Vermont Legislature SmartTranscripts:

[Virginia “Ginny” Lyons (Chair)]: You're welcome. All right, good morning. It is February 18 and this is the Senate Health and Welfare Committee meeting. We're taking up S-sixty four, which is the Optometry Scope of Practice Bill. And this morning we're taking testimony and then we'll be able to, I think this will be it for testimony and then we'll be able to sort out how to proceed when we next get it up on the agenda. So I know that Secretary of State is here, but I'm not sure you're providing testimony. That's just clarifying. It's good to have you in the room. So we'll start out with Christopher Brady, ophthalmologist who is on Zoom.

[Christopher (Chris) Brady, MD (Ophthalmologist; Retina Surgeon, UVM)]: Good morning.

[Virginia “Ginny” Lyons (Chair)]: Good morning, welcome.

[Christopher (Chris) Brady, MD (Ophthalmologist; Retina Surgeon, UVM)]: Thank you. You guys can see and hear me okay?

[Virginia “Ginny” Lyons (Chair)]: We can. So what we're gonna do before we begin and while you're there is introduce ourselves to everyone who's in the room and including on Zoom. We'll start over here with Senator.

[Senator John Morley III (Member)]: Senator John Morley from Boraleeps. John Benson from Orange District.

[Virginia “Ginny” Lyons (Chair)]: Ginny Lyons from Chittenden Southeast. Senator Martine Larocque Gulick from Chittenden Central. Ann Cummings, Washington. Okay, thank you for being available this morning. And why don't you go ahead and introduce yourself for the record and give us your testing.

[Christopher (Chris) Brady, MD (Ophthalmologist; Retina Surgeon, UVM)]: Of course, thank you and thank you so much for allowing me to do this virtually. I'm in between cases up here in the OR and I'm thankful that you guys were able to accommodate me. So I'd like to thank the chair and the committee for allowing me to speak this morning. My name is Chris Brady. I'm an ophthalmologist and fellowship trained retina surgeon with a master's degree in clinical epidemiology. I practiced here at UVM for nine years and I also conduct federally funded grant research developing and testing new tools for the detection of eye disease worldwide. So I was asked by the Vermont Ophthalmological Society to provide my interpretation of some of the outcome data presented on six specific eye procedures when performed by optometrists versus ophthalmologists. So I don't personally perform any of the procedures currently under review in Senate Bill 64 with the exception of fluorescein angiography though I was trained to do almost all of them. And I also, I hope I don't get too technical with my comments today, but my task was to try to dive deep into the details of the available evidence, so please stop me if I say something that's unclear. I've also provided written testimony, a red line version of a document of evidence that we that was shared with BOS by this committee for comment, as well as two other studies presented in prior testimony. And I would be happy to review any other documents in the future too. So in my written testimony, I review each of the procedures and the specific papers that were cited. And so what I'd like to do is I'd like to pick up on the previous testimony describing the optometry performed outcome data scan, because what I found was this was quite an understatement. So I'm trying to comment on all of the clinical outcome evidence or clinical effectiveness evidence for optometry performed procedures in The US, I was able to review a single study with three months of follow-up of 69 patients. This technically makes it effectiveness research rather than outcomes research. Nonetheless, previously you heard from an optometrist who's performed thousands of procedures, and one of the documents presented in testimony, describes 146 over 146,000 procedures, but the only high quality clinical data from The US presented that is in the peer reviewed published literature is a single small study of one procedure. Beyond that study, I have seen no publicly available peer reviewed clinical outcomes or clinical effectiveness evidence to support the safety and efficacy of the invasive procedures requested in Senate Bill 64 when performed by optometrists. The other documents that have been cited in my written testimony and the document I reviewed were either conducted in countries with very different contexts, such as UK based optometrists, practicing under the direct supervision of a subspecialist ophthalmologist, or a narrative description of the practice of a single optometrist without any clinical data presented, a general patient information article describing the eye condition called Chelazion without any clinical evidence, and finally, MD ophthalmology outcome data. In short, I've seen no data proving similarity in outcomes between US optometrists and ophthalmologists. So with that, I'd like to transition into a discussion of the two specific papers, that were presented in oral testimony to this committee and some of the specific reasons I don't believe those papers support particularly the safety of optometry performed lasers. It's important to note, and I'll say this a couple of times that it's very difficult from a biostatistical standpoint to prove safety, but that is how these documents are being used. I also wanna be very clear too. I don't believe that these papers established any direct evidence that optometry performed procedures are unsafe. I just believe we have insufficient evidence of their safety. And our classic saying is that no evidence of harm is not the same as evidence of no harm. Parenthetically, I also want to say for better or for worse, in the public health community, way we talk about safety has evolved over the past five or six years, and many of us have been chased into choose our words a lot more carefully when claiming a new type of treatment is safe and effective. So I believe the bar for declaring safety is higher than it's ever been. I've mentioned Doctor. Leitheiser's paper YAG laser capsulotomy efficacy and outcomes performed by optometrists already as the only prospective study, the only US based study and the only study reporting clinical effectiveness that has been presented as evidence to this committee and that I am aware of. This was a prospective three month study of 81 eyes of 69 people. The authors compared visual acuity outcomes to over 1,500 eyes pooled reported in table two of that paper. Almost all the patients in that study experienced, they did experience subjective and objective visual improvement in their visual function. But I would like to describe several significant limitations to that type of study design. For example, in the most rigorous types of studies clinical trials, I would need to see vision measured using a very strict standardized test testing method before and after the procedure. This is called best corrected visual acuity. We say BCVA with a protocol refraction, and it's designed to reduce the variability and bias in the testing of that measurement.

[Daniel Phillips, OD (Vice President, Vermont Optometric Association)]: If you've

[Christopher (Chris) Brady, MD (Ophthalmologist; Retina Surgeon, UVM)]: ever had your eyes tested at the eye doctor's office, you know, there's some variability in the lines, the letters that you read. Likewise, there could have been a control group, meaning some patients would be randomly assigned to receive a fake or what we call sham treatment or to MD treatment. That way researchers could compare the outcomes between those groups. This helps determine whether those improvements are truly due to the treatment or to other factors, including random fluctuation. Another key safeguard from bias in studies that we used is called masking. Other fields call it blinding. You may have heard of double blind. We avoid that term for obvious reasons, but the people measuring patients' vision ideally should not know who received which treatment nor should the patients themselves. If either group knows, it can unintentionally influence the results. This is just human nature and we strive to avoid it when we design our most rigorous studies. There's also an important concept that's called the test retest variability. When you repeat any test, results can naturally vary similar to similar to if you step on a scale more than once and you see a different number. And each test, we know what that variation ought to be. So with strict standardized vision testing, this BCVA protocol refraction, we expect a normal variation about one or one and a half lines on a specialized eye chart. That's like twenty twenty, twenty twenty five, 2,030. That's a line of vision. With less controlled testing variation can be even greater than that. In this study, the reported improvement was about two lines of vision, a little bit more than two lines of vision. This is a meaningful improvement in vision that should be significant to patients. But my concern is that that amount of change may fall within the range of normal testing variability, especially if the testing was not done under strict protocol conditions, such as this study. We'll talk about safety in this study. In this study, the investigators did not report any clinically significant adverse reactions. This is where things start to get a little technical and I personally don't understand the math, but I'll walk through the way that I understand it. So I am not a statistician, but I'd like to discuss a basic rule that researchers use that's called the rule of three. This helps estimate the true risk of a complication when a study doesn't report any. The basic idea that when a study reports zero bad outcomes, that can't, that doesn't prove that the risk is zero. And the way I think about it is if the study is only one or two patients and there's no side effects, it's pretty clear that you can't assume that the risk is zero under those circumstances. So what do you do? You look at the number of patients who are studied. So in the rule of three, you divide three by the number of patients in the study to estimate the highest likely risk that you could expect in a larger sample or when applied to the population at large. Using that rule here, the study supports that real complications could occur in as many as four point three percent of people. And that could be four to eight times higher than the complication rates that were reported for MDs in the sources cited earlier. So no complications observed does not mean no risk. It may mean the study was simply not large enough to detect those complications that occur at low, but still meaningful rate. Again, no evidence of harm does not mean evidence of no harm. Again, this is not a statement that this study proves or even suggests that the risk is that high. It simply highlights the importance of an appropriately powered study when making a safety claim. As I've said, it is very generally hard to prove evidence of safety and it requires a large study. I understand that this committee is obviously looking for the best evidence to support to support this hard decision, and I do not believe this study, the only study of US based optometrist outcomes reaches that threshold. I'd now like to discuss Doctor. Leithauser's other submitted paper used to support the safety of laser. This was a narrative review within which the authors presented results of a survey of state boards of optometry. The boards were asked about any patient complaints or provider reported negative outcomes. An estimated well, actually over 146,000 laser procedures were reported or estimated in this study period with two negative outcomes reported to those boards. I would like to emphasize that this type of evidence cannot be used to support the specifics claim of safety that was made in testimony. This type of data collection only captures the most serious, most extreme problems. It can be very valuable, but it does not track the routine or expected complications that happen in real world medicine and that are important to those people who experience them. Other evidence presented to this committee has shown MD performed procedures can have complication rates ranging in the range of a half a percent to five percent or so. This rate of zero point zero zero zero one four percent, is dramatically lower likely because it only includes those most catastrophic events. And so using that tiny percentage as proof that the procedures are nearly risk free, I think is quite misleading. So I'd like to close by restating what I said at the outset, no data proving similarity in outcomes between US optometrists and ophthalmologists has been presented, nor has any data establishing the safety of optometry performed procedures. And I would welcome the opportunity to review any other studies or reports that I'm not currently aware of and get back to you. So I thank you very much for the ability to present you this morning and I'd welcome any questions you have.

[Virginia “Ginny” Lyons (Chair)]: Committee questions. You've gone into a thorough, analysis of, you know, some research and thank you for doing that. It's a lot of work. Understood why you're doing everything else, and we appreciate your taking the time to bring this to us. Committee, are we all good? We're good. Thank you, Doctor. Brady. Very helpful. Thank you. So next on the list is on the next page. Okay. Will hope I'll say it right. Doctor. Lenny Hoole?

[Libby Gulick, MD (Oculoplastic Ophthalmologist)]: Yes. That's correct. Did I say that? Yes. You

[Virginia “Ginny” Lyons (Chair)]: did. Great. Thanks for being here.

[Libby Gulick, MD (Oculoplastic Ophthalmologist)]: Yeah. Thanks for having me.

[Virginia “Ginny” Lyons (Chair)]: And we have your testimony. Okay.

[Libby Gulick, MD (Oculoplastic Ophthalmologist)]: Chair and members of the committee, thank you for the opportunity to speak with you today. My name is Libby Gulick, I'm a practicing ophthalmologist here in Vermont. I was born right up the road in Berlin, and grew up in Danville. My father practiced general ophthalmology in St. John's Burry for over forty years, and part of the reason that I wanted to go to medical school was so that I too could serve the community where I work and live in a way that he did for so many years. Following medical school and residency, I completed a subspecialty fellowship training in ophthalmic plastic surgery, which gives me additional skills and expertise in the medical and surgical management of diseases of the eyelids, the orbit, which is the eye socket, and the tear drainage system. Then at long last, I returned to Vermont, where I've been happily taking care of patients and raising my family since 2015. I'm one of two oculoplastic specialists in our state. As part of my practice, I commonly remove the lumps and bumps referred to in this bill. I always send what I remove to pathology for interpretation because although I have a really pretty good sense after doing this for ten years about which lumps or bumps are malignant or cancerous and which are benign. I'm not always correct in my gross assessment, and so I leave that determination to the experts in this case or the pathologists, because making a mistake about which lesions are benign and which are malignant can have serious implications for patients. Now I'd like to focus on the substance and structure of S24s introduced, specifically on the training and competency framework it creates for the proposed advanced therapeutic procedures specialty. My testimony is really not about professional TERP. It is about competency based training and the implications that it has for patient safety, which is really my motivation for testifying here today. Under S-sixty four, an applicant must complete at least eight hours of didactic training, didactic and clinical instruction for each advanced therapeutic procedure, and then perform a minimum of two supervised cases of each procedure, only two supervised cases. In most procedural disciplines, whether medical or surgical, competency is not established by exposure to two cases. Competency is demonstrated through repetition, graduated responsibility, management of complications, and formal assessment of skill. S-sixty four does not define how proficiency is evaluated. It does not require objective skill assessments. It does not specify case complexity. It does not require documentation of outcomes. These are weaknesses of this bill. The two case threshold does not begin to capture the complexity, difficulties encountered, or proficiency assessment that are really integral to surgical training. N64 also creates a distinction based on graduation year. So optometrists licensed prior to 2019 must complete a thirty two hour, word approved course before beginning preceptorship. But graduates from 2019 forward are exempt from that requirement. There's no evidence cited in the bill that curricula changed in a way that substitutes for structured postgraduate training in 2019. So this means that two providers with essentially identical clinical experience could have materially different preparation based solely on their year of graduation. This is not a competency based distinction. S-sixty four allows the preceptor to be either an ophthalmologist or an optometrist with substantially similar scope for at least three years. It also allows an optometrist to get specialty by endorsement to serve as a preceptor here in Vermont. This means that a cohort of optometrists with the newly defined minimal specialty could systematically train subsequent cohorts with no external verification of skill or outcomes. In contrast, most procedural credentialing systems require preceptors with independent validation skills and expertise. For example, board certification, case volume requirements. The bill requires only five additional hours of continuing education every two years to maintain this specialty. It does not require minimum number of procedures per year to maintain proficiency. It does not require reevaluation of skills. So in a small state with a limited case volume, maintenance of competency becomes a central question, and this is really not addressed. S-sixty four includes an adverse event reporting requirement within thirty days, but it does not specify standardized definitions of adverse events. Independent review, public transparency, or enforcement mechanisms. So reporting alone is not the same as a safety system. A reporting duty without auditing or verification can result in no reported complications, narratives. All surgeons who perform surgery unfortunately have complications, so I'm highly skeptical of any report or study that claims to be comprehensive and also claims no complications, because that is simply not possible. S-sixty four authorizes procedures that include injections and management of anaphylaxis, but it does not define facility requirements, emergency readiness standards, or transport protocols. Finally, performing eye surgery requires providing emergency call coverage for our postoperative patients. Failure to provide emergency availability for postoperative patients is considered to be patient abandonment. When a patient starts experiencing eye pain at one a. M. After surgery, they're able to pick up the phone, call or stage their surgeon, who can address potential post operative complications, emergencies, or concerns. When you expand procedural authority, you also expand the associated risks and complications, and the infrastructure must expand as well to anticipate and prepare for the increased risks. This is not addressed in this bill. In summary, when a bill authorizes new invasive procedures, the framework must ensure demonstrable competency, durable skill maintenance, transparent outcome tracking, and emergency preparedness. S-sixty four lacks all of these. Again, this testimony is not about professional turf, It is about competency based training and the implications for patient safety. In my testimony here, I do not intend to imply that MDs have some sort of innate or intrinsic ability to perform surgery, or that well trained surgeons are somehow infallible. Neither is true. But what we do have are skills and judgment that have been learned and honed over many years of hands on practical training, with graduated responsibility and progressive autonomy based on demonstrated competence. Acquiring these skills takes a lot of time and a lot of practice. It is true that some optometrists, and probably some of you, have the capacity to do these procedures with proper training. I have a good friend and colleague who initially trained as an optometrist in her native Canada, and she practiced as an optometrist for several years, and then she decided that she wanted to do surgery and be an ophthalmologist. So she went to medical school, completed residency and fellowship training, and now is an accomplished and experienced ophthalmic surgeon. I would gladly send a family member to her for surgery if they needed it, because she has the training required to make the judgment, perform the surgery, and then recognize and manage any potential complications that ensue. I think this is an appropriate training pathway for someone who wants to perform eye surgery. This bill contains structural gaps that compromise patient safety, competency verification, and regulatory oversight, and for what reason? Whose interests does it serve? Does this bill truly serve the best interest of Vermonters? There's been no demonstrated surgical need beyond what is currently provided by ophthalmologists in our state. The wide gap in this bill and lack of adequate standardized training goes to the core of whether Vermonters receive safe and high quality care. Those are the concerns before you. Thank you for your time and your consideration, and thank you for your service to our state.

[Virginia “Ginny” Lyons (Chair)]: Thank you. Thanks for being here, and thanks for being in Vermont coming back home. It's great, So it's good.

[Libby Gulick, MD (Oculoplastic Ophthalmologist)]: Yeah. It's my dream, so I'm happy to be here. Everyone

[Virginia “Ginny” Lyons (Chair)]: can do that. Yes. I'm very lucky. Committee. Go ahead. I have a question, too, for thought. Oh, no. I'm happy to wait.

[Senator John Morley III (Member)]: Okay. Thank you. Your credentials are repentable. So thank you for coming to your testimony today. Are there any procedures in this bill that you feel that the optometrist could perform safely?

[Libby Gulick, MD (Oculoplastic Ophthalmologist)]: I mean, going back to what Doctor. Brady has said, I don't think that we have evidence to show that it's Yeah, I mean, none of the ones in this bill. Because I mean, bill really outlines those six procedures, are the laser procedures, removal of eye lesions. So of the ones listed in this bill, no, I don't. Not his name is very nice to him. Okay,

[Virginia “Ginny” Lyons (Chair)]: other questions? No. So, what is the frequency with which you're doing any one or more of these procedures? Which ones are you doing?

[Libby Gulick, MD (Oculoplastic Ophthalmologist)]: That's a good question. I mean, so I trained to all of these, but the only ones I do regularly, because I subspecialize in ophthalmic plastic surgery, are really the removal of eyelid lesions and the excision of chalazion. Those I do. I did them all day yesterday. So, I have a procedure day in the office every week. And I do other things in addition to revival lesion stuff. But yeah, I do that on a weekly basis.

[Virginia “Ginny” Lyons (Chair)]: Other questions? No, we're good. This is great. Thank you.

[Libby Gulick, MD (Oculoplastic Ophthalmologist)]: Thank you for coming in. Okay.

[Virginia “Ginny” Lyons (Chair)]: So we are on to Amy Burkto.

[Libby Gulick, MD (Oculoplastic Ophthalmologist)]: Doctor. Burkto? I think Doctor. Alicia Weiss. Doctor. Alicia Weiss.

[Virginia “Ginny” Lyons (Chair)]: And then- Oh, excuse me. You didn't write it. I skipped right over Doctor. Alicia Feis. It's all my air going on. Okay. Welcome, Doctor. Feis.

[Alicia Feis, OD (President, ASCO; Dean, Arizona College of Optometry, Midwestern University)]: Good morning, everyone. Can everyone hear me okay? Yes, we can. Okay, perfect. One, I just wanna say thank you. I hope it's nice and warm there in Vermont. I'm joining from sunny Arizona, so thank you for the time.

[Virginia “Ginny” Lyons (Chair)]: That is really unfair.

[Alicia Feis, OD (President, ASCO; Dean, Arizona College of Optometry, Midwestern University)]: Well to be fair, I do have a brother who is up in Northern California and he just sent me that they have over a foot of snow so you can't have cold weather.

[Virginia “Ginny” Lyons (Chair)]: Go ahead. No go ahead. I was I'm sorry to interrupt.

[Alicia Feis, OD (President, ASCO; Dean, Arizona College of Optometry, Midwestern University)]: No you're okay. I have a few slides that I'd like to prepare or that I have prepared so I'm hoping I think this is the my most nervous part is always trying to make sure that screen sharing works. Ann.

[Virginia “Ginny” Lyons (Chair)]: Okay, perfect.

[Alicia Feis, OD (President, ASCO; Dean, Arizona College of Optometry, Midwestern University)]: Everybody see my slides? Probably not when I'm moving them, but is everyone?

[Virginia “Ginny” Lyons (Chair)]: Yes, they're good, they're good. Good slides.

[Alicia Feis, OD (President, ASCO; Dean, Arizona College of Optometry, Midwestern University)]: So I'd like to thank the association for allowing me to present. I'd like to give you, I am the president of the Associated Schools and College of Optometry currently. I am also the dean of the Arizona College of Optometry, which has two campuses, one here in Arizona and one also in Chicago. It's an interdisciplinary graduate medical campus. So I have the opportunity to work with the medical school, the dental school, and some of the other several graduate medical educations that are there. I am a residency trained and practicing optometrist here in the state of Arizona, and I have over fifteen years of experience in optometric education. As the ASCO president, I wanted to clarify because I had heard previous testimony, there are currently 23 accredited optometry programs with two additional colleges that are in pre accreditation stages. The Accreditation Council on Optometric Education is the accrediting body that oversees all of these schools to ensure that we have competency based model guides, as we have approximately 1,700 graduates who graduate on a yearly basis from all these schools in College of Optometry. At Midwestern University, I agree with the ophthalmologist from previous testimony that there are several in our community, including patients and those that I work with that are very confused about the differences between optometry and ophthalmology. And I hope today to clarify that training that optometrists go through to practice the profession that we do. Very similarly, both, professions go through a four year bachelor's degree. And during the medical school training, as you can see, optometry school kind of just dives right into the focus in on the eye. I can attest at my college several of the basic sciences and all of the systemic diseases that students undergo are actually very similar to some of the medical training. In fact, the basic science faculty who teach at the university also teach to the medical school, in addition teach to the dental school and the optometry school. So it's same faculty, same individuals who are training our students at my college. We then also go into a deep dive of ocular disease management and skills for the eye examination. So several of the skills, that are introduced in F-sixty four are something that optometry students learn in their first year of optometry school, such as the slit lamp examination, and being able to ensure that the small hand skills that are eventually going to move into those minor surgical procedures are actually motor skills that are practiced as a first year optometry student. As you can see, the residency component is optional post graduation, but we do have two full time ophthalmologists who are at the college and our students train under them. So there's a lot of different things that I think our students are exposed to in order to help kind of complement one another. It comes to the training, again, there are mostly didactic training similar to medical school in those first two years. And then the last two years of the four year program are truly more in the patient care under the supervision of either an optometrist or under an ophthalmologist. In addition, after the training, there are three sets of National Board examinations that an optometry student takes in order to become a licensed optometrist. Part one of the applied basic sciences, part two focuses mostly on a patient assessment and management, so being able to ensure that the optometry student who will then be practicing understands the type of patient, how to diagnose them, when you would treat them, and then also how you would refer. And the Part III examination is where you are actually assessed on your skills based. So all of the National Board examinations are taking place at our NBEO, which is based in North Carolina. And the Part III skills is also where the LSP, which I'll talk a little bit later on, but that's where the national licensing exam comes in. And so all of those are standardized across The United States, and every single student who graduates from optometry school who intends to practice in The United States must pass those examinations in order to practice in those states. There are several things within the curriculum where we talk about diagnosis and management. And so I did discuss a little bit, you know, we learn all about diabetes and hypertension and what happens should something go wrong during a procedure or even in the back of the eye from a systemic disease or complex disease that might be affecting the eye. In addition, several optometrists and included in our curriculum, in that bottom left hand side, you'll see that there is a foreign body that is on the front part of the eye. We are trained in our clinical skills, as well as our didactic classroom in order to remove foreign bodies that are on the front part of the eye. And when we think about how the training ensues for optometry, several, before we begin anything, all of it begins with a classroom didactic setting. All of our classroom information is then always tested, and concurrently, wherever there is a skill, there are several hours of lab that the students are practicing not only on simulators now with virtual reality, but also practicing on their classmates. There are several competency examinations that are supervised by the optometry faculty, and then they are tested in order to be able to move forward in through the curriculum. If they have not mastered that skill, then they are not allowed to move forward, nor are they allowed to move into preclinical care. In those first two years of the curriculum, students learn several procedures and are tested on them several times during the courses, but even before they begin clinical care, they have to go through another preclinical proficiency. All of those are also done at all the schools and colleges of optometry. Before there's any patient care, there is also another complex ability to ensure that students are really ready to practice safely and effectively with patients. Once they move into their third year curriculum, again, this is across all the schools in College of Optometry, that's where the balance begins, where they are in clinical training, providing direct patient care to the patients that they are seeing within their clinical rotations, in addition to learning all of the specialties. That's where a lot of the advanced clinical procedures is hit. I apologize, I did want to mention at our particular institution, at the medical school, the optometry faculty actually deliver a lot of the education in relationship to the eye. Our medical colleagues, most of them within the college that are there as faculty do not have specialized training in the eye. And so in our interdisciplinary healthcare setting, we actually teach of the four and a half hours that they get, which most of those are in the lab. The optometry faculty are the ones that are delivering educating the medical students on those particular aspects. So our medical colleagues really do value the education that we have and recognize the significant contributions that we can make in order to help their students become experts in the eye as they move into possibly their ophthalmological residency later on. I do want to comment, I know in just previous testimony, we heard about the differences in the 2019 change curriculum. I have since taught at the college, and yes, we had a lot of advancements in our curriculum in 2019, thus why S-sixty four refers to changes in differences in what would be expected from the optometrist post 2019. In 2019, the ACOE and the ASCO moved so that every school and college of optometry would ensure that they were teaching to the highest scope that is happening in all of the states and colleges, thus why the differences between the change. I can vouch that as a graduate in 2008, I actually graduated from the Southern California College of Optometry in California. And when I graduated in 2008, I had an actual special component to my license that actually showed that I went through glaucoma training. So because I graduated in 2008 and every graduate after that into practice in the state of California, I didn't have to go through any specific training because the curriculum had showed I had gone through every evidence based medicine components needed for the treatment and management of glaucoma. So there are different precedents when it comes to that as far as training from one year versus another. As just a quick aside, everything that is taught within optometry, as we know, is an ever expanding scope of medical curriculum. All of it starts in comprehensive biomedical science foundations. Any new procedure that is given to an optometrist or anything within the eye care field, there is always a restart. And even with our continuing education, COPE approved continuing education actually all follows ACGME standards. And within the bill, there is continuing education that is added in to ensure that optometrists are following through with everything. And so again, those all follow ACGME guideline. And any advanced ocular training is very similar to ensuring that every optometrist understands the patient types that should be selected for this, and then of course, all the pre and post op management care and demonstration through simulation, through supervised clinical practice. I can assure you that every school in College of Optometry goes through every competency checklist to ensure that students are aware of all the different aspects, as well as those things that are going to be tested on the National Licensing Examination before they move into any of the minor surgical procedures or laser procedures that are mentioned within the bill. In addition, the ASCO continues to work upon the competency based framework to ensure all schools and colleges of optometry are held to the highest standard, but also each year, every school reviews every state that has increased scope and will update their curriculum in order to ensure that every optometrist is being educated to the highest standard that is happening nationally. In order to do that, we also have simulation based education and ensure that each student will go through an assessment that is overseen either by an optometrist or an ophthalmologist. We ensure that there are standardized checklists, and again, they cannot move forward if they haven't demonstrated competency. Now, differences, and I know that that was mentioned in previous testimonies, in the state of Arizona, I cannot perform these particular procedures. However, as Nate Lighthizer had mentioned, that Oklahoma has practicing many of these procedures for several years. Nate actually came to the Arizona College of Optometry, delivered that thirty two hour course to all of our faculty. And then we mirrored a lot of our curriculum against that particular program. And we continue to educate every single faculty member that is there. In our eye clinic at the Eye Institute in Arizona, we actually have two full time ophthalmologists that are there and they train our students. And so they observe and have guided participation in case discussions amongst students, amongst the patients that they're seeing. I can validate that every single one of my students works with the ophthalmologist during their third and or fourth year while they are there. In addition, how they gain additional clinical exposure as they go out on fourth year rotations. Every school in College of Optometry, fourth year students rotate out of their state where they are trained, and they have an opportunity to learn under an ophthalmologist or an optometrist if there is advanced training and scope in that particular area. In relationship to standardized components of the LSPR, the laser section content of the outline, as proposed in the S-sixty four, there is a standardized language that all particular faculty have to, or excuse me, new doctors have to complete the LSP, which again is the national standard that all optometrists do in order to perform any of the procedures that they will be licensed to do so in their practice, in addition to the surgical section. So there is an outside entity that is overseeing what is happening even within their previous preclinical and licensing. In addition, I appreciate there was a comment about additional safeguards. I do believe that S-sixty four is putting in additional safeguards. Should someone choose to move forward with the items that are being proposed in S-sixty four, I believe the additional patient safety measures, preceptorship, and guided manipulations within these particular skills are a benefit to the bill and allow optometrists to ensure that they are going to be having safe and effective practice. And it would allow them also to confirm with others that they can move forward and also our different colleagues to consult in the practice of the profession of the eye. So I do believe that the alignment and training and public safety are being discussed within the bill are something that optometrists are truly trained about. So thank you for your time. If there are any questions, I'd be happy to take them.

[Virginia “Ginny” Lyons (Chair)]: Oh, thank you, and we don't have that slide show on our webpage. If you could send it, it would be helpful. I know you also sent us two other testimony, I think, that covers what you said in a different way. So if you feel that what you've said on the slideshow is covered and what you've sent us, that's fine. Don't have to provide it. But if you think it will help expand your testimony, then please do send it.

[Alicia Feis, OD (President, ASCO; Dean, Arizona College of Optometry, Midwestern University)]: I will do that. Thank you.

[Virginia “Ginny” Lyons (Chair)]: All right, great. Thank you very much. Questions? We're good. We're going to move along and I just let you know that one thing that, I don't know whether it's on the agenda that you're all looking at, but we do have a hard stop just before 10:15, but if we go over a little bit, we'll be okay. Just gonna let you know we're gonna take a break after the exam. So we are on now, Doctor. Amy Puerto. Welcome.

[Amy Puerto, OD (Optometrist, Covington, Louisiana)]: Thank you so much, Chairman Lyons, Chairwoman Lyons, and members of the committee. Thank you for allowing me to speak. My name is Amy Puerto, and I'm an optometrist in private practice in Covington, Louisiana, forty five minutes north of New Orleans in a parish that borders rural Mississippi. And don't mind us, you may still hear some ruckusiness coming from my office staff as yesterday was Mardi Gras. I truly feel like I could be one of your constituents and that's why I want to speak to you today simply as an optometrist who has performed these procedures outlined in this bill effectively and responsibly for over a decade. I graduated optometry school in 2015. Today is my surgical clinic morning, and I'm not here to theorize about what optometry might be capable of. I'm here someone who lives this every week in clinical practice. In my practice, post cataract YAG capsulotomies are performed weekly. Managing posterior capsule opacification for patients who had cataract surgery is part of my daily care, whether it's discussing the condition with patients or making a clinical decision to schedule the patients for surgery. Selective laser trabeculoplasty for open angle glaucoma is primary surgical care. Evaluating narrow angles and managing acute angle closure glaucoma is part of all optometrists' comprehensive clinical decision making. Removing benign eye lesions, particularly Chelazian excisions, is part of my clinical skill set and honestly one of the most rewarding procedures to perform because of how immediately it helps a patient look, feel, and function better after other topical and systemic treatments have failed. Therefore, when I hear these procedures described as Bittenden's Optometry Scope, I can tell you that just simply has not been the case or nor reflected in the education I received nor the daily realities of my practice. For optometrists like me, the procedures outlined in S64 are not advanced procedures. They are skills and treatments integrated into the safe care I provide my patients daily and my patients expect me to provide them. I began optometry school in 2011 in Tennessee, a state that at the time did not yet have legislative authority for some of these procedures. Yet I was trained didactically and clinically in laser procedures, in management of surgical complications, and ordering then sending out lesions for reports, biopsy reports. The education existed regardless of statute. That's important. Our schools of optometry prepare us and continue to prepare students for where eye care is going, not only currently where it is at. Fluorescein angiography, for example, has been taught in schools of optometry for decades, including its risk of adverse effects. I learned it nearly fifteen years ago, and while it's not a major diagnostic tool outside of retina, in preparing for this testimony, I was surprised to learn Vermont law did not already reflect optometry's training and board certification to perform this diagnostic testing. Not every optometrist may provide this diagnostic tool just as Doctor. Chris Brady earlier mentioned in his testimony today that not all ophthalmologists perform every subspecialty procedure either. But the training exists for both of us, the education exists, and the proven competency pathway exists. Rest assured, S-sixty four does not invent new skills for optometrists to learn. It recognizes training that often has already occurred, but with stringent guardrails. In fact, as I read through this bill, Vermont's regulatory safeguards will become the strongest in the nation. It is true that no procedure should ever be considered minor in the sense that it is without consequence. When caring for another human being before surgery, patients are often anxious. Their blood pressure can rise. Some may even become lightheaded or pass out. But optometrists have been skilled and trained to prepare for those anticipated situations. We know patients move, they flinch, they may swear from the exam chair, and in those moments when a person is simply having a human response to stress, the provider, me, must remain steady, calm, and prepared. That gravity is not unique to one profession. It is inherent to all patient care. Because of my training and years of practice, I approach every procedure with deep respect for anatomy, physiology, the human condition. I am attentive to anxiety, vigilant about vital signs and bleeding risks, cautious and selective of the technique, medications, and instruments I use. Even more, surgical judgment is not just being able to perform a procedure. It is about recognizing when not to perform it. If someone is not appropriate as a candidate under my care for a procedure, I do not proceed. The visuals shown two weeks ago by ophthalmology were excellent. Truly. We see those same conditions in clinical practice. We are trained to recognize bleeding, inflammation, eye pressure spikes, complications, and to respond appropriately. I wish I could invite each of you to my practice this morning to observe what optometric surgical care looks like in practice. I want you to see that this again is not hypothetical or futuristic. It is careful. It's measured care that benefits patients. Through all of it, our guiding oath to patients remains the same: first, do no harm. These are serious procedures. They deserve serious discussion. I've listened carefully to the concerns raised here and I respect them, but I also recognize something familiar in this debate. When optometrists first sought authority to dilate patients, the public messaging was similar, that patients would be harmed, that the education and training of optometrists was insufficient, and that the risks were too high. Rhode Island passed dilation authority in 1971. Maryland, the fiftieth state, followed in 1989. It took nearly two decades for full national adoption. Today, dilation is standard of care in optometry and ophthalmology. The same was also said when optometrists sought pharmaceutical prescribing authority and when we obtained our DEA licensure. Change is uncomfortable, especially in healthcare, but modernization does not equal recklessness. It equals progress. I chose to complete a residency in Louisiana in 2015, just after their scope modernization passed. At the time, I did not fully appreciate how significant that was. As a new graduate, I simply wanted to practice comprehensive contemporary primary eye care at the fullest extent of my training. It wasn't until I attended conferences and met colleagues from other states I realized something striking. Many of them were trained in the same procedures I was trained in. They passed the same boards, they learned the same skills, but their state law did not allow them to use them. They would express curiosity at my surgical experience, yet there was nothing unique about what I was doing. I simply lived in a state that trusted optometry's education, board certification, and licensure. After residency, I considered moving closer to family, but I could not imagine stepping backward in the care I could provide. I stayed in Louisiana because I could practice responsibly at the level I was trained to provide. And now more than a decade into practice, I am rooted in my community and cannot imagine leaving my patients. There's just too much trust over the years built to abandon their care. And I also share your concern about safety. I take it personally and understand the seriousness of altering tissue with a laser or on the eyelid. I respect it deeply. Every procedure I perform reflects not only on me but on my entire profession. However, if widespread harm were occurring in states where optometrists perform these procedures, we would see it clearly in the literature, in malpractice trends, and increased rates in public safety alerts. We have not seen that materialize, and complication rates remain low and comparable. As the committee is well aware, Vermont's bill includes additional coursework preceptorship document competency informed consent and thirty day adverse event reporting. Those are significant protocols above and beyond education, board certification, and licensure. They are stronger guardrails than what Louisiana had a place when its law was regulated by our state optometry board, and tens of thousands of laser procedures have been safely performed since. Finally, I want to address something that struck me deeply after the last committee meeting with ophthalmology when Senator Morley asked if ophthalmology could work with optometry, I'm coming to an agreement on this bill, and he was told no. While I was still a student and did not fight the legislative battle in my state, I know the debates and news articles were equally contentious. From what I've seen, the intensity of this bill only exists in legislative rooms like this one, but once the bill passes, we all go back to work, serving in our complementary and now expanded roles and caring for our mutual patients just as we always have together. S-sixty four recognizes optometrists are trained to manage appropriate primary level surgical care and will continue to refer when complexity exceeds that level. For Vermont, the optometrists who acquire this additional licensure will help create a workforce better prepared for the growing eye care needs of this state safely and with defined guardrails and responsibly. Lastly, I'm not asking you to imagine what optometry could become in Vermont. I am speaking today as an example of what over several decades of responsible modernization already looks like. It looks like continuity of care. It looks like collaboration. It looks like sound clinical judgment. It looks like safety. And I believe Vermont is ready for that future now. Thank you.

[Virginia “Ginny” Lyons (Chair)]: Thank you. If you could send us that testimony that you've just provided, we don't have it on our webpage, that would be helpful. Thank you.

[Libby Gulick, MD (Oculoplastic Ophthalmologist)]: For Absolutely, thank you.

[Virginia “Ginny” Lyons (Chair)]: Yeah, great, that's good. Questions? Okay, we're good. Thank you very much, and I hope the weather's, whoop, she's gone. I tell you, I hope the weather's great in Louisiana. You're muted. You're muted.

[Amy Puerto, OD (Optometrist, Covington, Louisiana)]: We were getting a warm up just recently, but we've been hitting some pretty chilly weather. We had our largest snowstorm where we had a foot of snow last year around this time, and it it once in a 100 generation kinda situation, but we don't mind our little Vermont cool down when you guys give us a little Polar Express, so we appreciate now and then.

[Virginia “Ginny” Lyons (Chair)]: Well, as long as it doesn't get to be minus 25, you're okay. Thank you.

[Amy Puerto, OD (Optometrist, Covington, Louisiana)]: Thank you all.

[Virginia “Ginny” Lyons (Chair)]: So now we'll move on to, and I understand that Doctor. Phillips and Doctor. Keshava are gonna testify together. Is that right?

[Libby Gulick, MD (Oculoplastic Ophthalmologist)]: Yes. Do

[Virginia “Ginny” Lyons (Chair)]: you want to do it? Bring a chair up. Hi there. My

[Daniel Phillips, OD (Vice President, Vermont Optometric Association)]: name's Doctor. Daniel Phillips. I practice up in St. Albans, Vermont. I'm also the vice president of the Vermont Optometric Association. I'm originally a Western Mass native, I went to UMass, and was my undergraduate, University of California Berkeley for my doctorate in optometry, the Oklahoma College of Optometry, and Cherokee Nation Health Care Center in Oklahoma, where I studied under, did my residency under Doctor. Nate Lighthizer, who met previously. At Oklahoma, I not only taught, performed, supervised all the procedures covered on this bill. In second and third year class in pre clinic, all students of optometry, including the ones in Oklahoma, learn all about all of these procedures. In fourth year in Oklahoma, they have the opportunity to do all of these procedures and generally exceed the number of procedures done by an ophthalmologist, or what's required by an ophthalmologist who graduates their residency. Perfect. In a forty year history of optometrists doing this procedure, we have been well tracked, vigilantly monitored, and we have a strong record of efficacy and safety. We don't need significant amount of picture training, because all optometrists basically begin learning the SLIT lamp first year of optometry school, with gonioscopy, second year of optometry school. These are the basis of all of the laser procedures that we do. ODs, in general, have approximately ten thousand hours of didactic training. Everything is about the eye. Move systemic disease, physics, immunology, biochemistries, all optometrists to a minimum of 2,000 patient encounters. By the time they graduate, you might need to do much more. For example, in St. Almonds, we run a very advanced ocular disease clinic up there, where we are constantly managing glaucoma, diabetes, macular degeneration, anything that you could think of. For an example of what it's like treating a patient with glaucoma, first line treatment, since the 2022 light study, been the preferred first line treatment is selectively insert trabeculoplasty, which is one of the items on this bill. This is a procedure I perform many times. If I have to send a patient upstairs, there's an ophthalmologist right above me. It is approximately eight months wait, so I send all my patients to Burlington, which I can usually get in in one or two months. Basically, I have already evaluated this patient, so now I have to send them on a forty five minute drive to first get dilated, and then have a second visit to actually do the procedure. Yeah, these procedures are of little risk, and are absolutely necessary and the primary treatment of these kinds of diseases. So one of the reasons I chose to move to Vermont was because this is the state that is the farthest along in the scope of practice. Also, the practice that I work with is a very high level modern ocular disease practice where we do all the same diagnostic testing and imaging that they have available in ophthalmology office. Right now, I've been here since July, and I am booked up till August. My partner, Steve, is booked up till November. I came here to buy this practice, which we should see the sale in less than three years. I'm looking to hire at least four more ODs to work up there, and I need the top level trained ODs to be able to perform the kind of stuff that we are doing with them. In order to get people to move up to Vermont, we need to be able to allow top trained doctors to practice up to their training. So our numbers are shrinking here in Vermont, and this is an opportunity for us to basically be practicing modern eye care in Vermont before any other state in New England does. Both New Hampshire and Maine both have these bills on on the books, and they are on the Zoom, but this is an opportunity to take advantage of being the first day in the emergency. Well, I welcome any questions after Doctor. Chittenden speaks, but

[Virginia “Ginny” Lyons (Chair)]: Thank you. That's good.

[Tina Keshiba, OD (President, Vermont Optometric Association)]: Good morning, Madam Chair and members of this committee. My name is Tina Keshiba. I am an optometrist for Rutland and currently the president of the Vermont Optometrium Association. Thank you very much for allowing us to demonstrate the need for scope expansion of optometry in Vermont. Not only are current optometrists trained and educated to perform these procedures, but we have also shown that it is safe and effective when we do. As Doctor. Marcelo mentioned earlier, our profession in Vermont has developed over the past century from providing glasses and checking vision, to dilating patients in the early eighties to monitor eye health, and to treating eye disease and infections in the early two thousands. Our education evolved before these changes were made, and it's time again for our scope to match what optometry graduates are prepared to do. By allowing this expansion, patients will be able to have greater continuity of care with their local eye doctor and save on extra transportation, time, and co pays of unnecessary referrals. Like Doctor. Phillips was mentioning, he would be able to perform SLT, and he did it many times last year when he was in Oklahoma, but now he has to refer his patient out to another doctor that could get them in at least within one to two months. That patient has to go and get examined again before they can have their procedure. So it's a whole extra visit, a lot of extra time and energy put into that, when he could have taken care of it with much less time involved. That being said, not every optometrist will apply for this license. Only those that feel confident and have the desire to perform these skills will pursue it, just like not every ophthalmologist performs cataract surgery. Would also like to address concerns regarding complication management. Most of the common complications from these procedures are already managed by optometrists. The more severe ones, which are rare, thankfully, usually need to be addressed by a retinal specialist, regardless of who performs the procedure, whether it's an optometrist or an ophthalmologist. I would also like to speak a minute on the issue of access. We do not disagree with ophthalmology that access is an issue for eye care and for monitoring, just like it is for dentistry and primary care, unfortunately. I can personally tell you that one of the first questions fourth year students ask at your career fairs is, what is the scope in your state? These newly minted optometrists do not wanna be limited in what they can do based on this date line. We hope that by increasing the scope to this degree, Vermont will be attractive to these new grads and other highly trained optometrists, helping to fill the gaps in coverage we have now or will have as other optometrists retire. Additionally, as discussed in Doctor. Elo's article, there will be a shortage of ophthalmologists across the country within the next ten years as demand is soaring. Optometrists must be able to work to their full training to save the ophthalmologist chair time for patients with more complex needs like cataract surgery and injection for macular degeneration. Those are outside of this proposal. This bill is about working as a team to help deliver the best eye care possible to promoters. Given how long OPR feels it will take to get this advanced specialty license up and running, there's no time to delay. Vermonters cannot afford even worse eye care than we have now. Lastly, OPR supports the bill after months of exhaustive research. It contains high standards for doctors seeking a specialty license, including extra training, extra board exams, a preceptorship, proctored procedures, and adverse event reporting. It also requires more continuing education to renew this license than the traditional one that we have now. Additionally, the Oliver Wyman report shows that allowing providers to practice to the full extent of their education and training is a way to reduce healthcare costs and improve patient access. That is what S-sixty four is all about. Instead of being the forty ninth state, like we were for allowing optometrists to treat glaucoma, please help us join the other 14 states and be counted on the first in the Northeast to fully expand scope by voting yes on this bill. Let's not let Vermont fall behind. I really appreciate your time and we're happy to answer any questions I have. Thank you.

[Virginia “Ginny” Lyons (Chair)]: Thank you both. Very helpful. Questions committee. Alright. We're good. Thank you. And I think what we're going to do is we'll come back for a broader discussion on the bill as the committee looks at the bill and then any markup and possible votes are. That's where we are with this. And we're going