Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: You're welcome. All right, good morning. So we are back, this is Senate Health and Welfare. It's still February 4 and we have moved on to S-sixty four, a bill that we began last week, and it's an act relating to the amendment of scope of practice for optometrists, and we have Doctor. Jessica McNally.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: There you are. I'm right here.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Please come right up here into the seat and I didn't see you.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: We you did it now. Know. We're we're trying to expand the I'm almost next to your own.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: It does against my neighbor's Old. So excuse that. I would say, yeah, we have we have about an hour. We might be able to do a little bit more with it. We'll just see what we got to. This isn't the last time we'll be looking at this

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: bill so another many of you will be back again for the next month. Well welcome to the record. For the record, my name is Jessica McNally, and I'm an ophthalmologist and current president of the Vermont Ophthalmological Society. I just wanna make sure everyone knows that I will be splitting my testimony. So at the end, after we're getting to the end, I'm gonna be running in some legal 80s in a video, so folks will kind of understand what we do. Because I think that's probably one of the types of, you know, the kind of legislation that's often. Thank you for allowing me to testify on behalf of Vermont Ophthalmologists to voice our concerns about S-fifty four, a bill that would expand the scope of practice of Vermont optometrists to include eye surgery. To be clear, the singular goal of our monophthomologist is to ensure that Vermonters receive safe, high quality surgical eye care. With that in mind, we have great concerns about this bill and its interpatients. In the close to twenty years that I've been in practice, I have seen firsthand the confusion about the difference between an ophthalmologist and an optometrist. In fact, a 2018 survey conducted by the American Medical Association found that over half of respondents either did not know or were not sure if an ophthalmologist was a clinician. All ophthalmologists are physicians in the curriculum. As you will hear, ophthalmologists complete a four year undergraduate bachelor's degree program, after which they complete four years of medical school identical to other physicians in surgical. After completing medical school, ophthalmologists move on to obtain four to six more years of residency and fellowship. All ophthalmology residency programs are standardized across the country and must meet rigorous national accreditation council for graduate medical education requirements, called BC Jandy. As in all surgical residencies, ophthalmologists are held to the highest standard of care, and do not graduate from their program until they have proven competency, not simply by numbers of surgeries performed or passing board examination, but by meticulous formal assessments by our mentors. These include elements such as working cohesively with colleagues, professionalism, patient relationships, and surgical skills and progression. Each member of residency program clinical competency committees must agree that a resident has attained competency before the resident is allowed to graduate. Optometrists also complete a four year undergraduate bachelor's degree program. They then attend a four year optometric program, and have the option of completing additional training after that. This additional training is not required to obtain a doctor of optometry degree. In the materials by the optometrist in the OPR report, they have provided examples of such additional training, and that are given such as low visions, contact lenses, and oculars. What we and what OPR found is that in a four year optometric program, there are didactics, for example, lectures and videos, along with laboratory simulations and surgeries on model eye for model scan. The standardization of hours, numbers of hours of didactics, and numbers of simulations performed is not clear to us from one optometry program to another. What is clear, and what OPR has found, is that the majority of optometry schools, in that majority, there is no hands on surgical training, unlike human beings. In fact, there are only two states out of the 14 that we heard about last week with expanded scope that have optometry schools, and that can train their students in all of these surgeries on live human beings. We have observed that the system of licensing optometrists and perform advanced procedures is starting to develop cramps. Recently, was revealed that Kentucky allowed 21 optometrists to be licensed without passing all of the required thing. A malpractice lawsuit has been filed against one of these optometrists relating to use of the laser. Even optometrists have expressed concern about the lack of responsibility by the Kentucky Board of Optimal Proclamors. A West Virginia court also recently determined that their board overstepped its balance, and they voided a rule that allowed optometrists to perform eyelid surgery. The two main arguments that Vermont optometrists have brought forward since beginning their effort to expand scope involve access and cough. Optometrists in Vermont have repeatedly asserted that by allowing scope expansion, access to these surgeries will be improved. In Vermont, we are actually extremely fortunate in that we have enough ophthalmologists to provide all scalpel and laser surgical care in and around the eye. Ann has been suggested that the absolute numbers of ophthalmologists in Vermont does not reflect access because some of us subspecialize and don't perform the surgery. The fact is that there are only a handful of ophthalmologists, typically retina specialists, don't perform the surgeries. Furthermore, a July 2023 article published in the Journal of the American Medical Association showed that in Oklahoma, Kentucky, Louisiana, Arkansas, and Missouri, scope expansion to include lasers did not lead to shorter travel time or improved access. A more recent November 2025 article published in the Journal of the American Medical Association demonstrated that although there has been a decrease in the number of ophthalmologists, they are actually practicing in a greater number of locations. The article further determined that nationwide driving distances to optometrists and ophthalmologists is similar. We have approximately 33 practicing ophthalmologists in the state. Expecting one to be in every county is unrealistic. It would be like expecting to have a urologist in every country, in every county rather, and then have primary care physicians increase their scope by performing urological surgeries to Delta Cap. The four eye care providers that were mentioned by Doctor. Barzilow last Friday all practiced in Washington and Orange County. They were all of retirement age and in solo practice. To expect a young optometrist to come to Vermont and buy such a practice with the expectation of performing laser and scalpel surgeries is completely illogical. Lasers can cost anywhere from $40,000 to $50,000 and buying such a practice would be essentially impossible for a new graduate. And there are no studies showing that optometrists are flocking to areas with increased scope and settling in hurdle periods. And we continue to have concerns that the primary eye care needs of our monitors are not being met. According to OPR's website, there have been 31 newly licensed optometrists in Vermont in the last six years, so there are optometrists coming to Vermont. But it's still difficult to understand how expanding the workload of an already busy optometric provider to include surgeries could possibly improve access to primary eye care. Another major issue we are seeing is that some Vermont optometrists have stopped taking vision insurance, leaving patients in care outside of where they live and where they live. Indeed, both the 2020 and 2023 reports from OPR conclude quote, OPR is unable to determine whether expanding the optometric scope of practice would include patient access to care, unquote. I can assure the committee that if a Vermont patient needs expedited or urgent surgery, our optometrists know that they can reach out to us directly. In fact, of us have each other's personal phone numbers and email addresses. With regards to costs, many arguments have been put forward by optometry insisting that scope expansion will decrease costs. For example, they propose that scalpel or laser surgery could be performed on the same day as a diagnosis, right in their offices, thus saving the patient unnecessary visits and travel time to a surgeon. This argument does not hold longer. All ophthalmologists can cite examples of patients who were sent to them for the surgeries in S-sixty four that after being evaluated were deemed unnecessary or even ill advised. This in fact decreases cost by avoiding surgery. Furthermore, it is nearly impossible to perform surgery on the same day of patient evaluation because of complicated reimbursement issues and obtaining prior authorizations, which I'm sure this committee has heard of Doctor. The 2023 report from OPR invalidates optometry's claims by stating, quote, OPR is unable to determine whether scope expansion would have an impact on costs. Optometrists have repeatedly portrayed ophthalmic lasers as safe and easy. The Vermont Ophthalmological Society firmly disagrees with this characterization. Ophthalmic lasers, as proposed for use inside the eye, are categorized as surgical instruments used for altering tissue. Surgical treatment with ophthalmic lasers is not a primary eye care service and should be performed by physicians who are hospital residents trained surgeons. Furthermore, the existing and future laser in need eye care of Vermonters do not come close to providing the case load numbers needed for a optometrist to maintain health. Yesterday, I reviewed the laser data surgery from my own practice, which includes myself and Doctor. Young, between September November 2025, and has submitted a three year review. It demonstrates that relatively low numbers of lasers performed are compared to the number of actual referring optometry practices, and optometrists of two months. And that information is useful. Optometry scope expansion into the scalpel and injection surgery, let's say, in the middle would allow optometrists to remove lesions, what some refer to as lumps and bumps, on the eyelids and around the eye, but without characteristics or obvious signs of malignancy, as described in the length of death. The eye gloplastic specialist at UVM, Doctor. Blake Spule, has spoken and written at length about how difficult it is to predict a malignant lesion from a non malignant lesion, and how the vegan she, an expert, has been surprised with biopsy itself. Other challenges in removing lesions from the abdomen involve what happens with the skin after the removal. For example, how the wound is often much larger than expected once it has been put off. There can be unexpected bleeding. There can be anxiety provoking for the surgeon and a patient who's awake. The bill would also allow repair of traumatic eyelid laceration. Anyone who's ever repaired an eyelid laceration knows that even superficial lid lacerations can be extremely complex and is much more difficult than simply surgery, or surgical incision. Other proposed surgeries in the Ville include corneal cross linking. There is only one ophthalmologist in Vermont who's trained to perform this surgery, and that is because he is a fellowship trained cornea specialist. This surgery is outside the scope of practice of all other Vermont ophthalmologists, including myself and the other standing in the restroom. Our retina surgeons have significant concerns about the inclusion of something called fluorescent angiography in the bill. This is a dye test that looks at the structures in the back of the eye. The dye is injected into a vein, which can often cause nausea, and sometimes even vomiting, and potentially anaphylaxis. Our retina specialists maintain that the far majority of retinas and babies can be diagnosed with other equipment that is already widely available and utilized regularly in almost every optometric practice in the state. Even after hearing all of our concerns about training, risk to patient safety, and finding that there would be no increase in access to cost savings, OPR has concluded that it supports expanding the optometric scope of practice to include proposed advanced procedures so long as optometrists have the necessary training. So of course the question then becomes who decides what that necessary training is? Is it OPR? Is it the Vermont legislature? What OPR, perhaps unfairly, was tasked by the legislators to create a compromise that would make some people feel better about optometrists performing eye surgery, And to that end, they have created a training program for eye surgery, which they have labeled a preceptor treatment. Clearly, OKR did not find, does not find, that current optometric education provides the necessary training to perform these surgery. Otherwise, they would not have created a surgical training program themselves. We have the utmost respect for OPR and the work we have done on this issue. And we, and a lot of other people, have spent hours with them on us. But they do not have the expertise to make recommendations on the training required to safely perform eye surgery. Once early on, we asked them in one of our briefings, How can you possibly know in any detail about all of the professions you oversee? Because as you know, it is a laundry list of professions. And the answer we received was, we depend on the expert. Our response is that we, as ophthalmologists, are the experts. OPR's proposal to bolster training experience, some of which has been adapted for the bill, falls far short of ensuring safe eye surgery in Vermont. Setting appropriate standards for medical and surgical training should only be done by the properly accredited organization. These organizations should be comprised of individuals with firsthand knowledge and expertise in eye surgery and developing curriculum with proven standardization to ensure competency of surgeons and accountability of the accredited body. Safe surgery of Vermonters can only be provided by physicians who have completed medical school and an ACGN, meaning accredited ophthalmology residency program. I will close before I began that the singular goal of the Vermont Ophthalmological Society is to ensure that Vermonters receive safe, high quality surgical eye care. As legislators, your ultimate responsibility is to protect the safety and well-being of the people of Vermont. That includes yourselves, that includes everyone in this room. I think we all want safe surgical ID.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Thank you very much. Thank you. Thanks for including the references with the links.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: I do have a handout here that we couldn't link that shows the optometry schools within The United States are the two states that actually obtain or have the schools that can train optometrists to perform these procedures. There's only two of them. I've almost called the black dog sequences.

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: I guess one of the

[Unknown Committee Member (Senator)]: things that I'm struggling with, you hit it in the very end. For me, it's going to be safety, access, and cost. That's just what it has to be. We received a lot of testimony in here from OPR, you know, supporting the bill and thinking that it's safe, but you're the expert, something says, so if you disagree with OPR's opinion on that, then certainly.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: And we do. We agree,

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: and I am incredibly sympathetic to OPR. Mean, back when this started, like, seven years ago, I remember sitting with OPR for at least four hours, and in that initial bill, we submitted a huge binder of information, including photographs of all of these procedures, those different ACG and E requirements. We submitted them for other subspecialties to illustrate how many numbers of procedures are often required by other subspecialties. They had spent hours.

[Dr. Jeffrey Young (Comprehensive Ophthalmologist)]: And there's no way you

[Unknown Committee Member (Senator)]: and the optometrists can get together and

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: At this point, no. At this point, I think the division between where they are coming from and we are coming

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: from is very far apart.

[Unknown Committee Member (Senator)]: Because you guys work together.

[Unknown Committee Member (Senator)]: That Right? We What I envisioned, you

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: both

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: are

[Unknown Committee Member (Senator)]: in the same field and you work together.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: Yep. In fact, we often are in the same offices, share patients.

[Unknown Committee Member (Senator)]: You're not gonna make this easy, are you?

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: This is something that's important. It states for eye surgery. Go ahead. Thank you. Thanks for your testimony. You made a very good case for the difference in training and I totally understand that. Do you have far past data around outcomes that we could look at? Because when I look at the STANT information that I have around outcomes, it seems like they're actually pretty similar in terms of procedures that we're talking about with optometrists and ophthalmologists. So, can you provide us with data that actually bears out the danger and the poor outcomes that we see with optometrists? I think the word you used, scant, is actually very applicable in this situation. It is very, very difficult to get data about outcome measures because it's simply not out there. Well, that's a problem. That's the way. There are each state has different self reporting methods of optometrists reporting complications that they may have had or untoward events. The studies that have been referred to, Doctor. Leitheis' study that he referred to on Friday, they actually looked at different countries' data. They looked at The UK, New Zealand, Canada, and The US, and combined all that data. In those countries, optometrists are treated and trained completely differently than here in The United States. It's like creating, looking at outbreaks and allergists. You can't take all that data, put it together, and make a conclusion about a potential difference in complication rate because the training was completely different. I guess I just would caution to make claims that you can't back up with actual evidence because we're trying to make a hard decision here and I would like to request evidence. I wish that they had similar evidence. I wish that they had large studies that would show us that because then maybe we would all feel better about including optometrists. Well, the evidence that does exist doesn't show a big difference. What are you looking at? I can show it to you after a moment. Yeah, that'd be good. Yeah.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So, yeah, one of the concerns I've heard obviously is driving times and access in our rural parts of the state and you've got a reference there that will help us understand that. Okay so we have others and I understand you're coming are you going to come back after? I'm going to

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: come back after. So we'll move on to Doctor. Greenberg, Matthew Greenberg from

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: the Vermont Board of Medical Practice. And so one of the confusing parts of our lives and here is that the Office of Professional Regulation oversees a great number of healthcare professions and the Board of Medical Practice oversees another set of professionals.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: So Doctor. Greenberg, thank you for being here.

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: Madam Chair, thank you, community members. Thank you for having me here. First time testifying, I was nervous. My name's

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Matt Don't be nervous. We're all nervous. Yeah. My name's Matt Greenberg.

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: I'm an emergency physician by training. I have twenty five years of experience as an emergency physician at the lab of fifteen of those years was spent here in Central Vermont. During that time, I take care of a lot of people with eye injuries and eye infections and things like that, but I would not consider myself an eye expert. I would say that in those twenty five years, wanted to respect the eye with a great respect it greatly. There's a lot that can go wrong when you're messing with the eye. So I do not perform any of these procedures that this bill would afford to optometrists. I just want to make that clear. It's not something that I do. The main reason I have to hear though is representing the I'm on board of medical practice, which I currently chair. I've been on the board since 2022. We have this material multiple times, most extensively reviewed it between October 23 and February '24. That was the time period associated with the OPR report. We gathered the data, we looked at it. We don't get as much data. I think as you mentioned earlier, there really is a lot of scant data to support this. As physicians, scientists, you know, you need to look at data. After looking through that information, we unanimously voted to propose the expansion of optometry care. We didn't take that lightly. These are our optometry colleagues. We worked with them for various reasons, but we did not feel that the data supported such a significant change from the current standard of practice. What we looked at was we put the data sort of into three categories, and I think you actually said the same three categories that we were looking at, that is access, cost, and qualitysafety. In regards to access, we actually looked at some of the same studies that were already mentioned, the 2023 study from the Journal of Ophthalmology, basically looked at several of the states that were early adopters of expanded scope. And it really showed they used distance travels surrogate for access, and they didn't show the benefit.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I think more importantly, OPR's own report said that

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: they could not justify or they could not show that there would be an improvement in past. Anecdotally, many members of the committee themselves noted that they were already having difficulty accessing their own optometrist's weights up to several gloves, and there was concern that adding additional procedures, perhaps procedures that pay more, reimburse more, would only worsen access to the underlying optometry of care. So that was access was one thing. Cost is another thing. We all know that cost, in the state of the law. Healthcare costs are outrageous. We need to figure out ways. And honestly, there's arguments on both sides of this. But I don't think there's a clear winner, and that was what the board felt, was that there was no clear distinction or no clear winner in which would cost more. There is some evidence to suggest that there are increased procedures which would cost increased cost, but the data's just not really there. And again, OPR and their own very thorough investigations that they were unable to charter through the endoscopy. So taking cost and access out of the picture, we get left with quality. And the main role of the Vermont Board of Medical Practice is the safety, ensuring that Vermont residents get quality, safe, and respectful care. And so this is a really big thing. This is what we've said, we've been talking about, looking at quality of care. Know, fundamentally it comes down to numbers. Know, many of the medical quality metrics and companies and, you know, the IOM, all these boards, what they look at for quality in a lot of cases, is numbers. And most safety organizations have put out there a similar number of procedures that need to be done to initiate proficiency and then to maintain proficiency. And what we know from, you know, the training that an ophthalmologist goes through, undergraduate, four years of medical school, to six years of residency and surgical potential fellowship, they're gonna have several 100 of these procedures under the bed. My understanding from the bill itself requires a minimum of two, which is just not anywhere near what residency trained ophthalmologist would get. And so looking at all of those features together, again, without a clear benefit in accessing, a clear benefit in cost, and a very large difference in training provides a high risk of effective quality, the board felt that they would prefer to sit with the standards that we currently have for expanding the scope of practice. That's all I have. If you have a question that you have, I'll try and answer them.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: Question two. You for your testimony. So OPR, thank you for referencing their study in terms of access and cost. They did make a claim in the study that safety, if feel comfortable with the safety factor. I think that was one of the things that they really dived into in the study. You're, I guess, disagreeing with OPRE? In that respect,

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: I think the numbers, I've trained residents for many years, Gulick really needs to do a lot, whatever procedure you're getting. I don't do these procedures, but I've learned a lot of surgical procedures in my career. And you have to do them regularly, and you need a lot of them under your belt to get that first level of confidence. And from the training programs that we were really aware of, the number of them suggested that would be treated. And I think that runs a significant sum to this.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Other questions? Thank you for being here. We may have the board back again. I understand whether it's you or David Hurley or whoever, but it's important, I think, that we have some recognition of the board's work involved as happy return to people. So I won't ask you this question, but it's kind of a general question that keeps resonating with me. So if this is a scope that moves into ophthalmology, ophthalmological practices that are currently there, then maybe it should be overseen by the board that currently oversees those practices. So that's another kind of question. So instead of putting something new into OPRs, maybe it should be something that's regularly cared for at the Board of Medical Graduates. So we'll let that go for now. It's not a question, it's a

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: comment and a reportable. Okay. So we'll move on to Doctor. Young, who is an ophthalmologist. And then we have a resident from South Carolina. Thank you for being here.

[Dr. Jeffrey Young (Comprehensive Ophthalmologist)]: Thank you, good morning. I'm Jeffrey Young, I'm

[Dr. Jeffrey Young (Comprehensive Ophthalmologist)]: a comprehensive ophthalmologist practicing here in the Central Vermont area, just up the road in Berlin, for the past thirteen years. I've been given the opportunity to share some recent and real experiences from around the state that give me pause when considering the wisdom of passing this bill, S-sixty four. These stories, which affected real Vermonters, will illustrate the effect that inadequate training and misjudged confidence can have on real patients. I also want to mention that you have received examples that are included from Kentucky and Oklahoma of similar cases from ophthalmologists that speak to the fact that just because, as has been mentioned prior, that some of these boards have reported no bad outcomes, and that that does not necessarily mean that there are no bad outcomes. If the state optometry board says that they've never had a reported bad outcome, or a single complication from a procedure, I think we should all be skeptical. I'm not here to say that optometrists are worse than or better than ophthalmologists, or to say that they are not concerned with patient safety, but to show that comprehensive surgical training, as we've talked about earlier, where we deal with complex and simple cases, is necessary to develop the proper surgical skill and careful surgical judgment, and for the highest standard of safety for all Vermonters. Some of the cases are alarming, because the optometrist even mentioned to the patient that they would be performing these procedures in a year, and that the patient could just wait until then, as if passage of this bill was a foregone conclusion. Think of these stories as if this was your neighbor, your friend, or even your family member. The first story. An optometrist who is a recent graduate from an optometry school referred a patient to an ophthalmologist for evaluation of narrow angles, which is a condition that can cause dangerously elevated pressures and result in vision loss, or even blindness. The treatment for narrow angles at risk for this condition of angle closure is a laser peripheral iridotomy. This is one of the surgeries being proposed in this bill. Upon examining the patient, the ophthalmologist found that the patient had already had laser peripheral iridotomies, clearly visible on her examination. The patient was sent back to their optometrist without having an unnecessary surgery. This case is concerning to me because the optometrist had apparently been trained in these procedures, and had obtained this modern optometric education that has been spoken of. One would assume that this training would allow them to identify whether a procedure had been performed, or whether it was even necessary. As a result, the patient was sent for an evaluation, which cost both the patient and the system precious time and money. Now, second story. An optometrist referred a patient to an ophthalmologist specifically for a glaucoma laser. The patient reported that their optometrist described the laser as simple, and that optometrists would be fully trained to perform this laser, or are fully trained to perform this laser, and that they would soon be available in Vermont without referral to an ophthalmologist. The laser referral was made by an optometrist's office as a routine referral, a non urgent consultation, which scheduled approximately one month out. The ophthalmologist reviewed the incoming referral, and within twenty four hours of receiving it, and suspected a more severe condition requiring urgent evaluation, and asked the patient to come the same day. The evaluation revealed that the patient had been misdiagnosed, and was not a candidate for the referred laser. In fact, the use of this laser would have worsened the underlying condition, and likely would have resulted in permanent vision loss. The proper diagnosis was made, and the patient was treated appropriately without a laser, and their vision was preserved. This story is another example of a misdiagnosis, an inappropriate treatment plan, and in this case, a delay of treatment. The request for this non urgent referral put the patient at risk. The laser surgery, which was proposed by the optometrist, was contraindicated. Had it been performed by the referring optometrist in their office, the patient would likely have suffered permanent vision loss. It seems, from some of the testimony that has been given in this committee, as though simple laser procedures are the answer to everything. Let me say this clearly, they are not. A laser must be treated as any surgery, and recommended only when absolutely necessary. And now a third story. An optometrist referred a patient to an ophthalmologist for a YAG capsulotomy, another laser procedure proposed in his bill. Although the patient did have mild posterior capsular opacification, or clouding behind the lens implant in both of her eyes, she had no visual complaints. She had no blurred vision with her glasses, and no glare. Despite her lack of complaints, she had been referred for this laser surgery. The ophthalmologist who saw the patient felt that proceeding with a YAG capsulotomy in this situation with no medical necessity was contraindicated, and therefore did not perform the laser. Furthermore, the ophthalmologist found that the patient's only complaint had to do with dry eye, which was not being treated adequately, and can also cause decreased vision. The ophthalmologist felt that withholding an unnecessary surgery and avoiding exposing the patient to undue risk was the most appropriate. This patient was referred for laser surgery that was not medically necessary, and her main complaints were attributable to something that was medically treatable. Laser surgery would not have helped in this situation. This case shows that surgical judgment matters, especially knowing when not to do a surgery. Proper training, careful listening, and critical judgment are necessary in surgical decision making. The best way to protect patients and control healthcare costs is making sure that only those who truly need a surgery receive it. And now, a fourth and final story. An ophthalmologist received an urgent referral by an optometrist for a patient who had come to the optometrist with eye redness and vision loss. The optometrist noted a high eye pressure, and believed that the patient had narrow angles, which is the condition I mentioned earlier. The optometrist's diagnosis was angle closure glaucoma, which is an emergency, and recommended that the ophthalmologist perform a laser peripheral iridotomy. The ophthalmologist's exam showed that the patient's angles were not narrow, but were in fact wide open. The ophthalmologist noted inflammation inside the eye instead. The ophthalmologist did not perform a laser, and instead proceeded to investigate the cause for the inflammation. The results revealed that the patient actually had tuberculosis, a rare and serious infectious disease that is even life threatening. In this story, the optometrist made an incorrect diagnosis, in which performing this laser would have, A, not improved the pressure or opened the angle, B, would have worsened the underlying inflammation since laser surgery always causes some inflammation, and C, would have greatly confused the entire situation, possibly delaying the true diagnosis. What was needed in this case was identification of the eye inflammation and a search for the cause, which in this case included a medical workup of blood work and a chest x-ray. What makes this case even more concerning is that the referring optometrist had, the exact same week, published an essay in a prominent Vermont News publication, in which they assured lawmakers that optometrists have the proper training and skill to make advanced medical and surgical decisions for care of the eyes. The optometrist's own actions demonstrated that they had significant gaps in expertise that would have harmed the patient and the public. In this case, diagnosis of a deadly disease, tuberculosis, which must, by the way, be reported to the state, would have been missed, and an unnecessary laser surgery would have been performed. In each of these cases, the patient was referred for a laser surgery, which, if it had been performed, would have at the very least been medically unnecessary, and a waste of time and money, and at worst, resulted in blindness. I was only allowed a few minutes here to, and I've only chosen a few cases, you've received more that have been given to the committee, and these cases demonstrate that proper surgical skill, and more importantly, careful surgical judgment requires comprehensive training, not cursory courses. It requires brigant and guided surgical experience, not just fulfilling a checklist. It requires time,

[Dr. Jeffrey Young (Comprehensive Ophthalmologist)]: not measured in tens of hours, but measured in hundreds of hours, dealing with complexity and complications. Thank you. Thanks, Ginny. So, quick. Shut her, go ahead.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: I don't want my questions to mean that I've made up my mind on this or that I understand all of this. If I don't, I'm just trying to learn. So that's where these questions are coming from. I'm just curious, do ophthalmologists ever misdiagnose? Absolutely. Okay. There are inherent risks in any medical procedure, correct? Correct. And LASIK is an example of a procedure that is not necessarily medically necessary, correct?

[Dr. Jeffrey Young (Comprehensive Ophthalmologist)]: Correct, it's not being paid for by insurance either. Right. It's being paid totally out of pocket, and it's considered cosmetic.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: Yeah, I obviously don't have perfect vision. I asked an ophthalmologist about LASIK, and he actually said to me, don't do it, because there is a risk that you could ruin your eyesight. So, I just want, I'm pointing that out to show that it's just a very nuanced landscape, for sure.

[Dr. Jeffrey Young (Comprehensive Ophthalmologist)]: It absolutely is nuanced, and that's what I was trying to portray here, that there's a lot of nuance in making a diagnosis, and of course, any diagnosis is something that is taken seriously, but that the nuance comes in making the diagnosis, and then what do you do after that? You know, I think this speaks to the fact that there is scant data, because these cases, these would not be reported to anybody. These aren't reported to a board as saying, oh, these this, aren't reported because there's, a bad outcome was avoided because something wasn't done. And so, you know, I think that these just demonstrate that I

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: think we still need to look at this.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: Thank you. And we have

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: Doctor.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Did I say that? Close. You

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: were right there.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: Well, if I don't,

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: you introduce yourself to the

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: record, we'll get them right.

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: My name is Devi Mera. I'm one of the fourth year ophthalmology residents at Dartmouth Hitchcock Medical Center. I'm also the current chief ophthalmology resident at the White River Benson VA. Doctor Bill Ginny Lyons covered me today. But I don't know which back to the post op, so I'm gonna

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: get to sure.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: It wasn't a bad drive.

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: No, it's about over ten minutes, something like that.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I noticed about the weather.

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: It flurrying, think, closer to this area, but not so bad down south. I'm a current surgical trainee, so I just wanted to, I hope, clarify kind of what my training has entailed, and kind of paint a picture as to how this training enables me to be able to perform surgeries as best I can. I'm going try to keep this brief. I have a written testimony that's little bit more complete, so I encourage

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: you to read that if

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: you have time. So after college, the path to becoming an ophthalmologist begins with four years in medical school. I was in Florida at the time, and we also had an optometry school at Nova Southeastern. And so I made quite a few close friends there that are now practicing optometrists, so I

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: was just going to be one

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: of their weddings. So I don't think that I'm totally unfamiliar or biased to their experience. During my first two years, was inundated with textbook knowledge about how the whole body functions, including how the eyes fit within that system. In the final two years, I entered rotations, where I worked at hospital teams to treat various sick patients, and I started to perform simple procedures, skin lacerations in the emergency room, assisting in the operating room, things of that ilk,

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: but nothing too, too serious.

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: Next came residency. I matched at Dartmouth, so I moved to New England to start. We do a general surgery intern year at Dartmouth Hitchcock, and this was intense, to say the least, not for the faint of heart. Again, still taking care of very sick patients, but now starting to do much more surgery, Particularly, at least for me, was the abdomen, the face, the chest, things like hernia repairs, bowel resections, breast cancer, and skin cancer excisions. I wasn't doing eye surgery yet, but I must emphasize that the technical and decision making skills are foundational for the things that came after. We see the worst complication of our own surgery, and we have to own them. In addition, we learned how to do things like obtain informed consent, discuss risks and benefits, and understand complications firsthand. Only after that that I enter ophthalmology residency, and I started focusing full time on the eyes. Surgical training is progressive. We start by observing over and over, and then we start doing parts of procedures over and over, Only after proficiency with that are we allowed to operate under supervision and then independent. But even independent, it's still, I can't sign anybody up with the way to a junction VA without Doctor. Ginny approving it for anything. I think he's there in the room, but watching things only during the ankle surgery at all. And as confident as I am in my own abilities, I just have to tell you that this process is painstaking and really, really difficult. And interestingly enough, it is the more involved surgeries like cataract surgery or eyelid surgery that greatly improved my ability to perform procedures. Things like anal laser had a structure, it's thicker than a spider web, just micron stick. It's really hard. Much harder than it sounds like some people seem to convey to you all. But it's much easier if you've felt and manipulated that structure, or unfortunately broken that structure many times in the Operating Room. Optometrists also complete four years post graduate, or post college training. Most are without a doubt excellent clinicians. I grew up seeing an optometrist and credit my interest in ophthalmology to him, but their procedural training seems to be limited to lectures and short workshops or weekend courses, which are helpful introductions, but they lack the realism of live patient care, which takes a long time to develop. Models don't feel pain, move unexpectedly, or bleed. And sometimes what's more challenging than performing the procedure is knowing which procedure to do, when not to intervene, and when you're out of your depth as a clinician. That judgment comes from a wide breadth of surgical experience or clinical experience that I don't even know that I totally have yet. You have to see complications. You have to learn to weigh alternatives under supervision for years from someone smarter and more experienced than you. In residency, I constantly make these decisions and receive direct feedback from my attendings, often in not so nice ways. So why are so many years of training necessary? It's because performing surgery is hard, but knowing how and when to operate is even harder. I think ophthalmologists and optometrists share a common goal. We want to provide high quality, accessible, affordable care to people here. I have very modest views on scope issues generally. I'm a huge proponent of safely increasing access to healthcare, and I've worked on things in the past to do so, but I don't support this bill as written. So I urge you to think kind of long and hard before you change the status quo and change kind of the standard of healthcare in New England and beyond. But hopefully this bill is part of dialogue and we can all work together to improve the quality of care for all people in New England. Thanks Thanks for

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: your time. Thank you. When do you complete your residency?

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: About five months left.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Five months left. That must seem like a short time compared to what you went through.

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: Yeah, it seems like it's

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: actually Or eternity depending on what you're about. Thank you. Thank you very much.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: And let me ask you one more question while you're here. Sure.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Where do you attend to practice?

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: I don't know yet. You're gonna know yet. I'm gonna That's I will tell

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: you definitely. It's

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: Returning to the government legal system because it's academic, and I've been subspecialized in right now surgery, so I will probably never be performing these procedures as part of my own clinical practice. So I don't have a leg in the state, but I'm gonna go to New York for a fellowship for two more years. Just keep training.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: New York City? New York City. I'm gonna be fine. Okay. Well, thank you

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: for this and for your work. Very helpful. Alright. So, Doctor. McNally, we're back to you with the video. One of the things that's in the bill, you can come up, one of the areas of the bill that is sort of blind to us are all the different procedures that we, you know, failed to know about.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: That's I

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: can't even pronounce it right. So we're gonna learn how to pronounce it. And

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: as I noticed, they've even OPR was having trouble pronouncing them. I noticed that. Despite the fact that they forget the bell.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Well, it's important that they understand what they are the. And I so I will say that when my husband went through medical school and I used to go to lectures and I was helping out with some areas of

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: in the river. I think that river had a lot of stuff. But

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I remember going to the acute glaucoma. But the former lecture says, but

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: I didn't learn how to do the surgery. That's great. Yeah. Lectures and videos are great, but it takes a little more hands on to show how to do that. So I'll show the video first, and then I'll just pass around a few things here so you can get an idea of exactly what is used to train on and how that might translate into actual fatness on a real person. Any warnings about this video? Possibly. It's around the eye. Okay. It's not of, like, the intima part of the eye.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Well, around the eye just as bad as I know, but I not have watched.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: There is a Okay. There is a little

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: bit of watching. Yes.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: Okay, I guess we look at the screen. So the first video is myself performing a lesion excision.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Breathe out. Breathe in. K. Close. Okay.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: I think that's it. That part was just injecting the leg. Yeah. Sure. You can hear that. And this process of taking off this lesion is what? So this is the lesion of vision. Vision.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: It's a needle lesion.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: And these are two different types of lesions. Both of them are five millimeters or less, which is what the bill entails. So it says that they can only take off lesions that are five millimeters or less. That one right there is maybe about three, and you can see that it leaves a pretty large area there. This is cautery. And you can't hear it, but the cautery's actually making a little fuzzy sound, and I do warn patients that they're gonna smell something funny because now they're burning fun.

[Unknown Committee Member (Senator)]: Yeah, and

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: here I'm just making sure that there's no bleeding. Here's the second lesion I'm taking off, not on the artery's margin, which is one of the exclusions Can in the I

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: ask what type of lesions these are? Again, lid lesion.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: There's no way to know until these are sent for biopsy. Left? I

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: noticed that the individual is still blinking, but the injection was anesthesia. That's true.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: Here's just two turn gauge vision.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Do a common trust currently do this? How long do I do? The answer is no. Not that you're not.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: These are the these are some these are, you know, this is the myth match 14 states. In one state they do, in another state they don't. In some states they do lasers, in other states they don't. Which kind of, I think, reflects the confusion about Is this one of the

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: is this one of the procedures listed in? This would be an eyelid lesion removal.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: I don't have the bill right before I may add. I got it right there. So it begins on page three. And it includes injections, suturing.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So yeah. We got

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: it. Yep.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: The bill actually specifies those things. And this would be, when I talked about traumatic eyelid lesions, or traumatic eyelid lacerations, rather, what has been proposed is that sewing up a traumatic eyelid laceration is the same thing Say that, that which is absolutely not true. Can you say that again, please? Yeah. That sewing up a traumatic eyelid laceration is what's in the fill. That's something that would be allowed. It's completely different than sewing up an incision like that. Much more challenging, requiring much more training and understanding of the underlying anatomy. This is a Chelazian excision, which is also in the bill.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Say it again. Chelazion excision. Oh, there it is. This

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: is the type of condition that we typically recommend patients treat with warm compresses for a number of weeks before it gets to the stage where we may or may not provide a surgical option. So again, this is Doctor. Gulick. She's our oculoplastic specialist, and she has numbed up the patient. Patient's awake. Patient has a surgical cap on. The procedure that I did was required a draping. These are not chairside procedures. Doctor. Barcelo referred to these as chairside procedures on Friday. Right now, we'll

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: standing here to do it. This is Yeah.

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: No. Yeah. This is something this one.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: This is where she's using a very sharp blade to cut through the skin, and that's the material inside. But she's removing the material inside. This is not an

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: infection. Yes.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: But the patient is awake, again, in a special room that we have set up with a bed, a special lamp.

[Unknown Committee Member (Senator)]: Do they have a choice if they can be awake or?

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: No. Is this outpatient surgery?

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: Yeah, this is all within an office setting. Okay. But in a, like I said, in a special room, on a stretcher, a special kind of stretcher that we call the on bed. Not something I would just lean somebody back in a chair for in an exam room. And then now she's performing some cautery as well. You're doing okay?

[Dr. Devi Mera (Ophthalmology Resident, Dartmouth-Hitchcock; Chief Resident, White River Junction VA)]: Yep.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: Senator, can come back. That's fine right now.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Somebody wants to go. Yeah. So

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: these are other photos. Saw something like this on Friday with Doctor. Leitheizer showing his PowerPoint presentation of what a laser room might look like. This is our laser room in our office. What you didn't see in those photographs that he showed is that there is a danger sign on our door to illustrate to both patients and staff that there's something dangerous going on inside. There is a special kind of fire extinguisher that needs to be used if something were to happen. Anyone who is in the room observing is supposed to be wearing yellow goggles, which are here, and that's to protect their eyes from any given laser. This is our surgical suite. So you can see there's a special kind of bed, there's a special kind of light. That's an example of the instruments that we might use for external procedures. I have these here that I can pass around as well. Different kinds of knives that we use, the cautery, suture material, that sort of thing. This is the laser cancellotomy, which is also shown in the bill, which you may have seen pictures of, where that bubbly stuff is the film that can develop on the back of the implant lens after cataract surgery. And then the opening that you show is what happens after we use the laser. As Divvy was saying, that's four microns thick. It's very, very thin, that part of the eye that we're lasering. We have to be careful not to make marks in the lens, especially in the center of the lens that could potentially damage the lens and affect the vision. And then one thing that's not mentioned or specified in the bill, which I find interesting, is that there's no distinguishing between an anterior capsulotomy and a posterior capsulotomy. It just says, YAG capsulotomy in the bill. The photo all the way to the right is an anterior capsulotomy involving the anterior part of the capsule, which is a much more difficult procedure to perform. There's no distinction made in the bell about the things. Let's continue to

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Can I ask you a question here because it's something that Doctor? Metrie brought up, and that is the need for repetition in doing these, and what are the frequency with which we currently see a need for, I, don't answer this now, but it would be helpful to know from your experience, the frequency with which you see the need for these particular surgeries within a particular practice. So if repetition is a necessity, then how frequently are we seeing this in an individual practice and a need sort of can we predict across the state? So that is one of

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: the pieces of data that I submitted when I looked at our numbers in my practice between Doctor. Young and I. Between September and November this year, we performed 33 of these between us out of, I believe, about 12 separate optometrists that refer to us, and perhaps 21 optometrists in those practices.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay, so that's a different number. So if you've got 12, how many referral practices? I think if

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: you count them, I don't recall the exact number, it's been submitted, I think it was 12 optometric practices, but each optometric practice has a different number of optometrists in it. So some have two, some have one, some may have six. So you have to assume that each optometrist is seeing perhaps 10 to 20 patients a day, and they're referring to us for folks who might need or what they need or needed procedures. So one optometrist in each of those practices capable of performing this, they would get that It wouldn't even, right, and the numbers don't even match out that each optometrist would even have a referral on. Yeah, would be, yeah, exactly. Think it was a mad One optometrist, maybe one of these surgeries in a three month period, if you actually divide it with that. Okay,

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: next slide.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: So this is a laser peripheral iridotomy, is also listed in the bill. Again, as something that treats narrow angle. This was noted by Doctor. Young in his testimony about receiving referrals for laser peripheral iridotomies that were not only contraindicated but also could have caused more problems. So the photo on the right shows the hole at the side there where we've actually made the hole, but what the photo on the left shows is what's happening during the time that we're making a hole. The iris itself has blood, it has blood vessels, it has nerve endings, and bleeding can happen, which can make it very difficult to visualize what we're doing, And you really have to know how to take a deep breath and just wait. There's building so

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: far I wanna insert something here because I think this is important information for us to know because these are the procedures that we're talking about. What you're not saying is whether or not someone has the capacity to do the surgery. So I want to clarify because I've heard comments previously that this is all meant to scare us. This is not meant to scare us. This is meant to educate us about what the procedures are and the challenge of doing those procedures regardless of who's doing it. Correct. I just wanted to clarify that.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: This would not be considered a complication. This would never be reported as a complication. Got it. This is just a part of what can happen when you're doing the surgery and the more of these you do, the more comfortable you get with seeing the blood, and knowing that when the blood goes away you can continue doing the laser. So that's where that question of volume comes in, and training in all aspects of eye surgery. This is an example of an SLT, the selective laser trabeculoplasty, that can treat glaucoma. You can see that there's a laser that is directed into the eye, and it's actually lasering a very, very small area right at the very front part of the eye, along this internal drainage system of the eye. This is basically a microscopic area that we're lasering in this particular circumstance. Then these are injections into the subjunctival space, which is also listed as something that would be allowed in this legislation. As you can see, the needle comes pretty darn close to the eye, and if the patient were to jump, the needle could go inhabited. And this is that fluorescein angiogram that the retina doctors are very concerned about, where you inject the dye into the vein in an office setting, where you can develop anaphylaxis, I mean, nausea, vomiting, and which they have told us a number of times is not necessary in the far majority of the cases to diagnose. The very beginning, I have not, and Vermont ophthalmologists have not understood why this is out of the list of something that optometry wants to do because it's barely done by retina specialists anymore. And this is the final photo. This was corneal cross linking. Again, this is one of these surgeries that I never understood why it's been on the list, what the intent is there. Corneal cross linking is a surgery that generally is paid out of pocket, thousands of dollars, and again, there's only one ophthalmologist in the entire state of Vermont who has the training to do this surgery. Frequently is it sought? Rarely. I'm not even sure that our cornea doctor here does much at all. I've spoken with him about it. Okay. It's too expensive. And it's usually done on younger patients as well for this particular corneal abnormality. It's a genetic corneal abnormality. K. So this is another another thing in the middle. We just we don't understand what the intent is.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I'm gonna ask you if we can move and close.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: Yeah. Absolutely. Just because we're getting close to it. Need to

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: get to our next bill.

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: If you just pass these around for a second, you can feel Okay. This is what the material is that we actually learned to suture on. Yep, operator. Okay. Does not feel like skin at all. These are the eyeballs that are used to train on, and if you really look at it, you can see that there are four spots that are already stuck there. So those first spots are locations where an optometrist would be directed to direct the laser, so not taking into account that there are other places of the eye that may be more appropriate to do the laser. So this is basically a practice eye. It doesn't reflect on real submission. I have a good question. Sure. Thank you for this. Doesn't really mean much to me because I'm not a doctor, but my question is, it seems as though you have a real adverse reaction to some of the treatments that are in this bill. If they were removed from the bill, would that make this a little more palatable to the ophthalmologist community? I think we'd have to have a conversation about which things we're talking about. Okay. Well, that's what she's asking. Yeah. And that might take some time to get down.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Let's see what we can get with that one. That's an important question, I think. Is a huge interest in having this bill move forward. I understand that. There's also some concerns about the bill that magnified the front door. Having something would be great. And we really appreciate your time and the thought that you've given to this and the information that you brought. It takes away from the practice, know, seeing that each of

[Dr. Jessica McNally (Ophthalmologist; President, Vermont Ophthalmological Society)]: you has come in to present. Thank you, Martine. We're happy to be here. Thanks very much. We may see you again.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I appreciate that. You know, Doctor. Greenberg, we said the same thing, so, you know, we like the boots on the ground information, but we also are good to have the policy level decision making.

[Unknown Committee Member (Senator)]: They knew it Oh from my god. You're gonna Well,

[Dr. Jeffrey Young (Comprehensive Ophthalmologist)]: they go would make that so you

[Dr. Matthew (Matt) Greenberg (Emergency Physician; Chair, Vermont Board of Medical Practice)]: the value of the insert.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: You know what? I I wouldn't mind looking at somebody else.