CA Scope of Practice
In 2021, COA passed Assembly bill 407 (Salas), which established mechanisms that allow the optometric profession to grow and change as new technologies are developed. It also more fully utilize optometrists’ extensive training and experience to help expand health care access to Californians.
Procedures & Conditions
The practice of optometry includes:
The examination of the human eyes and their adnexa, including through the use of all topical and oral diagnostic pharmaceutical agents that are not controlled substances, and the analysis of the human vision system, either subjectively or objectively.
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.
The prescribing, using, or directing the use of any optical device in connection with ocular exercises, visual training, vision training, or orthoptics
The prescribing, fitting, or adaptation of contact and spectacle lenses to, the human eyes, including lenses that may be classified as drugs or devices by law, and diagnostic or therapeutic contact lenses that incorporate a medication or therapy the optometrist is certified to prescribe or provide.
Diagnosing and preventing conditions and diseases of the human eyes and their adnexa, and treating nonmalignant conditions and diseases of the anterior segment of the human eyes and their adnexa (including, but not limited to, ametropia, presbyopia, myopia, ptosis, and cataracts):
Using or prescribing, including for rational off-label purposes, topical and oral prescription and nonprescription therapeutic pharmaceutical agents that are not controlled substances and are not antiglaucoma agents or limited or excluded because the patient is under 18 (see exceptions and limitations). (medication examples: Upneeq, VUITY)
Prescribing the oral analgesic controlled substance codeine with compounds, hydrocodone with compounds, and tramadol. Limited to three days, with referral to an ophthalmologist if the pain persists.
Using or prescribing topical and oral antiglaucoma agents for the medical treatment of all primary open-angle, exfoliation, pigmentary, and steroid-induced glaucomas in persons 18 years of age or over. In the case of steroid-induced glaucoma, the prescriber of the steroid medication shall be promptly notified if the prescriber did not refer the patient to the optometrist for treatment.
Utilizing the following techniques and instrumentation necessary for the diagnosis of conditions and diseases of the eye and adnexa:
Laboratory tests or examinations ordered from an outside facility.
CLIA waved laboratory tests or examinations performed in an office classified, which shall also be allowed for detecting indicators of possible systemic disease that manifests in the eye for the purpose of facilitating appropriate referral to or consultation with a physician and surgeon.
Skin testing performed in an office to diagnose ocular allergies, limited to the superficial layer of the skin.
X-rays ordered from an outside facility.
Other imaging studies ordered from an outside facility subject to prior consultation with an appropriate physician and surgeon.
Other imaging studies performed in an office, including those that utilize laser or ultrasound technology, but excluding those that utilize radiation.
Performing the following procedures:
Corneal scraping with cultures.
Debridement of corneal epithelium not associated with band keratopathy.
Collection of blood by skin puncture or venipuncture for laboratory testing authorized by this subdivision.
Suture removal subject to co-management requirements in (see Co-Management).
Treatment or removal of sebaceous cysts by expression.
Lacrimal punctal occlusion using plugs, or placement of a stent or similar device in a lacrimal canaliculus intended to deliver a medication the optometrist is certified to prescribe or provide.
Foreign body and staining removal from the cornea, eyelid, and conjunctiva with any appropriate instrument. Removal of corneal foreign bodies and any related stain shall, as relevant, be limited to that which is non-perforating, no deeper than the midstroma, and not reasonably anticipated to require surgical repair.
Lacrimal irrigation and dilation in patients 12 years of age or over, excluding probing of the nasolacrimal tract. For any optometrist who graduated before May 1, 2000, you must submit proof to the State Board of Optometry of satisfactory completion of 10 procedures under the supervision of an ophthalmologist as confirmed by the ophthalmologist.
Administration of oral fluorescein for the purpose of ocular angiography.
Intravenous injection for the purpose of performing ocular angiography at the direction of an ophthalmologist as part of an active treatment plan in a setting where a physician and surgeon is immediately available.
Use of noninvasive devices delivering intense pulsed light therapy or low-level light therapy that do not rely on laser technology, limited to treatment of conditions and diseases of the adnexa.
Use of an intranasal stimulator in conjunction with treatment of dry eye syndrome.
Using additional noninvasive medical devices or technology that:
Have received a United States Food and Drug Administration-approved indication for the diagnosis or treatment of a condition or disease and successfully complete any clinical training imposed by a related manufacturer prior to using any of those noninvasive medical devices or technologies.
Have been approved by the board through regulation for the rational treatment of a condition or disease and successfully complete an appropriate amount of clinical training to qualify to use each noninvasive medical device or technology approved by the board.
Treatment with allowable topical and oral medications related to an ocular surgery shall be co-managed with the ophthalmologist that performed the surgery, or another ophthalmologist designated by that surgeon, during the customary preoperative and postoperative period* for the procedure, including treatment of ocular inflammation in a patient under 18 years of age.
Co-managed treatment may include addressing agreed-upon complications of the surgical procedure occurring in any ocular or adnexal structure with allowable topical and oral medications. For patients under 18 years of age, the patient’s primary care provider must agree to allow co-management of complications.
*Where published, the postoperative period shall be the “global” period established by the federal Centers for Medicare and Medicaid Services, or, if not published, a reasonable period not to exceed 90 days.
Exceptions & Limitations
The performing of surgery is prohibited. “Surgery” means any act in which human tissue is cut, altered, or otherwise infiltrated by any means. It does not mean an act that solely involves the administration or prescribing of a topical or oral therapeutic pharmaceutical.
Treatment of the following in patients under 18 years of age, unless explicitly allowed otherwise, is prohibited:
Anterior segment inflammation, which shall include treatment of:
Nonmalignant ocular surface disease, including dry eye syndrome.
Contact lens-related inflammation of the cornea.
An infection of the cornea.
Conditions or diseases of the sclera.
The use of any oral prescription steroid anti-inflammatory medication for a patient under 18 years of age unless a documented, timely consultation with an appropriate physician and surgeon occurs.
The use of any non-antibiotic oral prescription medication for a patient under five years of age unless a documented, prior consultation with an appropriate physician and surgeon occurs.
The following classes of agents are prohibited from use unless they have an explicit United States Food and Drug Administration-approved indication for treatment of a condition or disease authorized for optometrists:
Authorization of the following is prohibited:
A laboratory test or imaging study.
Any noninvasive device or technology that constitutes surgery (see above definition).
TPA-certified optometrists can administer flu, shingles, and pneumonia vaccines for adults 18 and older after receiving training and certification.
You must take an immunization training program endorsed by the federal Centers for Disease Control and Prevention (CDC) or the Accreditation Council for Pharmacy Education that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and maintain that training.
A spectacle lens prescription shall include all of the following:
The dioptric power of the lens. When the prescription needed by the patient has not changed since the previous examination, the prescriber may write on the prescription form “copy lenses currently worn” instead.
The expiration date of the prescription.
The date of the issuance of the prescription.
The name, address, telephone number, prescriber’s license number, and signature of the prescribing optometrist or physician and surgeon.
The name of the person to whom the prescription is issued.
The expiration date of a spectacle lens prescription shall not be less than two to four years from the date of issuance unless the patient’s history or current circumstances establish a reasonable probability of changes in the patient’s vision of sufficient magnitude to necessitate reexamination earlier than two years, or presence or probability of visual abnormalities related to ocular or systemic disease indicates, the need for reexamination of the patient earlier than two years. In no circumstances shall the expiration date be shorter than the period of time recommended by the prescriber for reexamination of the patient. Establishing an expiration date that is not consistent with this section shall be regarded as unprofessional conduct by the board that issued the prescriber’s certificate to practice.
The prescriber of a spectacle lens shall orally inform the patient of the expiration date of a spectacle lens prescription at the time the prescription is issued. The expiration date of a prescription may be extended by the prescriber and transmitted by telephone, electronic mail, or any other means of communication. An oral prescription for a spectacle lens shall be reduced to writing and a copy of that writing shall be sent to the prescriber prior to the delivery of the lenses to the person to whom the prescription is issued.
An expired prescription may be filled if all of the following conditions exist:
The patient’s spectacles are lost, broken, or damaged to a degree that renders them unusable.
Upon dispensing a prescription pursuant to this subdivision, the person dispensing shall recommend that the patient return to the optometrist or physician and surgeon who issued the prescription for an eye examination and provide the prescriber with a written notification of the prescription that was filled.
Contact Lens Prescriptions
The expiration date of a contact lens prescription shall not be less than one to two years from the date of issuance, unless the patient’s history or current circumstances establish a reasonable probability of changes in the patient’s vision of sufficient magnitude to necessitate reexamination earlier than one year, or the presence or probability of visual abnormalities related to ocular or systemic disease indicate the need for reexamination of the patient earlier than one year.
The date of issuance is the date the patient receives a copy of the prescription.
If the expiration date of a prescription is less than one year, the health-related reasons for the limitation shall be documented in the patient’s medical record. In no circumstances shall the prescription expiration date be less than the period of time recommended by the prescriber for reexamination of the patient.
A prescriber shall retain professional discretion regarding the release of the contact lens prescription for patients who wear the following types of contact lenses:
Rigid gas permeables.
Bitoric gas permeables.
Bifocal gas permeables.
Custom designed lenses that are manufactured for an individual patient and are not mass produced.
The contact lens prescription shall include sufficient information for the complete and accurate filling of a prescription, including, but not limited to, the power, the material or manufacturer or both, the base curve or appropriate designation, the diameter when appropriate, and an appropriate expiration date. When a provider prescribes a private label contact lens for a patient, the prescription shall include the name of the manufacturer, the trade name of the private label brand, and, if applicable, the trade name of the equivalent national brand.
The contact lens fitting process begins after the initial comprehensive eye examination, and includes an examination to determine the lens specifications, an initial evaluation of the fit of the lens on the patient’s eye, except in the case of a renewal prescription of an established patient, and followup examinations that are medically necessary, and ends when the prescriber or registered dispensing optician determines that an appropriate fit has been achieved, or in the case of a prescription renewal for an established patient, the prescriber determines that there is no change in the prescription.
FTC regulations require ODs give patients their prescription after an eye exam or contact lens fitting, whether they ask for it or not.
Eyeglass prescription prescriber requirements:
Provide patients with a copy of their prescription upon completion of the eye exam.
Verify prescriptions to any third-party seller designated by the patient within eight business hours.
Adhere to “passive verification,” which means that if the provider does not respond to a verification request within eight business hours, the seller can fill the prescription.
Contact lens prescriber requirements:
Contact lens prescriptions must be released immediately upon completion of the eye exam or the contact lens fitting (if a fitting is necessary). If specialty lenses must be purchased in order to complete to the fitting process, the charges for those lenses can be passed along to the patient as part of the fitting process.
Contact lens fitting means the process that begins after an initial eye examination for contact lenses and ends when a successful fit has been achieved. In cases of renewal prescriptions, the fitting ends when the prescriber determines that no change in the existing prescription is required.
If a patient elects to purchase contact lenses from a third party, the seller must verify the prescription before filling it. When requested, optometrists are required to respond to sellers’ requests for prescription verification within eight business hours.
Adhere to “passive verification,” which means that if the provider does not respond to a verification request within eight business hours, the seller can fill the prescription
All prescribers must:
give a copy of the contact lens prescription to the patient at the end of the contact lens fitting – even if the patient doesn’t ask for it. You may provide the prescription digitally if the patient agrees to get it digitally instead of on paper, and if the patient also agrees to the specific method (for example, e-mail, text, or portal), and if the electronic means can be accessed, downloaded, and printed by the patient. You also must keep records or proof that a patient agreed to digital delivery for at least three years.
In addition, if you are a prescriber who sells lenses or with a direct or indirect financial interest in the sale of contact lenses, you have to:
ask patients to sign a statement confirming they got their prescription. They’d confirm by signing an acknowledgment of receipt, a prescriber-retained copy of a contact lens prescription, or a prescriber-retained copy of the examination receipt. Keep those confirmations for at least three 3 years. If a patient refuses to sign the confirmation, note the refusal, sign it, and keep it.
if you provided a digital copy of the prescription, keep records or proof for at least three years that it was sent, received, or made accessible, downloadable and printable.
give the contact lens prescription to anyone who is designated to act on behalf of the patient, including contact lens sellers, within 40 business hours.
In any response to a verification request, you have to correct any inaccuracy in the prescription, inform the seller if it’s expired, and give the reason if it’s invalid.
You cannot require patients to:
buy contact lenses
pay additional fees or
sign a waiver or release in exchange for a copy of the contact lens prescription.
You may require a patient to pay for the eye exam, fitting, and evaluation before giving them a copy of the contact lens prescription, but only if you also require immediate payment from a patient whose eye exams show no need for glasses, contact lenses, or other corrective eye care products. Proof of valid insurance coverage counts as payment for purposes of this requirement.
You cannot disown liability or responsibility for the accuracy of an eye examination.
Beginning January 1, 2022, all practitioners must have the capability to issue and receive e-prescriptions to and from a pharmacy selected by the patient. All prescriptions, excluding eyeglass and contact lens prescription, must be issued as an e-prescription.
Prescribers can choose to purchase a standalone prescribing software, or a software application associated with an electronic health record. Optometrists will want to consider several other factors before purchasing prescribing software, including whether the software needs to have the ability to electronically prescribe controlled substances.
Software that can prescribe controlled substances costs more because of the additional regulatory compliance costs; the software must be certified that it complies with a 2010 DEA regulation and must include:
The payment of professional fees for the eye exam, fitting, and evaluation may be required prior to the release of the prescription, but only if the prescriber would have required immediate payment from the patient had the examination revealed that no ophthalmic goods were required. A prescriber shall not charge the patient any fee as a condition to releasing the prescription to the patient. A prescriber may charge an additional fee for verifying ophthalmic goods dispensed by another seller if the additional fee is imposed at the time the verification is performed.
A prescriber shall not condition the availability of an eye examination, a contact lens fitting, or the release of a contact lens prescription on a requirement that the patient agree to purchase contact lenses from that prescriber.
A prescriber shall not place on the contact lens prescription, deliver to the patient, or require a patient to sign a form or notice waiving or disclaiming the liability or responsibility of the prescriber or registered dispensing optician for the accuracy of the ophthalmic goods and services dispensed by another seller. This prohibition against waivers and disclaimers shall not impose liability on a prescriber for the ophthalmic goods and services dispensed by another seller pursuant to the prescriber’s prescription.