CA Scope of Practice

• • 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.

  • 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 or directing the use of, or using, any optical device in connection with ocular exercises, visual training, vision training, or orthoptics.

  • 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.

  • The use of topical pharmaceutical agents for the purpose of the examination of the human eye or eyes for any disease or pathological condition, for those TPA certified.

• 1. Infections of the anterior segment and adnexa, excluding the lacrimal gland, the lacrimal drainage system, and the sclera in patients under 12 years of age, through medical treatment.

  2. Ocular allergies of the anterior segment and adnexa.

  3. Ocular inflammation, nonsurgical in cause except when co-managed 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.

  4. Traumatic or recurrent conjunctival or corneal abrasions and erosions.

  5. Nonmalignant ocular surface disease and dry eye disease.

  6. Ocular pain, nonsurgical in cause except when comanaged with the treating physician and surgeon, associated with conditions optometrists are authorized to treat.

  7. Hypotrichosis and blepharitis.

  8. All primary open-angle glaucoma, exfoliation and pigmentary glaucoma, and steroid induced glaucoma in patients over 18 years of age, if certified to treat glaucoma.

     1. • If you treat for steroid induced glaucoma, you must promptly notify the prescriber of the steroid medication if the prescriber did not refer the patient to you for treatment.

• 1. Corneal scraping with cultures.

  2. Debridement of corneal epithelia.

  3. Mechanical epilation.

  4. Collection of blood by skin puncture or venipuncture for testing patients suspected of having diabetes.

  5. Suture removal, with prior consultation with the treating physician and surgeon.

  6. Treatment or removal of sebaceous cysts by expression.

  7. Administration of oral fluorescein to patients suspected as having diabetic retinopathy.

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

  9. A waived CLIA test or examination and designated below (10) necessary for the diagnosis of conditions and diseases of the eye or adnexa, or if otherwise specifically authorized.

  10. Ordering of 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. You may order other types of images subject to prior consultation with an ophthalmologist or appropriate physician and surgeon.

  11. Punctal occlusion by plugs, excluding laser, diathermy, cryotherapy, or other means constituting surgery as defined in this chapter.

  12. The use or prescription of diagnostic or therapeutic contact lenses, including lenses or devices that incorporate a medication or therapy.

  13. Removal of foreign bodies from the cornea, eyelid, and conjunctiva with any appropriate instrument other than a scalpel. Corneal foreign bodies shall be nonperforating, be no deeper than the midstroma, and require no surgical repair upon removal.

  14. For patients over 12 years of age, lacrimal irrigation and dilation, excluding probing of the nasal lacrimal tract.

      1. • If you graduated before May 1, 2000, you must submit proof of satisfactory completion of 10 procedures under the supervision of an ophthalmologist as confirmed by the ophthalmologist. Any OD who graduated on or after May 1, 2000 is exempt from this requirement.

  15. 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.

  16. Skin testing to diagnose ocular allergies, limited to the superficial layer of the skin.

  17. Use of any noninvasive medical device or technology authorized that are FDA-indicated for a condition optometrists can treat. (You must complete any clinical training imposed by a device/technology manufacturer). If not FDA-indicated for an allowed condition, the State Board of Optometry has the ability to approve a medical device or technology for an allowed condition by regulation.

      1. • This does not include any medical device or technology involving cutting, altering, or otherwise infiltrating human tissue by any means, a clinical laboratory test or imaging study not already authorized by law, or treatment of any disease or condition that could not be treated by an optometrist before January 1, 2018.

• • The use of all non-controlled substance medications that are FDA-indicated for a condition optometrists can treat. You must complete any clinical training imposed by a medication manufacturer. This does not include any medications that alter, or otherwise infiltrate human tissue by any means, a clinical laboratory test or imaging study not already authorized by law, or treatment of any disease or condition that could not be treated by an optometrist before January 1, 2018.

  • Topical pharmaceutical agents for the examination of the human eye or eyes for any disease or pathological condition, including, but not limited to, topical miotics.

  • Topical lubricants.

  • Anti-allergy 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.

  • Topical and oral anti-inflammatories.

  • Topical antibiotic agents.

  • Topical hyperosmotics.

  • Topical and oral antiglaucoma agents if glaucoma certified.

  • Nonprescription medications used for the rational treatment of an ocular disorder.

  • Oral antihistamines.

  • Prescription oral nonsteroidal anti-inflammatory agents.

  • Oral antibiotics for medical treatment of ocular disease.

  • Topical and oral antiviral medication for the medical treatment of herpes simplex viral keratitis, herpes simplex viral conjunctivitis, periocular herpes simplex viral dermatitis, varicella zoster viral keratitis, varicella zoster viral conjunctivitis, and periocular varicella zoster viral dermatitis.

  • Oral analgesics that are not controlled substances.

  • Codeine with compounds, hydrocodone with compounds, and tramadol. The use of these agents shall be limited to three days, with a referral to an ophthalmologist if the pain persists. You must have a DEA number to prescribe.

A spectacle lens prescription shall include all of the following:

• 1. 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.

  2. The expiration date of the prescription.

  3. The date of the issuance of the prescription.

  4. The name, address, telephone number, prescriber’s license number, and signature of the prescribing optometrist or physician and surgeon.

  5. 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:

• 1. The patient’s spectacles are lost, broken, or damaged to a degree that renders them unusable.

  2. 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.

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.

  • Keratoconus lenses.

  • 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:

• 1. Provide patients with a copy of their prescription upon completion of the eye exam.

  2. Verify prescriptions to any third-party seller designated by the patient within eight business hours.

  3. 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:

• 1. 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.

  2. 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.

  3. 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:

1. 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.

2. 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.

3. 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 prescribers 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 prescriptions, must be issued as an e-prescription.

Options for optometrists

The national e-prescription network linking providers, pharmacies and insurance or benefit management systems is called Surescripts. They are essentially the portal that all the various computer software providers go through. While COA does not endorse any electronic prescribing systems, the following are large companies that offer e-prescription services: Allscripts, DrFirst, MD Toolbox, NewCrop, and RXNT. A full list of prescribing software applications is available on the Surescripts website. COA was unable to find any free e-prescribing software.

Prescribers can choose to purchase a stand-alone prescribing software or a software application associated with an electronic health record (EHR). If you have EHR system you should contact your vendor for more information.

Questions to ask when purchasing prescribing software

Optometrists will want to consider several other factors before purchasing prescribing software, including:

• Do you want a standalone prescribing software, or a software application associated with an electronic health record? EHR-based applications allow for automation of patient demographic information and attachment of a prescription to the patient’s treatment record. An associate who works at more than one practice may opt to purchase standalone prescribing software since it is not tied to a specific EHR. And if a practice has multiple locations that use the same EHR, a separate user license for each location may be required. 

• Is the software available on Android, IOS or other mobile platforms?

• Do you want enhanced software that provides additional features, such as the ability to check for drug interactions or a patient’s drug allergies?

• Do you need the ability to electronically prescribe controlled substances?

Exceptions to e-prescribing mandate

Optometrists can provide paper prescriptions for medications directly to a patient or “call in” a prescription to a pharmacy only in situations that qualify as exceptions to the electronic data prescribing mandate. Exceptions include:

• The electronic data transmission prescription is not available due to a temporary technological or electronic failure of a computer system, application or device or a service interruption. If prescribing a controlled substance, the prescriber must document in the patient’s record the reason for the failed electronic transmission.

• The prescriber is issuing a prescription for dispensing by a pharmacy located outside of California.

• The prescription is issued at a time when a patient’s preferred pharmacy is likely to be closed.

• The prescribing health care practitioner and the dispenser are the same entity.

• The prescription is issued under circumstance whereby the prescriber reasonably determines that it would be impractical for the patient to obtain substances prescribed by an electronic data transmission prescription in a timely manner and the delay would adversely impact the patient’s medical condition.

If you believe that one of the above exceptions applies, you must document it in the patient’s record within 72 hours of filling the prescription. Only in emergency situations can prescribers not transmit a controlled substance prescription electronically, and this action is subject to several limitations.

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:

• Third-party certification that prescription software applications meet DEA requirements.

• Identity proofing of prescribers.

• Two-factor authentication when signing prescription.

• Software users establishing access controls.

Each prescribing optometrist will need to have their own subscription, identity proofing, and hard token.

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.