Alberta ophthalmologists challenge new rules allowing optometrists to perform eye procedures

Alberta ophthalmologists are calling on the provincial government to reverse its decision to allow optometrists to perform certain laser procedures and minor surgeries, raising concerns that differences in medical training could put patients’ vision at risk.

The Canadian Ophthalmological Society (COS), the Eye Physicians and Surgeons Association of Alberta (EPSAA) and the Alberta Medical Association’s Section of Ophthalmology are raising concerns about the changes.

They say questions remain about training, patient safety and whether the expansion will improve access to care.

The regulatory changes, announced Oct. 26 and effective Nov. 1, allow optometrists to perform certain laser procedures, minor surgical procedures and injections, provided they meet additional training, authorization and oversight requirements.

Alberta is the first province in Canada to authorize optometrists to perform these procedures.

Dr. Colin Mann, past president of the Canadian Ophthalmological Society and its current chair of advocacy, says the concern centres on the significant difference between the education and clinical experience of optometrists and ophthalmologists.

“Optometrists are not medical doctors; they have a Doctor of Optometry, which is a four-year training program,” Mann told CTV News.

“Medical doctors do four years of medical school, and ophthalmologists then go on to do five years of supervised, graded clinical training in an accredited centre supervised by experienced eye surgeons. That’s a big difference.”

Training concerns

The medical organizations point to a University of Waterloo course for optometrists covering office-based laser and minor surgical procedures.

Its published curriculum includes approximately 40 hours of training, including 12 hours of in-person practical laboratory instruction.

Mann says that training is substantially different from the years of supervised clinical experience ophthalmologists receive.

He acknowledges Alberta has introduced additional authorization requirements but says the adequacy of those safeguards needs independent evaluation.

“Whether those requirements are sufficient to protect patient safety needs transparent and independent evaluation,” he said.

The concerns extend beyond the technical ability to perform a procedure.

Mann says practitioners also need to understand which patients are appropriate candidates, when a procedure should not be performed and how to respond if something goes wrong.

“If a laser is applied to the wrong place in the eye, if it’s applied in a way that’s improper, then it can cause all sorts of complications, which can be sight threatening,” he said.

“At the end of the day, Albertans’ vision and the health of patients is what’s at stake.”

Mann acknowledges participation is voluntary but says that does not address the broader concerns about training and patient safety.

“The proposal here is for an authorization to be able to do it, not an obligation,” Mann said.

The three laser procedures include peripheral iridotomy, which creates a small opening in the iris to help prevent or treat certain forms of glaucoma; selective laser trabeculoplasty, which improves fluid drainage to lower eye pressure; and YAG capsulotomy, which restores clearer vision when a membrane becomes cloudy following cataract surgery.

While the procedures are generally performed on an outpatient basis, they still require careful patient selection and carry potential risks, including increased eye pressure, inflammation, bleeding and, in rare cases, complications that could threaten vision.

Improve access

Alberta’s Minister of Primary and Preventative Health Services Justin Wright says the government considered the safety implications before moving forward.

He says the province reviewed 26 proposals from professional colleges and rejected a number of additional procedures optometrists had requested.

“I hear their concerns and this was not a decision that was taken lightly,” Wright told reporters.

“We said ‘no’ to a great number of the expansions that the optometrists wanted to bring forward.”

Wright adds that the changes are intended to make services more accessible, particularly for people in rural communities who may have to travel elsewhere to receive ophthalmology care.

He says more than 50 per cent of optometrists have expressed interest in the expanded scope of practice.

The minister also points to other jurisdictions, including New Zealand and the United Kingdom, where optometrists are already performing similar procedures.

Wright says the government consulted with professional colleges, ophthalmologists, optometrists and Albertans between 2021 and 2026.

“We took a very calculated approach to really make sure that the scope of practice expansion fell within public safety concerns and making sure that Albertans’ safety was first and foremost in this,” he said.

Mann, however, questions whether the province has demonstrated a significant access problem with these specific procedures in the first place.

“First of all, let’s find out exactly what the problem is. Is there a wait time for these procedures specifically? And if there is, then let’s examine why that is,” he said.

He suggests the province could consider increasing specialist training positions or expanding mobile and outreach clinics instead to bring services closer to patients.

Medical groups want province to reconsider

In a joint statement released Nov. 2, the three medical organizations called on the government to rescind the changes and undertake further consultation with ophthalmology representatives.

“We have worked with successive Alberta governments for several years to raise these concerns and to ensure that patient safety remains central to any proposed changes,” said Dr. David Ehmann, president of EPSAA.

“Despite our longstanding engagement, important questions remain unanswered. We are disappointed that the decision was made without the further consultation we had anticipated.”

Dr. Nina Ahuja, president of the Canadian Ophthalmological Society, says patient safety must also remain the priority.

“Decisions like this must be guided by evidence and meaningful consultation with medical and surgical experts,” she said.

The organizations say they support improving access to timely eye care and recognize the important role optometrists play in primary eye care.

They argue, however, that expanded responsibilities must be matched with appropriate training and clinical safeguards.

Questions remain

There are also unanswered questions about how patients will pay for the newly authorized procedures when performed by optometrists.

Mann says the procedures are currently covered by public health care when performed by ophthalmologists, without additional billing to patients.

However, he says it remains unclear how billing will work for optometrists under Alberta’s new framework.

“How it would work with optometry remains to be seen between the government,” he said.

Mann says the provincial government will determine the circumstances under which the procedures are covered by public health care and whether patients could face additional costs.

“I would anticipate they probably would,” he said, referring to the likelihood of public coverage.

The province has not provided a definitive answer on whether optometrists will be able to bill Alberta Health for performing the procedures or whether reimbursement rates will differ from those paid to ophthalmologists.

For now, the changes are in effect, with optometrists required to meet the additional authorization and training requirements before performing the newly permitted procedures.