Amended in Senate April 24, 2013

Amended in Senate April 16, 2013

Amended in Senate April 1, 2013

Senate Bill No. 492

Introduced by Senator Hernandez

February 21, 2013

An act to begin delete repeal and add Sections 3041 and 3041.2 end delete begin insert amend Sections 3041 and 3041.1 end insert of the Business and Professions Code, relating to optometry.

LEGISLATIVE COUNSEL’S DIGEST

SB 492, as amended, Hernandez. Optometrist: practice: licensure.

The Optometry Practice Act creates the State Board of Optometry, which licenses optometrists and regulates their practice. Existing law defines the practice of optometry to include, among other things, the prevention and diagnosis of disorders and dysfunctions of the visual system, and the treatment and management of certain disorders and dysfunctions of the visual system, as well as the provision of rehabilitative optometric services, and doing certain things, including, but not limited to, the examination of the human eyes, the determination of the powers or range of human vision, and the prescribing of contact and spectacle lenses. begin delete Existing law provides that the State Board of Optometry is required, by regulation, to establish educational and examination requirements for licensure to ensure the competence of optometrists to practice. end delete begin insert Existing law authorizes an optometrist certified to use therapeutic pharmaceutical agents to diagnose and treat specified conditions, use specified pharmaceutical agents, and order specified diagnostic tests. end insert Any violation of the act is a crime.

begin delete

This bill would delete the definition of the practice of optometry and would instead provide that a licensed optometrist would be authorized to perform certain health-related services, including, but not limited to, examining, preventing, diagnosing, and treating any disease, condition, or disorder of the visual system, the human eye, and adjacent and related structures of the visual system, prescribing appropriate drugs, including narcotics, and administering immunizations and to diagnose other common primary care conditions that have ocular manifestations. The bill would also authorize an optometrist, who is operating under a protocol with a physician and surgeon or a health care facility, or participating in a specified system of care in which the patient is being otherwise treated, to initiate treatment and manage medications for those diagnosed conditions. The bill would require the board to require applicants for licensure to successfully complete specified examinations, and would authorize the board to require the passage of additional examinations with regard to competency to utilize diagnostic and therapeutic pharmaceutical agents, if not covered by the required examinations.

end delete begin insert

This bill would add the provision of habilitative optometric services to the definition of the practice of optometry. The bill would expand the practice parameters of optometrists who are certified to use therapeutic pharmaceutical agents by removing certain limitations on their practice and adding certain responsibilities, including, but not limited to, the ability to immunize and treat certain diseases, and deleting the specified drugs the optometrist would be authorized to use, and authorizing the optometrist to use all therapeutic pharmaceutical agents approved by the United States Food and Drug Administration, as provided. The bill would also delete limitations on what kinds of diagnostic tests an optometrist could order and instead would authorize an optometrist to order appropriate laboratory and diagnostic imaging tests.

end insert begin insert

Existing law requires optometrists in diagnosing or treating eye disease to be held to the same standard of care as physicians and surgeons and osteopathic physicians and surgeons.

end insert begin insert

This bill would expand this requirement to include other diseases, and would require an optometrist to consult with and, if necessary, refer to a physician and surgeon or other appropriate health care provider if a situation or condition was beyond the optometrist’s education and training.

end insert

Because this bill would change the definition of a crime, it would create a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

The people of the State of California do enact as follows:

begin insert

begin insert SECTION 1. end insert   

end insert

begin insert Section 3041 of the end insert begin insert Business and Professions
Code end insert begin insert is amended to read: end insert

3041.  

(a) The practice of optometry includes the prevention
and diagnosis of disorders and dysfunctions of the visual system,
and the treatment and management of certain disorders and
dysfunctions of the visual system, as well as the provision of
begin insert habilitative or end insert rehabilitative optometric services, and is the doing
of any or all of the following:

(1) The examination of the human eye or eyes, or its or their
appendages, and the analysis of the human vision system, either
subjectively or objectively.

(2) The determination of the powers or range of human vision
and the accommodative and refractive states of the human eye or
eyes, including the scope of its or their functions and general
condition.

(3) The prescribing or directing the use of, or using, any optical
device in connection with ocular exercises, visual training, vision
training, or orthoptics.

(4) The prescribing of contact and spectacle lenses for, or the
fitting or adaptation of contact and spectacle lenses to, the human
eye, including lenses that may be classified as drugs or devices by
any law of the United States or of this state.

(5) The use of topical pharmaceutical agents for the purpose of
the examination of the human eye or eyes for any disease or
pathological condition.

(b) (1) An optometrist who is certified to use therapeutic
pharmaceutical agents, pursuant to Section 3041.3, may also
diagnose and treat the human eye or eyes, or any of its or their
appendages, for all of the following conditions:

(A) Through medical treatment, infections of the anterior
segment and begin delete adnexa, excluding the lacrimal gland, the lacrimal
drainage system, and the sclera in patients under 12 years of age. end delete
begin insert adnexa. end insert

(B) Ocular allergies of the anterior segment and adnexa.

(C) Ocular begin delete inflammation, nonsurgical in cause except when
comanaged with the treating physician and surgeon, limited to
inflammation resulting from traumatic iritis, peripheral corneal
inflammatory keratitis, episcleritis, and unilateral nonrecurrent
nongranulomatous idiopathic iritis in patients over 18 years of age.
Unilateral nongranulomatous idiopathic iritis recurring within one
year of the initial occurrence shall be referred to an
ophthalmologist. An optometrist shall consult with an
ophthalmologist or appropriate physician and surgeon if a patient
has a recurrent case of episcleritis within one year of the initial
occurrence. An optometrist shall consult with an ophthalmologist
or appropriate physician and surgeon if a patient has a recurrent
case of peripheral corneal inflammatory keratitis within one year
of the initial occurrence. end delete begin insert inflammation. end insert

(D) Traumatic or recurrent conjunctival or corneal abrasions
and erosions.

(E) Corneal surface disease and dry eyes.

(F) Ocular begin delete pain, nonsurgical in cause except when comanaged
with the treating physician and surgeon, associated with conditions
optometrists are authorized to treat. end delete begin insert pain. end insert

(G) Pursuant to subdivision begin delete (f), end delete begin insert (e), end insert glaucoma in patients over
18 years of age, as described in subdivision begin delete (j). end delete begin insert (i). end insert

begin insert

(H) Eyelid disorders.

end insert

(2) For purposes of this section, “treat” means the use of
therapeutic pharmaceutical agents, as described in subdivision (c),
and the procedures described in subdivision begin delete (e) end delete begin insert (d) end insert .

(c) In diagnosing and treating the conditions listed in subdivision
(b), an optometrist certified to use therapeutic pharmaceutical
agents pursuant to Section 3041.3 may use all begin delete of the following
therapeutic pharmaceutical agents: end delete begin insert therapeutic pharmaceutical
agents approved by the United States Food and Drug
Administration for use in treating eye conditions set forth in this
chapter, including narcotic substances other than those listed in
Schedule I. end insert

begin delete

(1) Pharmaceutical agents as described in paragraph (5) of
subdivision (a), as well as topical miotics.

(2) Topical lubricants.

(3) Antiallergy agents. In using topical steroid medication for
the treatment of ocular allergies, an optometrist shall consult with
an ophthalmologist if the patient’s condition worsens 21 days after
diagnosis.

(4) Topical and oral anti-inflammatories. In using steroid
medication for:

(A) Unilateral nonrecurrent nongranulomatous idiopathic iritis
or episcleritis, an optometrist shall consult with an ophthalmologist
or appropriate physician and surgeon if the patient’s condition
worsens 72 hours after the diagnosis, or if the patient’s condition
has not resolved three weeks after diagnosis. If the patient is still
receiving medication for these conditions six weeks after diagnosis,
the optometrist shall refer the patient to an ophthalmologist or
appropriate physician and surgeon.

(B) Peripheral corneal inflammatory keratitis, excluding
Moorens and Terriens diseases, an optometrist shall consult with
an ophthalmologist or appropriate physician and surgeon if the
patient’s condition worsens 72 hours after diagnosis.

(C) Traumatic iritis, an optometrist shall consult with an
ophthalmologist or appropriate physician and surgeon if the
patient’s condition worsens 72 hours after diagnosis and shall refer
the patient to an ophthalmologist or appropriate physician and
surgeon if the patient’s condition has not resolved one week after
diagnosis.

(5) Topical antibiotic agents.

(6) Topical hyperosmotics.

(7) Topical and oral antiglaucoma agents pursuant to the
certification process defined in subdivision (f).

(A) The optometrist shall refer the patient to an ophthalmologist
if requested by the patient or if angle closure glaucoma develops.

(B) If the glaucoma patient also has diabetes, the optometrist
shall consult with the physician treating the patient’s diabetes in
developing the glaucoma treatment plan and shall inform the
physician in writing of any changes in the patient’s glaucoma
medication.

(8) Nonprescription medications used for the rational treatment
of an ocular disorder.

(9) Oral antihistamines.

(10) Prescription oral nonsteroidal anti-inflammatory agents.

(11) Oral antibiotics for medical treatment of ocular disease.

(A) If the patient has been diagnosed with a central corneal ulcer
and the central corneal ulcer has not improved 48 hours after
diagnosis, the optometrist shall refer the patient to an
ophthalmologist.

(B) If the patient has been diagnosed with preseptal cellulitis
or dacryocystitis and the condition has not improved 48 hours after
diagnosis, the optometrist shall refer the patient to an
ophthalmologist.

(12) Topical and oral antiviral medication for the medical
treatment of the following: herpes simplex viral keratitis, herpes
simplex viral conjunctivitis, and periocular herpes simplex viral
dermatitis; and varicella zoster viral keratitis, varicella zoster viral
conjunctivitis, and periocular varicella zoster viral dermatitis.

(A) If the patient has been diagnosed with herpes simplex
keratitis or varicella zoster viral keratitis and the patient’s condition
has not improved seven days after diagnosis, the optometrist shall
refer the patient to an ophthalmologist. If a patient’s condition has
not resolved three weeks after diagnosis, the optometrist shall refer
the patient to an ophthalmologist.

(B) If the patient has been diagnosed with herpes simplex viral
conjunctivitis, herpes simplex viral dermatitis, varicella zoster
viral conjunctivitis, or varicella zoster viral dermatitis, and if the
patient’s condition worsens seven days after diagnosis, the
optometrist shall consult with an ophthalmologist. If the patient’s
condition has not resolved three weeks after diagnosis, the
optometrist shall refer the patient to an ophthalmologist.

(13) Oral analgesics that are not controlled substances.

(14) Codeine with compounds and hydrocodone with
compounds as listed in the California Uniform Controlled
Substances Act (Division 10 (commencing with Section 11000)
of the Health and Safety Code) and the United States Uniform
Controlled Substances Act (21 U.S.C. Sec. 801 et seq.). The use
of these agents shall be limited to three days, with a referral to an
ophthalmologist if the pain persists.

(d) In any case where this chapter requires that an optometrist
consult with an ophthalmologist, the optometrist shall maintain a
written record in the patient’s file of the information provided to
the ophthalmologist, the ophthalmologist’s response, and any other
relevant information. Upon the consulting ophthalmologist’s
request and with the patient’s consent, the optometrist shall furnish
a copy of the record to the ophthalmologist.

(e)

end delete

begin insert (d) end insert  An optometrist who is certified to use therapeutic
pharmaceutical agents pursuant to Section 3041.3 may also perform
all of the following:

(1) Corneal scraping with cultures.

(2) Debridement of corneal epithelia.

(3) Mechanical epilation.

(4) Venipuncture for testing patients suspected of having
diabetes.

(5) Suture removal begin delete , with prior consultation with the treating
physician and surgeon end delete .

(6) Treatment or removal of sebaceous cysts by expression.

(7) Administration of oral fluorescein begin delete to patients suspected as
having diabetic retinopathy end delete .

(8) Use of an auto-injector to counter anaphylaxis.

(9) Ordering of begin delete smears, cultures, sensitivities, complete blood
count, mycobacterial culture, acid fast stain, urinalysis, tear fluid
analysis, and X-rays necessary for the diagnosis of conditions or
diseases of the eye or adnexa. An optometrist may order other
types of images subject to prior consultation with an
ophthalmologist or appropriate physician and surgeon end delete begin insert appropriate
laboratory and diagnostic imaging tests end insert .

begin delete

(10) A clinical laboratory test or examination classified as
waived under CLIA and designated as waived in paragraph (9)
necessary for the diagnosis of conditions and diseases of the eye
or adnexa, or if otherwise specifically authorized by this chapter.

end delete begin delete

(11)

end delete

begin insert (10) end insert  Punctal occlusion by plugs, excluding laser, diathermy,
cryotherapy, or other means constituting surgery as defined in this
chapter.

begin delete

(12)

end delete

begin insert (11) end insert  The prescription of therapeutic contact lenses, including
lenses or devices that incorporate a medication or therapy the
optometrist is certified to prescribe or provide.

begin delete

(13)

end delete

begin insert (12) end insert  Removal of foreign bodies from the cornea, eyelid, and
conjunctiva with any appropriate instrument other than a scalpel
begin delete or needle end delete . Corneal foreign bodies shall be nonperforating, be no
deeper than the midstroma, and require no surgical repair upon
removal.

begin delete

(14)

end delete

begin insert (13) end insert  For patients over 12 years of age, lacrimal irrigation and
dilation, excluding probing of the nasal lacrimal tract. The board
shall certify any optometrist who graduated from an accredited
school of optometry before May 1, 2000, to perform this procedure
after submitting proof of satisfactory completion of 10 procedures
under the supervision of an ophthalmologist as confirmed by the
ophthalmologist. Any optometrist who graduated from an
accredited school of optometry on or after May 1, 2000, shall be
exempt from the certification requirement contained in this
paragraph.

begin insert

(14) Immunizations for influenza and shingles and additional
immunizations that may be necessary to protect public health
during a declared disaster or public health emergency.

end insert begin insert

(15) In addition to diagnosing and treating conditions of the
visual system pursuant to subdivision (a), diagnoses of diabetes
mellitus, hypertension, and hyperlipidemia.

end insert begin delete

(f)

end delete

begin insert (e) end insert  The board shall grant a certificate to an optometrist certified
pursuant to Section 3041.3 for the treatment of glaucoma, as
described in subdivision begin delete (j) end delete begin insert (i) end insert , in patients over 18 years of age
after the optometrist meets the following applicable requirements:

(1) For licensees who graduated from an accredited school of
optometry on or after May 1, 2008, submission of proof of
graduation from that institution.

(2) For licensees who were certified to treat glaucoma under
this section prior to January 1, 2009, submission of proof of
completion of that certification program.

(3) For licensees who have substantially completed the
certification requirements pursuant to this section in effect between
January 1, 2001, and December 31, 2008, submission of proof of
completion of those requirements on or before December 31, 2009.
“Substantially completed” means both of the following:

(A) Satisfactory completion of a didactic course of not less than
24 hours in the diagnosis, pharmacological, and other treatment
and management of glaucoma.

(B) Treatment of 50 glaucoma patients with a collaborating
ophthalmologist for a period of two years for each patient that will
conclude on or before December 31, 2009.

(4) For licensees who completed a didactic course of not less
than 24 hours in the diagnosis, pharmacological, and other
treatment and management of glaucoma, submission of proof of
satisfactory completion of the case management requirements for
certification established by the board pursuant to Section 3041.10.

(5) For licensees who graduated from an accredited school of
optometry on or before May 1, 2008, and not described in
paragraph (2), (3), or (4), submission of proof of satisfactory
completion of the requirements for certification established by the
board pursuant to Section 3041.10.

begin delete

(g)

end delete

begin insert (f) end insert  Other than for prescription ophthalmic devices described in
subdivision (b) of Section 2541, any dispensing of a therapeutic
pharmaceutical agent by an optometrist shall be without charge.

begin delete

(h)

end delete

begin insert (g) end insert  The practice of optometry does not include performing
surgery. “Surgery” means any procedure in which human tissue
is cut, altered, or otherwise infiltrated by mechanical or laser
means. “Surgery” does not include those procedures specified in
subdivision begin delete (e) end delete begin insert (d) end insert . Nothing in this section shall limit an
optometrist’s authority to utilize diagnostic laser and ultrasound
technology within his or her scope of practice.

begin delete

(i)

end delete

begin insert (h) end insert  An optometrist licensed under this chapter is subject to the
provisions of Section 2290.5 for purposes of practicing telehealth.

begin delete

(j)

end delete

begin insert (i) end insert  For purposes of this chapter, “glaucoma” means either of the
following:

(1) All primary open-angle glaucoma.

(2) Exfoliation and pigmentary glaucoma.

begin delete

(k)

end delete

begin insert (j) end insert  For purposes of this chapter, “adnexa” means ocular adnexa.

begin delete

(l)

end delete

begin insert (k) end insert  In an emergency, an optometrist shall stabilize, if possible,
and immediately refer any patient who has an acute attack of angle
closure to an ophthalmologist.

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Section 3041.1 of the end insert begin insert Business and Professions Code end insert
begin insert is amended to read: end insert

3041.1.  

With respect to the practices set forth in begin delete subdivisions
(b), (d), and (e) of end delete Section 3041, optometrists diagnosing or treating
eye begin delete disease end delete begin insert or other diseases end insert shall be held to the same standard
of care to which physicians and surgeons and osteopathic
physicians and surgeons are held. begin insert An optometrist shall consult
with and, if necessary, refer to a physician and surgeon or other
appropriate health care provider if a situation or condition occurs
that is beyond the optometrist’s education and training. end insert

begin delete

SECTION 1.  

Section 3041 of the Business and Professions
Code is repealed.

SEC. 2.  

Section 3041 is added to the Business and Professions
Code, to read:

3041.  

(a) An optometrist license authorizes the holder to do
all of the following:

(1) Examine, prevent, diagnose, and treat any disease, condition,
or disorder of the visual system, the human eye, and adjacent and
related structures of the visual system.

(2) The use or prescription of appropriate drugs, including
narcotic substances other than those listed in Schedule 1.

(3) The performance of minor surgical and nonsurgical primary
eye care procedures requiring no more than topical or local
anesthetic, or both, consistent with an optometrist’s education and
training.

(4) The use or prescription of visual therapy, ocular exercises
or vision habilitation, and rehabilitation services.

(5) The performance or ordering of appropriate laboratory and
diagnostic imaging tests.

(b) An optometrist may administer immunizations.

(c) In addition to diagnosing and treating conditions of the visual
system pursuant to subdivision (a), an optometrist may diagnose
other common primary care conditions that have ocular
manifestations.

(d) In addition to the authority provided in subdivisions (a) to
(c), inclusive, an optometrist who is operating under a protocol
with a physician and surgeon or a health care facility, or
participating in a medical home, accountable care organization,
or other system of care in which the patient is being otherwise
treated, may initiate treatment and manage medications for
conditions diagnosed pursuant to subdivision (c).

SEC. 3.  

Section 3041.2 of the Business and Professions Code
is repealed.

SEC. 4.  

Section 3041.2 is added to the Business and Professions
Code, to read:

3041.2.  

(a) The State Board of Optometry shall establish, by
regulation, educational and examination requirements for licensure
to ensure the competence of optometrists to practice.

(b) On and after January 1, 2014, the board shall require each
applicant for licensure to successfully complete the Part I, Part II,
and Part III examinations of the National Board of Examiners in
Optometry.

(c) On and after January 1, 2014, the board shall require each
applicant for licensure to successfully complete an examination
in California law and ethics developed and administered by the
board.

(d) On and after January 1, 2014, the board may require passage
of additional examinations to ensure the competency of licentiates
to utilize diagnostic and therapeutic pharmaceutical agents, if not
otherwise covered by the examinations required pursuant to
subdivisions (a) and (b).

end delete

begin delete SEC. 5. end delete
begin insert SEC. 3. end insert   

No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of
the Government Code, or changes the definition of a crime within
the meaning of Section 6 of Article XIII B of the California
Constitution.