In early August, the Veterans Health Administration announced a new policy that would require optometrists who perform laser surgery in VA hospitals to do so under the supervision of an ophthalmologist. What form this supervision will take is still being decided by the VA, however.

The announcement was prompted by the debate over the Veterans Eye Treatment Safety Act, currently in Congress, that would make it illegal for anyone but a licensed medical doctor or doctor of osteopathy to perform surgery in a VA facility. The legislation was in response to an outcry from the VETS Coalition, a group composed of the American Academy of Ophthalmology, congressional leaders and veteran service organizations. The coalition was disturbed by an incident of an Oklahoma-licensed optometrist performing laser eye surgery in a Kansas VA hospital, even though such surgery was outside the legal optometric scope of practice in Kansas.

"With all due credit to the VA, we may have taken a step in the right direction with the supervision requirement," says H. Dunbar Hoskins Jr., MD, the AAO's executive vice president. "But, we don't believe optometrists have the education, training or background to be doing intraocular eye surgery. Also, we don't believe that veterans should be subjected on a national basis to the whims of a single state's legislature … We don't understand the rationale behind this decision. However, the VA has the power and authority to make such a decision, and we're now waiting to see how the supervision aspects roll out."

On the other side of the debate, David Cockrell, OD, president of the Oklahoma state board of examiners in optometry, isn't pleased with the decision because it establishes new limitations on optometric surgery where there once were none.

"I don't think it's a good policy," says Dr. Cockrell. "I don't know of any other health-care providers that require supervision. It's a restriction that we don't think is necessary, and certainly hasn't been proven to be necessary prior to this. To the best of my knowledge, there's been no documented case of harm done to any veteran patient due to the optometric utilization of lasers."
With regard to the issue of credentialing in Oklahoma allowing optometrists to perform laser surgery in any state's VA hospitals, Dr. Cockrell says there are numerous precedents for such a situation.

"In the federal system, as ophthalmology is acutely aware, whatever your license happens to be, whether it's MD, OD or DDS, each practitioner is allowed to practice to the extent that his license allows," he says. "I'd ask you to apply that same question to dentistry [in the VA], because there are many different dental statutes that allow different procedures in different states, but I don't hear that question being asked by medicine as it concerns dentistry … My concern is that I hear medicine saying that it wants a national law that applies to optometry only."

Dr. Hoskins has also expressed a concern that the new policy establishes two standards of care, one in which the patient undergoes surgery by an ophthalmic surgeon, and another in which he undergoes surgery by someone with ostensibly less experience, the optometrist. In a written response to this and other issues prepared by the VA for Review, the agency says, "For performance of therapeutic laser eye procedures by optometrists at VA medical facilities, there will be ophthalmologist supervision to ensure one standard of care."

This prompts the question: If you were a patient, would you rather have the presumably more-experienced surgeon just supervise or actually perform your laser procedure?

The VA responds, "The VA credentialing and privileging process ensures that all VA health care providers—including optometrists and ophthalmologists—are well-qualified to perform in their respective roles. Veterans are fully informed and involved in decisions concerning their care. Veterans undergoing surgery are provided with the names and roles of the practitioners performing or supervising the procedure. When patients make specific requests regarding the practitioners assigned to their care, VA makes an effort to accommodate them."

The big question remains, how will the supervision be structured? The VA has formed a work group to "develop recommendations and an implementation plan" to meet the requirements of the policy directive governing laser eye procedures, specifically the ophthalmologist-supervision requirement. Members of the work group include James C. Orcutt, MD, the VA's national clinical program director for ophthalmology, and John C. Townsend, OD, the clinical program director for optometry. According to the VA's statement, "The group's efforts are under way."

Protective Effect of Estrogen Against Cataract Doubtful
Past research has come down on both sides of the possibility that increased levels of estrogen in women may have a protective effect against development of cataract. A study published in the July 2004 Epidemiology lines up on the side of no protective effect.

Researchers at the Wilmer Eye Institute at Johns Hopkins Hospital in Baltimore say their population-based study of women over age 65 found no associations between use of hormone replacement therapy and the two-year incidence or progression of lens opacities (nuclear, cortical or posterior subcapsular opacities).

Data from this study are drawn from participants in the Salisbury Eye Evaluation project, a population-based study of 1,458 women between the ages of 65 and 84 years living in Salisbury, Md., in 1993. Women included in this analysis had one or two eyes with a natural, intact lens and on whom photographs were taken and graded at Round 1. Two years later, 1,035 of these women returned for the follow-up examination and had Round 2 photographs taken. Investigators collected information on HRT, oral contraceptive use and reproductive and medical history. HRT questions included information about the type, dose, duration and time of use.

While no associations between HRT use and either development or progression of cataract were found, researchers also looked for associations between several reproductive characteristics and lens opacities that would have resulted in fluctuation of estrogen levels (age at menarche, age at menopause, pregnancy history, oral contraceptive use and hysterectomy/ oophorectomy).

They discovered a notable association in only one of these, age at menopause, which was related to progression of nuclear opacities in a linear fashion.

Women who had an early menopause (natural or surgical, before age 45) had a higher odds ratio of progression of nuclear opacities compared with women who were between 45 and 49 years of age at menopause. Women who had a late menopause (after age 55) had a lower risk of nuclear progression.

Ellen Freeman, a doctoral student in epidemiology at Johns Hopkins and lead author of the study, compared this study to her group's initial cross-sectional analysis done in 2001 that did show that women taking HRT had less cataract.

"Our 2001 study, along with other epidemiological studies and animal studies that showed that estrogen slowed the opacification process gave us some hope that maybe HRT could be beneficial against cataract," she explains. "However, this more rigorous longitudinal study just published, and now others, do not support our initial optimism that hormone replacement therapy might help a number of medical conditions." Ms. Freeman suggests that female patients continue to discuss the risks and potential benefits of HRT use with their ophthalmologist and general physician or ob-gyn.

Epidemiology 2004:15(4);451-457

Researchers Find a Surprise in the TM
Gene researchers at the University of North Carolina School of Medicine have discovered genetic activity in the trabecular meshwork that may help explain how the eye responds to increases in intraocular pressure.

"In earlier work, we found that the trabecular meshwork appears to have a homeostatic mechanism," explains the lead researcher Terete Borras, PhD, "because when we artificially raised the intraocular pressure, the outflow facility increased rather than decreased, meaning that the tissue was trying to counteract the insult."

This led her team to repeat the procedure to try to learn which genes were upregulated and downregulated during the increase in outflow. "We found a series of genes that had never been described before in relation to regulation of IOP by the trabecular meshwork," she says. Namely matrix Gla protein, or MGP, a gene usually associated with bone physiology, in which it prevents the hardening of cartilage to bones.

"We think MGP may be there to try to keep the tissue in the trabecular meshwork soft to help facilitate the flow of the aqueous," says Dr. Borras. Another gene from bone physiology that was upregulated in the trabecular meshwork was perlecan, which researchers think helps tissues withstand compression.

Now that the researchers have an idea of the genes present in the trabecular meshwork, and which ones are upregulated or downregulated during increased IOP insults, the next step is to try to prove that these genes are actually performing the functions the researchers suspect they are.

"We're going to do that by taking a gene out of the trabecular meshwork and inserting it back in with a viral vector," explains Dr. Borras. "For instance, we'll take MGP and re-insert it to see if it does the same thing in the trabecular meshwork that it does in cartilage."

Eventually, who knows? These genes may prove to be helpful to glaucoma patients. "That's the reason I'm doing this experiment," Dr. Borras says. "One of my projects is gene therapy to treat glaucoma. I hope we can deliver a gene someday that's beneficial to the trabecular meshwork."

Tests May Predict MD Burnout
Future dissatisfaction may be predicted when individual doctors apply to medical school, by assessing their personality, motivations and learning styles, says a British study.

The 12-year study of UK doctors found that approaches to work are predicted by earlier measures of study habits and learning styles. Doctors' perceptions of their work environment, and their feelings of stress and burnout, are predicted mainly by personality.

The research involved 1,668 doctors who were asked about their approaches to work, stress levels, satisfaction with medicine as a career, and their personality. These doctors had previously answered similar questionnaires when they applied to medical school in 1990, upon leaving medical school, and during their first medical job.

Doctors who reported a high workload find it difficult to organize their time effectively, and often read things without understanding them. They also consistently reported higher levels of neuroticism and lower levels of conscientiousness over the 12 years of study.

Doctors who felt that they were not receiving enough support from their colleagues were themselves less agreeable. Those who described their colleagues as receptive and supportive were deemed to be more agreeable both from this questionnaire, and from the questionnaire they filled in six years previously.

Doctors who reported a high degree of satisfaction with medicine as a career tended to be more extraverted and less neurotic. In addition, these medics have a deep approach to work, favoring an integrative approach that leads to higher levels of personal understanding. In addition, they were categorized as having a similarly deep learning style both at the beginning and end of their medical school training.

Study Assesses Routine Eye Examinations
Researchers in Australia and Wisconsin conclude that frequent routine eye examinations of those with normal examination results will have a low yield and may not be cost effective.

Their prospective, population-based study of people aged 40 or more years included standardized examination protocols that included presenting and best corrected visual acuity, visual field testing, and comprehensive eye examination with dilation.

There were 2,529 people with a full data set, including 1,590 with a normal baseline exam. The five-year incidence of vision loss (<6/12 presenting acuity in the worse eye) was 2.39 percent. Overall, 24 (63 percent) of 38 of those with vision loss had noticed a change in their vision, and 18 (75 percent) of these 24 had attended an eye exam. This left only 14 (0.88 percent) people who had had normal baseline examination results and had asymptomatic vision loss develop over this five-year period.

The authors recommend that health promotion messages target those who notice a change in vision and those at higher risk, such as those with diabetes or a family history of eye disease. 

Investigative Ophthalmology and Visual Science. 2004;45:2539-2542