Texas optometrists "just roll our eyes" over treatment restrictions in the state

Eliecer Arce has his retina checked by Dr. Noor Abushagur in Fort Worth. He originally came in with severe swelling in his eyes, unable to see, and was diagnosed with an autoimmune condition.
Eliecer Arce has his retina checked by Dr. Noor Abushagur in Fort Worth. He originally came in with severe swelling in his eyes, unable to see, and was diagnosed with an autoimmune condition.
Leslie Boorhem-Stephenson

FORT WORTH — Eliecer Arce is waiting for his eyes to dilate as he sits in a chair at the Community Eye Clinic, recounting how he went from perfect 20/20 vision to blurred vision and back again.

It started one day last year when he looked outside and found everything was alarmingly fuzzy. Arce went to an optometrist in a Walmart who recommended he see an ophthalmologist, a doctor who specializes in surgical and medical eye care. But he wouldn’t be able to get an appointment for two months.

“I was nervous, I couldn’t see,” Arce said in Spanish. “How was I going to support my family or pay my rent? There are a lot of things to pay.”

Patients like Arce are why Texas optometrists say there’s an eye care crisis and unmet need in the state. They’re hoping the Legislature will give them more power to help patients without needing an ophthalmologist or other doctors. Currently, Texas law requires optometrists — who go to optometry school instead of medical school — to refer patients to doctors for a second opinion if they find patients have glaucoma. Optometrists are also only allowed to prescribe antibiotics for a limited amount of time.

In terms of restrictions on patients’ access to optometric eye care, Texas ranks fourth in the nation, according to the Texas Optometric Association. Optometrists say the laws put patients’ vision at risk if they have to wait weeks for an ophthalmologist appointment. They also say that as Texas’ population grows, the state will need more eye care professionals who can help patients in one visit, particularly among older adults and in rural communities.

But ophthalmologists argue they have medical training that can potentially save patients from losing their vision. They point out that some eye issues can be difficult to diagnose and need extra scrutiny to make the right treatment plan. They also have pushed back against the idea that there’s a crisis in Texas.

Dr. Jennifer Deakins, an optometrist and clinic director who helped establish Community Eye in 2013, said most of her day is spent “spinning my wheels” trying to connect patients with the right doctors who can quickly see them or prescribe medication. The clinic sees as many as 70 low-income patients a day for eye exams and finding glasses.

But Deakins said it also treats people who have high blood pressure, diabetes, HIV, Crohn’s disease and other autoimmune diseases that can affect the eye. Some patients come in not realizing they have an underlying illness affecting their vision. Some haven’t been able to navigate signing up for Medicaid, the joint federal-state health program for the poor and disabled, or Medicare, the federal program for adults 65 and older. Patient referrals to the clinic come from county hospital emergency rooms, community organizations, homeless shelters and local health centers.

Patients may need tests that are not always covered by their insurance, and the clinic sometimes is forced to send patients to the emergency room so they can get tests or other care right away. Deakins said she wishes she could easily do procedures with patients that involve lasers, treat a sty on a patient’s eye or write a prescription instead of having to send patients out for another appointment. Currently, optometrists are not allowed to prescribe oral anti-viral or anti-inflammatory medication.

“It’s bad for patients because they look at you like, ‘Why can’t you just fix this?’” Deakins said.

Arce said he couldn’t wait for an ophthalmologist to see him because he was missing work. The managers at the apartment complex where he does maintenance understood his predicament, but Arce was growing worried about not being able to drive or go outside without help. He went to two hospitals, one of which referred him to a retina specialist who said the liquid in his eyes would go away on its own.

Eliecer Arce, Enedina Puente and their daughter, Melissa Arce pose for a portrait in the waiting room at Community Eye Clinic where Eliecer had a follow up appointment. They also have a child in kindergarten and one in eighth grade.
Eliecer Arce, Enedina Puente and their daughter, Melissa Arce pose for a portrait in the waiting room at Community Eye Clinic where Eliecer had a follow up appointment. They also have a child in kindergarten and one in eighth grade.
Leslie Boorhem-Stephenson
Dr. Noor Abushagur discussed what she sees in her examination and in the images taken of his Eliecer Arce's eyes at a Community Eye Clinic. Dec 4, 2018.
Dr. Noor Abushagur discussed what she sees in her examination and in the images taken of his Eliecer Arce’s eyes at a Community Eye Clinic. Dec 4, 2018.
Leslie Boorhem-Stephenson

Left: Eliecer Arce, Enedina Puente and their daughter, Melissa Arce pose for a portrait in the waiting room at Community Eye Clinic where Eliecer had a follow up appointment. They also have a child in kindergarten and one in eighth grade. Right: Dr. Noor Abushagur discusses what she sees in Eliecer’s examination and in the images taken of his eyes at a Community Eye Clinic. Dec 4, 2018.

Leslie Boorhem-Stephenson for The Texas Tribune

He eventually found Community Eye Clinic, and optometrists diagnosed him with an autoimmune condition that can affect the eyes, ears and skin. In Arce’s case, it caused severe swelling of his eyes, and he needed oral steroids. But the runaround to get help with his eyes is still costing him. He owes both hospitals more than $2,000 for his emergency room visits. Arce is unsure of who to talk to about payment arrangements.

The optometry-versus-ophthalmology fight is “like David and Goliath” said Dr. Tommy Lucas, director of advocacy for the Texas Optometric Association and an optometrist in Killeen.

Texas optometrists’ asks for this year’s legislative session are likely to include getting rid of restrictions on oral prescription medication and not being required to send patients to ophthalmologists for glaucoma cases. Currently, if patients need antibiotics for longer than 10 days, optometrists have to send them to another doctor, nurse or physician assistant. If patients need antivirals or other drugs, their optometrists must find a doctor, nurse or physician assistant who can help them quickly obtain a prescription. Optometrists say this puts patients at risk of a prolonged infection or worse, blindness. They also say sending patients to ophthalmologists for a second opinion on glaucoma can hinder treatment because patients sometimes are unable to go to that appointment or can’t pay for it.

Lucas said optometrists are not asking to be allowed to perform Lasik, commonly known as laser vision correction, cataract surgery or other invasive eye procedures.

House Bill 1413, which was filed during the 2015 session and would have given optometrists more power to treat glaucoma without a second opinion, prescribe more medications and perform minor surgeries, was referred to the House Public Health Committee but was withdrawn.

In the last five years, nearly 30 percent of new Texas optometrists have left the state upon graduation to practice in places such as Louisiana or Oklahoma, where they are allowed to provide more services to patients, according to the Texas Optometric Association.

“When you’re an optometrist and you look at our laws, I hate to say it, we just roll our eyes at how sad the law is,” Lucas said. “It’s a total underutilization of our qualification.”

Texas optometrists cite Louisiana as a top place to practice because optometrists allowed to manage glaucoma cases without getting a second opinion and prescribe medications without another medical professional. Louisiana optometrists can also perform surgical procedures for sties, remove items from an eye or use a special laser to treat glaucoma when drops don’t work for a patient.

Dennis McManaman of Amarillo, a retired officer with the Potter County and Randall County sheriff’s offices, said he knew something was wrong with his vision in 2006 when he didn’t pass his shooting test on the first try. His optometrist never told him there was anything wrong. Three years later, fed up with his optometrist and worried about his sight, McManaman asked for his medical records so he could see an ophthalmologist. His optometrist tried to talk him out of it. The Texas Optometry Board, the licensing board for optometrists in the state, sanctioned McManaman’s doctor for failing to provide proper care for his glaucoma.

Dennis McManaman of Amarillo and a retired officer with the Potter County and Randall County sheriff's offices has had vision problems since 2006. Jan. 30, 2019.
Dennis McManaman of Amarillo and a retired officer with the Potter County and Randall County sheriff’s offices has had vision problems since 2006. Jan. 30, 2019.
Gary Rhodes for The Texas Tribune

McManaman saw an ophthalmologist and found out he had lost most of his vision in his right eye, and his left eye was not doing much better. His doctor told him, “There’s nothing we can do to bring back that vision,” and the best option was treat it aggressively to prevent it from getting worse. He went home “devastated and angry and going through denial.” He was forced to retire early from his job and now spends most of the day close to home, managing his glaucoma with special eye drops.

“They need a lot less access to the human eye than they had even back then,” McManaman said. “I’m sure there are some that are very conscientious, but they don’t have the medical doctor’s oath and training, so dispensing glasses is all the optometrists should be allowed to do.”

Rachael Reed, executive director of the Texas Ophthalmological Association, said optometrists “want the Legislature to give them a shortcut instead of going to medical school.” She said there are unlimited ways for both kinds of professionals to work together, but straying away from that model “has the potential to result in a patient going blind,” particularly when it comes to treating glaucoma.

“If you stopped the average person on the street and asked them if they think their medical condition should be treated by someone who didn’t go to medical school, I think you know the answer,” Reed said.

She also pushed back on optometrists’ argument that there’s an ophthalmologist shortage in Texas. There are 1,670 licensed ophthalmologists in Texas, compared to 4,000 optometrists. Although they’re outnumbered, Reed said new technology is allowing ophthalmologists to see an average of 65 patients a day and perform surgeries faster than they could five or 10 years ago. She said seeing Louisiana, Oklahoma and other states change their standards for optometrists is “alarming” and something her organization would fight to prevent from happening in Texas.

There’s an argument that rural communities need more eye care professionals, but that’s not true for ophthalmology, said Dr. Sanjiv Kumar, an ophthalmologist in Uvalde. He said there’s a growing number of ophthalmologists with smaller offices scattered around rural areas filling the need. He pointed out that the real shortage is often among rural primary care doctors who can have weeks-long waiting lists for appointments.

Kumar said most of his patients are older, but if he suspects glaucoma, he sometimes refers them to other specialists for a second opinion. He said if he were an optometrist, he would not look at the current laws as an administrative burden or loss of autonomy but instead as “trying to do the best for your patient.”

“I’m supposedly as well trained as you can be in this field, and even I’m scared about making the wrong diagnosis when it comes to some glaucoma patients,” Kumar said. “I think the more you know about certain things, the more concerned you get about what else it could be or what other problems it could be.”

Back in Fort Worth, Arce said his vision is back to normal, but he said he sometimes feels more tired or like he has “a stone” in his eye. It doesn’t happen every day, but it’s part of the aftermath of the infection.

“I’m very grateful for this clinic because I had the best experience and the best care here,” Arce said. “And after all this time, I can see well now.”

Eliecer Arce walks out of the exam room at Community Eye Clinic after a follow up appointment. Dec 4, 2018.
Eliecer Arce walks out of the exam room at Community Eye Clinic after a follow up appointment. Dec 4, 2018.
Leslie Boorhem-Stephenson

Teo Armus contributed to this story.

Disclosure: Walmart has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.


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