirements to become certified to treat adult open-angle
glaucoma. Another 15 optometrists have submitted their twenty cases and
should be certified in early 1999. The table below provides an analysis on the
progress of licensees towards their 20 cases for glaucoma certification.
| No. of cases | No. of Optometrists |
| 20 or more | 72 |
| 11-19 | 56 |
| 5-10 | 45 |
| 4 or less | 48 |
The Interprofessional Advisory Committee (IAC) provided SBEO with
recommendations that would meet the statutory requirements of the glaucoma
co-management process. This section provides an analysis of those
responsibilities and the recommendations to address them.
According to K.S.A. 74-1501 (c):
(c) The committee shall submit
recommendations to the board on the following: (I) An
ongoing quality
assessment program including the monitoring and review of co-management of
patients pursuant to subsection (d) of K.S.A. 65-1505 and amendments
thereto,
The IAC recommended co-management reporting forms, approved by SBEO, to be filed for each patient being co-managed (Appendix B). Forms must be signed by the participating ophthalmologist and optometrist and the patient record should reflect any changes in treatment plan. General definitions were adopted by the committee to designate inadequate reporting, and such reports are flagged and returned to the participating optometrists for further work. To assist participating optometrists and ophthalmologists, a sample glaucoma case form was developed by the Committee and provided to all (Appendix B).
(2) requirements for the education and clinical training necessary for
glaucoma
licensure, which shall be submitted to the board within 90 days
following appointment;
The State Board of Examiners in Optometry accepted the recommendations of the IAC and established rules and regulations (Appendix C):
K.A.R. 65-5-10 (b) For the purposes of this paragraph, an “approved course of glaucoma instruction” shall be the 24 hour course in glaucoma management offered by the University of Missouri - Saint Louis School of Optometry as that course existed on May 9, 1996, and any course which has been determined by the board to be of comparable content. The glaucoma course outline is included in Appendix D. The textbook for the course was Clinical Decisions in Glaucoma written by Elizabeth Hodapp, MD, Richard Parrish, II, MD, and Douglas Anderson, MD. This course was team taught with classes of 15 to 18 students to allow maximum interaction and participation.
(3) criteria for evaluating the training or experience acquired in other states by applicants for glaucoma licensure,
After committee discussion, the IAC recommendation was that the current reciprocity requirements for licensure assured that the applicant would have equivalent training and experience.
(4) requirements for annual reporting during a glaucoma licensee’s co-management period to the committee and the board which shall be submitted to the board within 90 days following appointment,
Applicants must file annual reports prior to May 31 on all cases being co-managed. The annual reporting forms developed by the committee and approved by SBEO are attached in Appendix B.
(5) the classes and mix of patients either suspected of having or diagnosed as having adult open-angle glaucoma who may be included in the number of co-management cases required by subsection (d) of K.S.A. 65- 1505 and amendments thereto, which shall be submitted to the board within 90 days following appointment; and…
The State Board accepted the recommendations of the committee that the twenty patients must be a “reasonable” mix of adult open angle glaucoma and glaucoma suspects. The SBEO indicated that the mix must include at least 10 adult open angle glaucoma cases in order to qualify.
(6) …requirements for annual continuing education by glaucoma licensees.
Glaucoma licensees must complete at least four (4) hours of glaucoma specific continuing education annually, as recommended by the IAC and implemented by the State Board of Examiners in Optometry.
(d) After considering the recommendations of the committee pursuant to subparagraph (c), the board shall proceed to adopt procedures to confirm that each applicant has completed the requirements for glaucoma licensure.
The Board of Examiners in Optometry has established an application form (Appendix B) on which the optometrist must certify the completion of 20 approved co-management cases over a minimum of two years, case reporting, annual reporting, completion of the 24 hour educational course and proof of liability insurance ($1,000,000). The application states the applicant understands that only after these requirements are met will the State Board of Examiners in Optometry review the file. At this time, the State Board grants a glaucoma license to manage and treat adult open-angle glaucoma.
As part of the review process, the SBEO will consider all pertinent information about an applicant. Co-managing ophthalmologists and optometrists may submit any information for board consideration. Information should be forwarded to the board before the review is completed and the license issued.
Committee Summary and Recommendations on Co-Management of Adult Angle Glaucoma
According to K.S.A. 74-1501 (e):
(e) The interprofessional advisory committee shall also review the educational and clinical prerequisites of optometrists to use oral pharmaceutical drugs and identify those classes of oral pharmaceutical drugs which are effective treatments for ocular diseases and conditions. The interprofessional advisory committee and the board shall prepare a report of the results of co-management pursuant to subsection (r) of K.S.A. 65-1501a and amendments thereto and findings on the subject of the advisability of expanding the scope of practice of optometrists to prescribe, administer and dispense oral pharmaceutical drugs, which report shall be submitted to the Legislature not later than January 1, 1999.
Educational and Clinical Prerequisites of Optometrists to Prescribe Oral Drugs
During the initial discussions by the Interprofessional Advisory Committee, the Kansas Optometric Association agreed to provide background information on optometric education and the specific state laws allowing optometrists to use oral pharmaceuticals. This report provides the information requested by the Interprofessional Advisory Committee.
Undergraduate Educational Requirements and Curriculum
The recommended undergraduate educational requirements for optometry school
emphasize science and math courses. Potential optometry students are
encouraged to take science courses designed for pre-professional students, which
must include laboratory experience. A sample undergraduate curriculum is
outlined in this section. Most optometry school applicants sit for the entrance
exam following their sophomore or junior year in college. The senior year
is not listed since most students use it to complete general education
requirements and for elective course work for their degrees.
| Freshman Year | Sophomore Year | Junior Year |
| General Chemistry | Organic Chemistry | Calculus |
| College Algebra | Microbiology or Bacteriology | Physiology |
| Trigonometry | Calculus | Biochemistry |
| English | Physics | Anatomy |
| Biology | Psychology | History |
| Speech | ||
| Sociology | ||
| Intro to Business | ||
| Total Hours 30 | Total Hours 30 | Total Hours 30 |
Source: Optometry: A Career with Vision. published by the American Optometric Association.
Some optometry schools have additional prerequisites for more than one semester of science and math courses. Many schools also encourage a course in statistics.
Entrance Exam Required for Optometry School Admission
The Optometry Admission Test (OAT) is a standardized examination designed to measure general academic ability and comprehension of scientific information. The OAT is sponsored by the Association of Schools and Colleges of Optometry (ASCO) for applicants seeking admission to an optometry program.
The OAT includes quantitative reasoning, reading comprehension, physics,
biology, general chemistry and organic chemistry. It is recommended that
students complete two or more years of college prior to taking the exam.
Optometry schools and colleges are accredited to ensure quality
instruction and education. The Council on Optometric Education of the
American Optometric Association is recognized by the U.S. Department of
Education and the Council of Postsecondary Accreditation as the accrediting body
of optometric education programs. This agency also determines the
accrediting bodies for dental and medical schools.
Once admitted to optometry school, students must undergo an intensive, four-year regimen of educational and clinical training to become a doctor of optometry. Each school of optometry has its unique curriculum and as a result the total hours spent on didactic education vs. clinical experience will vary between institutions. A recent survey of optometry school curricula found that 2,187 hours represented the mean number of hours spent on didactic education. This represented coursework in basic biomedical sciences, which includes human anatomy, human physiology, biochemistry, general and ocular pharmacology, general pathology, and epidemiology, with additional emphasis on vision. This emphasis includes coursework in optometric science, vision science and sensory and perceptual psychology. In addition to these didactic hours, 1,910 hours represents the mean value optometry schools devoted to clinical education. This clinical setting is taught at various locations including VA hospitals and outpatient centers, military hospitals and outpatient centers, Indian Health Centers and hospitals, ophthalmology referral centers and offices, optometric offices, and educational institutions with outpatient clinics.
National Board of Examiners in Optometry In 1951, the National Board of
Examiners was formed by the International Association of Boards of Examiners in
Optometry, the federation of state optometry licensing boards and the
Association of Schools and Colleges of Optometry. The "National Boards"
provide a reasonable national standard of entry-level competence. A letter
from Dr. Norm Wallis, the Executive Director of the National Board of Examiners
in Optometry, (included in Appendix D) provides an overview of the components of
the national board exams along with excerpts from a recent Candidate
Guide. The excerpts from the candidates guide provide an excellent
overview of the different parts of the national boards. In 1985, the
Treatment and Management of Ocular Disease (TMOD) was developed as a stand-alone
examination to assess knowledge of the use of drugs for therapeutic
purposes. Beginning in 1993, these questions have been incorporated into
other sections of the test.
In 1977, the Kansas Legislature authorized optometrists to use diagnostic
drugs, provided that optometrists passed a 50-hour pharmaceutical course offered
by Wichita State University. It was taught by a professor from the
University of Indiana School of Optometry and faculty members from the KU
Department of Ophthalmology. During the last twenty years, optometrists
have exercised this privilege cautiously and responsibly. The Kansas State Board
of Examiners in Optometry has not received any complaints about the misuse of
diagnostic drugs.
In 1987, the Kansas Legislature authorized optometrists to use topical drugs for the treatment of eye disease. Kansas optometrists were required to pass a 100-hour course on diagnosis and pharmaceutical treatment. The Pennsylvania College of Optometry (PCO) provided faculty for this course, including pharmacologists, ophthalmologists, pathologists and optometrists on staff. Several Kansas ophthalmologists also participated in this course, which covered both topical and oral drugs. In addition to the test to successfully complete the PCO course, the State Board of Examiners also gave a test covering diagnosis and treatment before issuing therapeutic drug licenses in 1987. The optometrists were required by the State Board to have successfully completed a CPR course as well. Since 1985, the National Board has included more extensive testing on pharmacology and the treatment of eye disease for graduating optometry students.
In 1996, the Kansas Medical Society (KMS), Kansas State Ophthalmological Society (KSOS), and the Kansas Optometric Association (KOA) cooperated for statutory changes allowing optometrists to treat adult open angle glaucoma with a 24-hour education course and two years of co-management with an ophthalmologist.
Through twenty hours of annual continuing education, optometrists have also
stayed current with the latest developments in pharmacology. Continuing
education courses are offered through the American Optometric Association,
American Academy of Optometry, optometry schools, Heart of America Contact Lens
Society and numerous programs offered by state optometric associations.
The
KOA proposal would add oral medications as a form of treatment for the same
conditions treated topically since 1987 by optometrists. Ocular
infections, inflammations, glaucoma, and injuries have been successfully treated
topically. The interactions, side effects and adverse responses of oral
medications can be similar, although potentially more severe than those
encountered in topical treatment. Kansas optometrists will be treating
many of the same ocular conditions with similar medicines administered
differently.
The ocular tissue and adnexa is subject to various infections and
demonstrates an inflammatory response to many offending agents. The
following classes of oral pharmaceutical drugs are effective treatments for
ocular disease and conditions:
The IAC and the SBEO have attempted to gather helpful information
regarding the advisability of expanding the scope of practice of optometrists to
prescribe, administer and dispense oral pharmaceutical drugs. This has
been the most difficult issue to obtain a consensus. The following are the
findings for the 1999 Kansas Legislature to consider: