Protecting Veterans’ Sight Together

Over the past three years, I have spent a significant amount of time at the Salt Lake City, Utah Veteran Affairs (VA) Medical Center. The VA clinical rotation is one of the most challenging aspects of residency. Every day, it’s an all-hands-on-deck approach to get through our high volume, high acuity clinic. Even with our exceptional team, the number of patients we see – and the problems they face – can leave us exhausted. And yet, all that stress melts away each time you call a patient’s name and see their familiar face smiling at you from the waiting room.

The patients at our VA are exceptional, and I’ve been lucky to get to know them. Our interactions often start playfully: “Hey, Dr. Kennedy, ever since you told me you liked the Utah Jazz, they haven’t won a game!” However, over the years, those relationships have developed into incredibly meaningful connections. I know who needs extra numbing before their intravitreal injection, who needs a handwritten list of their medications to post on their refrigerator, who is recovering from a recent hospitalization, who recently lost a spouse, and who is expecting a new grandchild. I am honored to be part of the team these patients trust for their eye health.

The burden of responsibility I share to protect our veterans’ eyesight is something that became evident almost immediately after starting residency. But one patient in particular has stuck with me as an example of how heavy that burden can be. During an overnight on-call shift in my first year of residency, a veteran presented with sudden vision loss. He was very distraught – not just out of concern for his vision, but also as the sole caretaker of his ailing wife. The thought that he may not be able to care for her brought him to tears. With the help of my attending, I diagnosed him with an acute iris vascular tuft hemorrhage. Blood was pouring from a vessel in his iris and filling his eye, blurring his vision, and raising his intraocular pressure. He had a history of a branch retinal vein occlusion, and I suspected the bleed was from iris neovascularization. We successfully treated him with intravitreal bevacizumab and pressure patched his eye temporarily to stop the bleeding. The hyphema resolved, and his vision and intraocular pressure normalized. I have followed him closely since then and have gotten to know him well as a person. Whenever I need a reminder of why I’ve chosen this profession, he is the person who comes to mind.

Such commitment to patient care is the beauty of working at the VA, where ophthalmology residents work alongside attending physicians to serve those who have served us. They have earned the best care our medical system can provide. Unfortunately, a recent initiative proposed by the Federal Supremacy Project threatens to jeopardize veteran’s medical care and simultaneously impact residency education nationwide.

Let’s go back to 2004, when federal policy was enacted to ensure veterans have the highest standard of eye care – establishing that eye surgery could only be performed by ophthalmologists, regardless of state regulations. Now, the Federal Supremacy Project threatens to challenge these standards and could allow optometrists to perform laser eye surgery. The repercussions of this are far reaching and would allow non-physicians to perform laser eye surgery in every state in the country, regardless of state laws.

Permitting laser eye surgery to be performed by any providers other than trained ophthalmologists unequivocally threatens patient safety. Ophthalmologists are trained to perform these laser procedures under the supervision of an attending physician who has been performing these procedures safely for years. Notably, the clinical decision making that precedes the treatment ultimately influences patient outcomes and safety – even more so than the skill needed to perform them. The decision of who is a good candidate, consideration of less invasive alternatives, weighing the potential complications and how to handle them – and the ability to handle them when they arise – are skills simply not taught in a few lectures. These nuanced decisions, thought processes, and fine motor skills are learned over time with experience, mentorship, and repetition – they are the direct result of the additional years of training that ophthalmology residents undergo.

An example: A patient was referred to me for YAG laser capsulotomy by a non-ophthalmologist. This veteran had multifocal lenses and complained of blurred vision and debilitating dysphotopsias in each eye. Examination demonstrated bilateral minimal, non-central posterior capsule opacification. It was immediately clear that his PCO was not the cause of his symptoms and a YAG would not be therapeutic. The best solution in this case was an intraocular lens exchange to treat the dysphotopsias and blurred vision. In fact, had the initial YAG laser capsulotomy been performed, as suggested by the referring provider, the definitive treatment with intraocular lens exchange would have made the needed surgery far riskier for the patient.

To put things more directly, I fear the Federal Supremacy Project may act as a gateway to lower the standards of eye care veterans receive across the country.

Ophthalmologists are highly specialized surgeons, with extensive training to ensure the safety and best quality of care for our patients. After four years of medical school, every ophthalmologist completes four years of residency training – and many opt to pursue an additional one to two years of subspecialty training in fellowship. Optometrists attend four years of optometry school. The training any ophthalmologist receives is – at a minimum – four-to-six years longer than the non-ophthalmology providers who might be allowed to perform laser eye procedures under the Federal Supremacy Project.

The VA prepares the next generation of ophthalmologists to be safe, reliable, and high-quality clinicians and surgeons and is an integral component of residency training. Much of our required procedure volume comes from experience at veteran hospitals. Learning these skills in a protected setting, with an appropriate balance of autonomy and supervision, optimizes both patient outcomes and resident training. Diluting the volume of procedures and veteran care under the Federal Supremacy Project has the potential to negatively impact residency training, risk patient safety, and confuse leadership of care.

What can be done to promote the continued safeguarding of procedures? The first steps are education and awareness. And that includes being transparent with both colleagues and patients about potential complications of procedures and how to avoid and manage them.

Ophthalmologists can be involved with their local ophthalmology society, the American Medical Association (AMA), and the American Academy of Ophthalmology (AAO) to advocate for our patients. Local representatives and senators should be contacted with the approach of collaboration to protect veteran sight. We can work together to promote safe care and protect our patients. I am excited to continue to learn, partner, and advocate – and I hope you are too.