Drug - Optometry Jurisdictional Review · The Optometry profession is governed under the Optometry Act with associated regulations. Scope of Practice2 3. The practice of optometry

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Suite 806 Box 18 Toronto Ontario Canada M4V 2Y7

Toll-Free 1-888-377-7746 Telephone 416-326-1550

Fax 416-326-1549 Web wwwhpracorg

Prescribing and Use of Drugs by Non-Physician Health Professionals

A Jurisdictional Review of the Profession of Optometry

November 2008

Prescribing and Use of Drugs Jurisdictional Review ndash Profession of Optometry November 2008

1) Authority to Prescribe andor Administer Drugs in Canadian Jurisdictions

Province (Regulatory Body)

Prescribe andor

Administration of drugs

Framework Authority Standard of PracticeGuidelinesPolicies

Use of list class

Ontario College of Optometrists of Ontario

Administration (current) Prescribing (developing regulations)

Self-regulation via the Regulated Health Professions Act 1991 (RHPA) an omnibus law related to the regulation of 23 health professions1

The Optometry profession is governed under the Optometry Act with associated regulations

Scope of Practice2 3 The practice of optometry is the assessment of the eye and vision system and the diagnosis treatment and prevention of (a) disorders of refraction (b) sensory and oculomotor disorders and dysfunctions of the eye and vision system and (c) prescribed diseases 1991 c 35 s 3 Authorized Acts3

4 In the course of engaging in the practice of optometry a member is authorized subject to the terms conditions and limitations imposed on his or her certificate of registration to perform the following 1 Communicating a diagnosis identifying as the cause of a personrsquos symptoms a disorder of refraction a sensory or oculomotor disorder of the eye or vision system or a prescribed disease 2 Applying a prescribed form of energy 21 Prescribing drugs designated in the regulations 3 Prescribing or dispensing for vision or eye problems subnormal vision devices contact lenses or eye glasses 1991 c 35 s 4 2007 c 10 Sched B s 17 (1) Regulations4

12 (1) Subject to the approval of the Lieutenant Governor in Council and with prior review by the Minister the Council may make regulations

(a) specifying the drugs that a member may use in the course of engaging in the practice of optometry (b) designating drugs for the purposes of paragraph 21 of section 4 2007 c 10 Sched B s 17 (3)

The College has a Guideline for Use of Drugs in the Practice of Optometry5

The Guideline applies only to drugs that are not available over-the-counter Accordingly optometrists may continue to recommend and provide samples of over-the-counter drugs to their patients6

The Guideline includes a list of Diagnostic Pharmaceutical Agents and Therapeutic Pharmaceutical Agents

1 Regulated Health Professions Act 1991 Government of Ontario httpwwwe-lawsgovoncahtmlstatutesenglishelaws_statutes_91r18_ehtm 2 Optometry Act 1991 SO 1991 c 35 s3 3 Optometry Act 1991 SO 1991 c 35 s4 4 Optometry Act 1991 SO 1991 c 35 s12 5 College of Optometrists of Ontario Guideline for the Use of Drugs by Optometrists April 15 2004 httpwwwcollegeoptomoncaFINAL20Drug20Guideline20May2012-04pdf 6 College of Optometrists of Ontario Guideline for the Use of Drugs by Optometrists April 15 2004 httpwwwcollegeoptomoncaFINAL20Drug20Guideline20May2012-04pdf

Prescribe andor

Use of list class

(2) A regulation made under subsection (1) may specify or designate individual drugs or categories of drugs 2007 c 10 Sched B s 17 (3)

Alberta Alberta College of Optometrists

Administration and Prescribe

All Albertan regulated health professions are governed under the Health Professions Act7 umbrella legislation to 23 professions Schedule 17 of the Health Professions Act specifically pertains to the profession of Optometry Optometrists Profession Regulation Alta Reg 832003 provides the specifics

Scope of Practice8

3 In their practice optometrists do one or more of the following (a) examine assess measure and diagnose disorders and diseases of the human visual system the eye and its associated structures (b) provide and prescribe treatment management and correction (c) conduct research and promote education in the visual sciences and (d) provide restricted activities authorized by the regulations AuthorizedRestricted activities9 11 A regulated member may perform the following restricted activities within the meaning of Schedule 71 to the Government Organization Act (a) to prescribe and dispense corrective lenses (b) to prescribe the following Schedule 1 drugs for the purpose of diagnosis

(i) mydriatics (ii) cycloplegics (iii) miotics

(c) to give as samples to the regulated memberrsquos patients (i) Schedule 1 drugs listed in clause (b) (ii) Schedule 2 drugs used in the practice of optometry and (iii) if the regulated member meets the requirements of sections 12 and 13 Schedule 1 drugs listed in section 12(1)(a)

12(1) A regulated member may perform the following restricted activities within the meaning of Schedule 71 to the Government Organization Act (a) prescribe the following Schedule 1 drugs for topical application in the treatment of ocular anterior segment disorders

(i) mydriatics (ii) cyclopegics (iii) miotics

The College has a Standards of Practice document which stipulates the expected standards for Prescribing Therapeutic Pharmacological Agents 10 There is also a guideline for the Standards of Practice on the same topic

Schedule 1 and Schedule 2 of the Pharmaceutical Profession Act

7 Health Professions Act RSA 2000 c H-7 Government of Alberta httpwwwcanliiorgablawsstah-720080818wholehtml 8 Health Professions Act RSA 2000 c H-7 Schedule 17 s39 Optometrists Profession Regulation Alta Reg 832003 s11 and s12 10 httpwwwcollegeofoptometristsabcaleg-standards-practiceasp

Prescribe andor

Use of list class

(iv) non-steroidal anti-allergy medications (v) non-steroidal anti-inflammatory medications (vi) corticosteroids (vii) anti-infective medications including steroidal anti-infectives (viii) anti-glaucoma medication

(b) perform surgical procedures on body tissue below the dermis or the mucous membrane or in or below the surface of the cornea in the removal of superficial foreign bodies from the eye (2) Despite subsection (1) a regulated member may only perform the restricted activities under subsection (1) if the member has (a) successfully completed a 100 hour course approved by the Council of which 40 hours must be in a clinical setting dealing with therapeutic agents or (b) graduated from a program approved by the Council (3) Despite subsection (1) regulated members may only prescribe anti-glaucoma medication referred to in subsection (1)(a)(viii) in a consultative co-management arrangement with an ophthalmologist who is licensed to practice in Canada (4) The Council must establish criteria respecting (a) administrating and prescribing Schedule 1 drugs referred to in subsection (1)(a) and (b) the requirements of the co-management arrangement with an ophthalmologist referred to in subsection (3)

British Columbia The Board Of Examiners In Optometry

Administration The Optometrists Act and associated Rules Please note in 2002 Board of Examiners submitted proposed amendments to its rules which would permit optometrists certified in Ocular Therapeutics to treat and manage ocular disease11

Repeal of the Optometrists Act is provided for in British Columbiarsquos Health Professions Amendment

Scope of Practice

33 Any one or any combination of the following practices constitutes the practice of optometry (a) investigation of the functions of the human eye by diagnostic drugs in accordance with the rules made under this Act and by test lenses test cards trial frames and other instruments or devices designed for that investigation (b) prescription or adaptation of lenses prisms or the use of orthoptic instruments of any kind to improve or correct the visual function or to adapt the visual function to the requirements of a special occupation12

Standards of practice are set out by the College

No mention is made of the prescription or administration of a drug

SCHEDULE A15

Pursuant to Section 10 (1) of the Optometrists Act and the Rules under the Optometrists Act respecting the use of diagnostic drugs the Board of Examiners in Optometry permits the following classes of pharmaceuticals for use by optometrists in British Columbia

11 Information available at wwwhealthgovbc calegnotice optometryhtml 12 Optometrists Act Rsbc 1996 Chapter 342 s33

Prescribe andor

Use of list class

Act 2003 amp Optometry is expected to become regulated under the Health Professions Act

AuthorizedRestricted activities13

10(1)(l) respecting the use and the prohibition of the use for diagnostic purposes of drugs or classes of drugs by optometrists RulesRegulations14

601 No optometrist shall use any drug in the practice of optometry except as permitted by these Rules and a breach of this Rule shall be deemed to be unprofessional conduct upon proof thereof the penalty for which may include cancellation of registration whether or not the conduct complained of is part of a repeated pattern of practice or an isolated incident 602 An optometrist may use only such drugs as are listed from time to time on Schedule ldquoArdquo to these Rules as approved by the Board 603 An optometrist may use such drugs listed on Schedule ldquoArdquo as approved by the Board for diagnostic nutritional or prophylactic purposes only 604 For the purpose of this Rule drug shall mean any pharmaceutical product the sale of which is regulated restricted or controlled by the Pharmacy Act of British Columbia the Narcotic Control or Food and Drug Acts of Canada

1 Topical Anaesthetics 2 Hyperosmotic Drugs 3 Irrigating Solutions 4 Lubricant Preparations 5 Antihistamine and

Vasoconstrictor Drugs 6 Dyes and Stains 7 Contact Lens Preparations 8 Mydriatics 9 Cycloplegics 10 Drugs for testing Pupillary

Abnormalities 11 Cushioning Agents 12 Oral Vitamins Mineral

Supplements 13 Ocular Hygiene

Preparations 14 Over the Counter

Antibiotics 15 Drugs for managing angle

closure 16 Miotics

Manitoba Manitoba Association of Optometrists

Administration Optometrists in Manitoba are governed by The Optometrists Act and its associated Regulation The Council is empowered by the Act to create

Scope of Practice practice of optometry means the science related to the assessment of the health of the eye its related structures and environment and the diagnosis and treatment of anomalies affecting the functional status and efficiency of the visual system including (a) the qualitative and quantitative characteristics of the refraction accommodative and sensory ocular motor and perceptual components (b) the employment of preventive corrective or rehabilitative procedures

The following drugs and dosages may be used for diagnostic purposes and not for treatment purposes by the holder of an optometric drug licence19 (a) Mydriatics

13 Optometrists Act Rsbc 1996 Chapter 342 s10(1)(l) 14 The Board Of Examiners In Optometry Province Of British Columbia Rules Part 5 15 The Board Of Examiners In Optometry Province Of British Columbia Rules Schedule A

Prescribe andor

Use of list class

regulations pertaining to the educational requirements for the optometric drug licence Note On June 11 2008 amendments to the Optometry Act provided that qualified optometrists could independently prescribe and administer certain therapeutic drugs Additional regulations may be developed to specify the drugs minor procedures and tests that would be available to qualified optometrists

(c) the detection of disease evident in the examination process and (d) the offering of advice consultation and counselling16

Optometric Drug Licence17

12(1) Any optometrist who desires to use topically administered drugs for diagnostic purposes shall (a) satisfy the board of examiners that he has completed a course in the proper use of those drugs in an accredited school of optometry as specified in the regulations (b) satisfy the board of examiners of his competency in general and ocular pharmacology as it applies to optometry and (c) be approved by the board of examiners as a fit and proper person to be licensed by the board to use topically administered drugs for diagnostic purposes Optometric Drug Licence Categories18

7(2) There shall be two classes of optometric drug licences namely a full drug licence and a limited drug licence 7(3) The holder of a full drug licence is entitled to use all of the drugs referred to in section 6 and the holder of a limited drug licence is entitled to use only those drugs referred to in clause 6(c) 7(4) An optometrist who graduated from University of Waterloo in the Province of Ontario in 1980 or later is entitled to be issued a full drug licence 7(5) A full drug licence may be issued to a person who has graduated in optometry from any of the accredited schools or institutions referred to in section 8 and has passed an examination required by the board and approved by the University of Waterloo or the Universiteacute de Montreacuteal

(i) phenylephrine up to 25 (b) Cycloplegics (i) tropicamide up to 10 (ii) cyclopentolate up to 10 (c) Topical anaesthetics (i) proparacaine up to 05 (ii) benoxinate up to 04 (iii) tetracaine up to 10

New Brunswick New Brunswick Association of Optometrists

Administration authority is given under the Optometry Act

Both the Optometry Act and the associated Optometry Regulations govern the practice of physiotherapy in New Brunswick and both

Scope of Practice 21

ldquopractice of optometryrdquo means those functions usually performed by an optometrist including (a) the examination of the human eye and its adnexa by any acceptable procedure to diagnose visual defects or abnormal conditions

ldquodiagnostic drugsrdquo mean those drugs listed by category in the by-laws and administered for the diagnosis of visual defects or abnormal conditions of the

16 Optometry Act CCSM c O70 s1 17 Optometry Act CCSM c O70 s12(1) 18 Optometry Regulation Man Reg 45688 R s7(1)to s7(5) 19 Optometry Regulation Man Reg 45688 R s6

Prescribe andor

Use of list class

Prescribing authority is given under the Prescription Drug Payment Act20

are private pieces of legislation The Pharmaceutical Certification Board is empowered by the Act to establish bylaws for the administration of pharmaceutical drugs

(b) the treatment of visual defects or abnormal conditions of the human eye or its adnexa by the use of any acceptable procedures other than surgery including the prescription and application of lenses or other devices and the use of pharmaceutical drugs (c) the removal of superficial foreign bodies from the human eye or its adnexa (exercer lrsquooptomeacutetrie) AuthorizedRestricted activities22

ldquoCertified Therapeutic Optometristrdquo means an optometrist who holds a certification to administer pharmaceutical drugs (optomeacutetriste theacuterapeute accreacutediteacute) ldquodiagnostic drug licencerdquo means a licence for the use of diagnostic drugs (permis de meacutedicaments diagnostiques) Anti-glaucoma medications shall be used only to provide emergency treatment for angle closure glaucoma23

In the Optometry Act24

20(2) The Pharmaceutical Certification Board shall (a) by by-law establish the requirements necessary for certification to administer pharmaceutical drugs (b) verify the successful completion of such requirements (c) certify optometrists who are qualified to prescribe and administer pharmaceutical drugs (d) establish requirements necessary for the renewal of certification and (e) recommend to the Minister the formulary of categories to be used as pharmaceutical drugs

eye or its adnexa (meacutedicaments diagnostiques) ldquopharmaceutical drugsrdquo mean those drugs listed by category in the by-laws and administered for the diagnosis or treatment of visual defects or abnormal conditions of the eye or its adnexa (meacutedicaments) The Pharmaceutical Certification Board has established by by-law the following topical medication categories for use by a certified therapeutic (a) MydriaticsCycloplegics (b) Miotics (c) Non-Steroidal Anti-Allergy Medications (d) Non-Steroidal Anti-Inflammatory Medications (e) Corticosteroids (f) Anti-Infective Medications (g) SteroidAnti-Infective Combination Medications

20 Prescription Drug Regulation - Prescription Drug Payment Act NB Reg 84-170 s2(d) prescriber means a legally qualified medical practitioner nurse practitioner optometrist or dentist who gives a prescription 21 Optometry Act 2004 c 50 s2 22 Optometry Act 2004 c 50 s2 23 E-mail correspondence with Registrar New Brunswick Association of Optometrists October 13 2008 24 Optometry Act 2004 c 50 s20(2)(e) 25 httpwwwnbpharmacistscaLinkClickaspxfileticket=LyKCD9Vd8wc3Damptabid=244ampmid=688

Prescribe andor

Use of list class

(h) Anti-Glaucoma Medications 16(2) The medication named in paragraph 16(1)(h) shall only be used to provide emergency treatment for angle closure glaucoma and for no other purposedrugs 25

Newfoundland Newfoundland Optometric Board

Prescribe and Administration

The practice of optometry is governed by the Optometry Act and its associated Regulations

(j) optometry means the services usually performed by an optometrist and includes (i) measuring or attempting to measure the refractive or muscular condition of the eye (ii) prescribing and ophthalmic dispensing of ophthalmic appliances (iii) prescribing orthoptic treatment for the relief or correction of a visual or muscular error or defect of the eye (iv) removing superficial foreign bodies from the human eye and surrounding tissue in accordance with the regulations and (v) prescribing and administering pharmaceutical agents in accordance with the regulations where the optometrist is certified by the board as qualified

Pharmaceuticals

40 A practitioner shall not prescribe or administer pharmaceutical agents except in accordance with a certificate issued under the regulations

Diagnostic drug licence 2 (1) The board may issue to an optometrist a diagnostic drug certificate (2) An optometrist who holds a diagnostic drug certificate may administer and prescribe

(a) topical ophthalmic anaesthetics for the purpose of measuring a patients intra-ocular pressure and

(b) topical ophthalmic cycloplegics and mydriatics for the purpose of dilation and

The categories of drugs are outlined in the Diagnostic and Therapeutic Drug Regulations NLR 9505

26 Optometry Act 2004 SNL 2004 c O-701 27 Diagnostic and Therapeutic Drug Regulations NLR 9505 s2 and s3

Prescribe andor

Use of list class

to facilitate examination of the eye Therapeutic drug certificate (3) An optometrist who holds a therapeutic drug certificate may administer and prescribe the following pharmaceutical agents for the diagnosis and treatment of ocular anterior segment disorders (a) mydriatics (b) cycloplegics (c) topical local ophthalmic anaesthetics (d) topical ophthalmic non-steroidal anti-allergy medications (e) topical ophthalmic non-steroidal anti-inflammatory medications and (f) topical ophthalmic anti-infective medications

Northwest Territories The Commissioner and the Board of Inquiry

Scope of Practice Northwest Territories Health and Social Services specifically indicated there is no defined scope of practice for optometrists28 However in the Optometry Act practice of optometry means the employment of means other than drugs and surgery for the measurement of the refractive or muscular condition of the eye and the prescribing or supplying of lenses prisms or spectacles for the relief or correction of any visual or muscular defect of the eye (exercice de lrsquooptomeacutetrie)29

Nova Scotia Nova Scotia College of Optometrists

The practice of optometry in Nova Scotia is governed by the Optometry Act and its associated regulations The regulations outline the requirements to obtain a licence to administer drugs30

(l) practice of optometry means those functions usually performed by an optometrist including (i) the examination of the human eye and its adnexa by any acceptable procedure to diagnose visual defects or abnormal conditions (ii) the treatment of visual defects or abnormal conditions of the human eye or its adnexa by the use of any acceptable procedures other than surgery including the prescription and application of lenses or other devices and the use of therapeutic drugs as set forth in the by-laws and regulations (iii) the removal of superficial foreign bodies from the human eye or its adnexa

The categories of drugs are outlined in the Optometry Regulations NS Reg 4532007 section 23 and 24

28 Northwest Territories Health and Social Services Professional Licensing Optometrists httpwwwhlthssgovntcaenglishservicesprofessional_licensingoptometristshtm 29 Optometry Act RSNWT 1988 C O-3 s1 30 Optometry Act SNS 2005 c 43 s19(1)(h) 31 Optometry Act SNS 2005 c 43 s2(l)

Prescribe andor

Use of list class

AuthorizedRestricted Activities32

Optometric drug licence 23 (1) An optometrist must not use diagnostic drugs or therapeutic drugs unless they have an optometric drug licence or therapeutic drug certificate in accordance with these regulations (2) An optometrist may only use the diagnostic drugs or therapeutic drugs authorized by these regulations (3) An optometrist who holds an optometric drug licence may use any of the following ophthalmic drugs applied topically on the eye when practising optometry

(a) topical anaesthetics (b) topical diagnostic dyes and stains (c) topical mydriatics to dilate a pupil and to facilitate examining the fundus of the eye (d) topical cycloplegics to inactivate the accommodative reaction and to dilate the pupil to facilitate measuring the refractive error of the eyes

(4) An optometrist who was issued an optometric drug licence by the Registrar or by the Board of Examiners under the former Act may use any of the drugs listed in subsection (3) when practising optometry (5) The Registrar may suspend or revoke an optometristrsquos drug licence if the optometrist fails to adhere to standards respecting the use of ophthalmic drugs in the practice of optometry Therapeutic drug licence 24 (1) In this Section a ldquotherapeutic drug licencerdquo means a licence granted to an optometrist to use specified therapeutic pharmaceutical agents (2) The Registrar may issue a therapeutic drug licence that authorizes an optometrist to use the therapeutic drugs listed in subsection (3) to an optometrist who meets all of the following qualifications

(a)if they graduated on or after January 1 1995 (i) they graduated from a post-secondary educational institution approved by the Board (ii) they successfully completed the ocular therapeutic (OT) Section of the Canadian Standards Assessment Examinations administered by the

32 Optometry Regulations NS Reg 4532007 s23 and s24

Prescribe andor

Use of list class

Canadian Examiners in Optometry and (iii) they completed at least 40 hours of clinical training in administering and prescribing therapeutic drugs in a post-secondary educational setting approved by the Board

(b) if they graduated before January 1 1995 (i) they graduated from a post-secondary education institution approved by the Board (ii) they successfully completed a post-graduate course approved by the Board in administering and prescribing therapeutic drugs and

(iii) they passed an examination approved by the Board dealing with the use of therapeutic drugs

(3) An optometrist who holds a therapeutic drug licence may use the following topical drugs for the treatment of ocular anterior segment disorders

(a) mydriatics (b) cycloplegics (c)non-steroidal anti-allergy medications (d) non-steroidal anti-inflammatory medications (e) anti-infective medications (f) topical ocular steroids but only in the manner set out in subsection (4)

(4) An optometrist who holds a therapeutic drug licence may use topical ocular steroids and steroid and anti-infective combination drugs to treat specific conditions of the ocular surface and adnexa meaning eyelids eyelashes conjunctiva and related tissue when there is no corneal ulceration present (5) An optometrist may treat with topical ocular steroids either alone or in combination with anti-infectives for short term therapy only meaning less than 4 weeksrsquo duration in most cases and may prescribe only a single non-refillable course of these drugs

Prince Edward Island

The practice of optometry is governed by the Optometry Act and its associated

(i) ldquopractice of optometryrdquo means those functions usually performed by an optometrist including (i) the examination of the human eye and its adnexa using instruments devices or

Use of individualized list35

(3) A confirmation issued by the College under this section

33 Optometry Act RSPEI 1988 c O-6 s1(i) after Bill 30 has been assented on May 23 2008 34 Once amendments to the Optometry Act have been proclaimed licensed optometrists will be required to apply for written confirmation from the College that the licensed optometrist has the necessary training and education to competently give a prescription for a therapeutic drug or class of therapeutic drugs if authorized by the Minister The confirmation will specify each therapeutic drug or class of therapeutic drugs that the licensed optometrist has the necessary training and education to prescribe Amendments to the Optometry Act have received Royal Assent but has not yet been proclaimed ndash PEI Government is waiting until PEI College of Optometry has completed its Regulations before proclamation 35 Optometry Act RSPEI 1988 c O-6 s151 after Bill 30 has been assented on May 23 2008

Prescribe andor

Use of list class

Prince Edward Island College of Optometrists

Regulations ldquoAn Act to Amend the Optometry Actrdquo was given Royal Assent on May 22 2008

diagnostic drugs to diagnose visual defects or abnormal conditions (ii) the treatment of visual defects or abnormal conditions of the human eye or its adnexa by the prescription or application of lenses or other devices and subject to this Act and the regulations the prescription or application of therapeutic drugs and (iii) the removal of superficial foreign bodies from the human eye or its adnexa Further Amendment from Bill 3034

(d2) ldquodiagnostic drugrdquo means a drug that is administered topically for examination investigation or diagnosis of disease injury or other abnormal conditions of the visual system (d3) ldquodrugrdquo means a drug as defined in the Pharmacy Act RSPEI 1988 Cap P-6 (l) ldquotherapeutic drugrdquo means a drug that is administered topically for the prevention treatment or management of disease injury or other abnormal conditions of the anterior segment of the human eye (e) the training and education required of licensed optometrists to competently give a prescription for a therapeutic drug or class of therapeutic drugs 111 (1) There is hereby established a committee to be called the Therapeutic Drug Prescription Committee (4) The Committee shall

(a) compile maintain and provide to the Minister a list of therapeutic drugs or classes of therapeutic drugs that the Committee is satisfied licensed optometrists may be competent to give a prescription for if the College confirms their qualifications and they are authorized to do so by the Minister under section 141 of the Pharmacy Act RSPEI 1988 Cap P-6

shall (a) indicate the name of the licensed optometrist in respect of which the confirmation is given (b) specify the date on which the confirmation is given and (c) specify each therapeutic drug or class of therapeutic drugs that the licensed optometrist has the necessary training and education to prescribe if authorized to do so by the Minister

Quebec Ordre professionnel des optomeacutetristes du Queacutebec

Administer and Prescribe

Queacutebec optometrists are regulated under the Professional Code which applies to all regulated professions in Queacutebec The Professional Code also

The practice of optometry is an act which except the use of medication deals with vision and is related to examination or functional analysis of the eyes and assessment of visual disorders as well as orthoptics prescription fitting adjustment sale and replacement of ophthalmic lenses

Authority under the Act List for administration and prescribing in regulations 1 Medications that an

optometrist may administer Regulation

Prescribe andor

Use of list class

outlines the various activities that members of the Ordre may engage in Its associated regulations provide additional requirements regarding specific issues relating to the profession In addition the Ordre oversees the regulation of its members The Office des professions must consult with Conseil du meacutedicament the Ordre des optomeacutetristes du Queacutebec the Ordre des meacutedecins du Queacutebec and the Ordre des pharmaciens du Queacutebec for a list for administration The Office des professions must consult with the Conseil du meacutedicament the Ordre des optomeacutetristes du Queacutebec the Ordre des meacutedecins du Queacutebec and the Ordre des pharmaciens du Queacutebec for medication that can be administered or prescribed 36

191 Notwithstanding section 16 an optometrist may administer a medication for the sole purpose of examining the eyes of a patient if the following conditions are met 1) the optometrist holds the permit referred to in the first paragraph of section 192 2) the medication is mentioned in the list established by regulation under the first paragraph of section 194 3) the optometrist complies with the terms and conditions fixed in the regulation where such is the case 1911 Notwithstanding section 16 an optometrist may also administer and prescribe medication to a patient for therapeutic purposes and provide eye care to the patient if the following conditions are met 1) the optometrist holds the permit referred to in the second paragraph of section 192 2) the medication or care provided is mentioned in the regulation made under the second paragraph of section 194 3) the optometrist acts in the cases and complies with the terms and conditions provided in the regulation where such is the case 192 The Bureau shall by regulation fix the standards for the issue and holding of a permit authorizing an optometrist to administer medication to his patients in accordance with section 191 The Bureau shall also by regulation fix the standards for the issue and holding of a permit authorizing an optometrist to administer and prescribe medication to a patient for therapeutic purposes and to provide eye care to the patient in accordance with section 1911

respecting the RQ c O-7 r42

2 Medications that may be administered and prescribed for therapeutic purposes by an optometrist and respecting the eye care that may be provided by an optometrist Regulation respecting the RQ c O-7 r4201

36 Optometry Act RSQ c O-7 s194 37 Optometry Act RSQ c O-7 s16 38 Optometry Act RSQ c O-7 s191 to s192

Prescribe andor

Use of list class

Saskatchewan Saskatchewan Association of Optometrists

The practice of optometry in Saskatchewan is governed by the Optometry Act In addition the Council is empowered to pass bylaws designating the pharmaceutical agents and dosages that may be prescribed or used and the qualifications necessary39

(l) practice of optometry means the performance of services usually rendered by an optometrist which may include (i) measuring and assessing vision (ii) prescribing and dispensing ophthalmic appliances and orthoptics for the relief or correction of visual or muscular errors or defects of the eye and (iii) prescribing and using pharmaceutical agents for diagnostic and treatment purposes as set out in the bylaws AuthorizedRestricted Activities41

(1112) Members who hold a Therapeutic Pharmaceutical Agents Certificate may prescribe agents for the treatment of ocular diseases and abnormal conditions with the exception of antiglaucoma agents (1113) Members who use and prescribe topical corticosteroid agents for the treatment of anterior uveitis must arrange for the patient to be examined by an ophthalmologist if no improvement is noted The treatment of posterior uveitis is not permitted

Diagnostic Pharmaceutical Agents Certificate may use the following categories of topically applied pharmaceutical agents for diagnosing diseases or abnormal conditions of the eye adnexa and visual system42 (a) anesthetics (b) cycloplegics (c) miotics and (d) mydriatics

Yukon Administration and Prescribe

The practice of optometry in the Yukon Territory is governed by the Optometry Act and its associated Optometry Regulation The Optometry Act empowers the Executive Council to create regulations for prescribing qualifications necessary and practice guidelines43

Scope of Practice44

ldquooptometryrdquo means (a) the examination of the human eye and its related structures and the human vision system in order to measure assess diagnose or refer for consultation or treatment any conditions of the human eye or its related structures or the human vision system (b) the treatment of conditions of the human eye and its related structures and the human vision system through the prescribing and dispensing of ophthalmic appliances therapeutic pharmaceutical agents as authorized by the regulations or other aids and the prescribing and provision of orthoptics or perceptual training and the offering of advice consultation or counselling (c) the provision of other vision care services as authorized by the regulations laquooptomeacutetrieraquo

Schedule A Professional Practice Guidelines for TPA Certified Optometrists is established as the professional practice guidelines for optometrists to follow when they prescribe or dispense therapeutic pharmaceutical agents47

The Drug Formulary lists categories of medications designated optometrists may prescribe48

39 Optometry Act 1985 SS 1984-85-86 c O-61 s11(2)(k) and s11(2)(l) 40 Optometry Act 1985 SS 1984-85-86 c O-61 s2(l) 41 Bylaws of the Saskatchewan Association of Optometrists s1112 and s1113 42 Bylaws of the Saskatchewan Association of Optometrists s115 43 Optometrists Act RSY 2002 c 164 s20

Prescribe andor

Use of list class

AuthorizedRestricted Activities 10(2) No optometrist shall prescribe or dispense a therapeutic pharmaceutical agent except as authorised by the regulations45

In the Optometrists Regulation46

Extended scope of practice 1(1) An optometrist who has been designated under the Act as qualified to prescribe therapeutic pharmaceutical agents may (a) prescribe and administer the following topical therapeutic medications in the treatment of ocular disorders (i) mydriatics (ii) cycloplegics (iii) miotics (iv) non-steroidal anti-allergy medications (v) non-steroidal anti-inflammatory medications (vi) corticosteroids (vii) anti-infective medications (viii) steroidal anti-infective medications (ix) in a consultative co-management arrangement with an ophthalmologist

who is licensed to practise in Canada oral corticosteroids oral anti-glaucoma and anti-glaucoma medications

(b) remove superficial foreign bodies from theeye (c) use for diagnostic testing drugs that are in the following categories

(i) local anaesthetics (ii) mydriatics (iii) cycloplegics (iv) miotics (v) non-prescription drugs

44 Optometrists Act RSY 2002 c 164 s1 s4 45 Optometrists Act RSY 2002 c 164 s10(2) 46 Optometrists Regulation YOIC 1999150 s1 47 Optometrists Regulation YOIC 1999150 s5 48 Optometrists Regulation YOIC 1999150 Schedule A Drug Formulary

Prescribe andor

Use of list class

Designation for TPArsquos 4 (1) In order to be designated as qualified to prescribe and dispense therapeutic pharmaceutical agents an optometrist must satisfy the Executive Council Member that they (a) are registered or qualified for registration under section 3 of the Act (b) hold Diagnostic Pharmaceutical Agent certification from an accredited school of optometry (c) hold a current Level ldquoCrdquo CPR certificate and (d) meet the requirements of either subsection (2) or subsection (3) (2) If they have graduated from an accredited school of optometry after 1995 the optometrist must supply proof that they have successfully challenged the TPA component of the Canadian Standards Assessment in Optometry Examination or of the United States National Examination (3) If they have graduated from an accredited school of optometry in or before 1995 the optometrist must supply proof that they have (a) successfully completed a course of at least 100 hours in the treatment and management of ocular disease from an accredited school of optometry or (b) passed the examination ldquoTreatment and Management of Ocular Diseaserdquo administered by the National Board of Examiners in Optometry

2) Authority to Prescribe andor Administer Drugs in Australia New Zealand and the United Kingdom Jurisdiction Prescribing andor

administration of drugs

Framework Authority to prescribe andor administer drugs

Standard of Practice Guidelines Policies

Use of formulary listclass

Approval process for new drugs

Australia Administration and Prescribe Legislation in each state except Western Australia) grants therapeutically endorsed optometrists the authority to prescribe ocular drugs The Board in Western Australia has submitted a proposal to amend the Poisons Act49

Optometrists register in one of 6 Australian states or 2 territories

Legislation in most states permits the Health Minister to approve a list of drugs for groups of prescribers

Separate list for each state Legislation in (Tasmania50 Victoria51and Northern Territory52) Alternatively a committee that is constituted or approved by the Minister may in themselves have the authority to approve drug lists (New South Wales53 Australian Capital Territory54 and Queensland55)

New Zealand

Prescribe An optometrist may prescribe an optometric medicine if he or she meetsmdash

All prescribing in New Zealand is regulated by the Medicines Act 1981 and Regulations The Health Practitioners

Scope of Practice for Optometry (TPA Endorsement) (Optometrist with Therapeutic Pharmaceutical Agents (TPA) Endorsement) Qualifications The applicant is qualified for the scope of practice for optometry and holds

List57 An amendment Regulation is submitted to substitute a new schedule into the principal regulation58

49 The Optometrists Registration Board Of Western Australia Annual Report 2006 section 83 50 Tasmania Optometrists Registration Act 1994 section 29 51 Victoria Drugs Poisons and Controlled Substances Regulations 2006 section 6 52 North Territory Optometrists Board of the Northern Territory Ocular Therapeutic Protocol for Therapeutic Authorised Optometrists March 2007 53 New South Wales Optometrists Act 2002 section 21 54 Australian Capital Territory Optometrists Legislation Amendment Act 2005 section 4 55 Queensland Health (Drugs and Poisons) Regulation 1996 s170(2) 56 Medicines (Designated Prescriber Optometrists) Regulations 2005 (SR 2005256) s5

Jurisdiction Prescribing andor administration of drugs

(a) the requirements in regulation 6 for commencing for the first time to prescribe the medicine and (b) the additional requirements (if relevant) in regulations 7 and 8 for prescribing the medicine56

Competence Assurance Act 2003 outline the regulatory bodies responsible for dictating the qualifications for prescribing

bull a Certificate in Ocular Pharmacology University of Auckland and an acknowledgement from the University of Auckland Faculty of Science stating that the applicant has successfully completed all the requirements of the Auckland programme in ocular therapeutics or bull a BOptom University of Auckland conferred in 2007 and thereafter or bull a pass in a therapeutics programme accredited by Optometry Council of Australia and New Zealand (OCANZ) or bull a pass in a therapeutics programme accredited by the Board

United Kingdom Health Professions Council

Prescribe as a supplementary prescriber Prescribe under an exemption in the Medicine Act59

Some Allied Health Professions (AHPs) (nurses pharmacists optometrists physiotherapists radiographers and chiropodistspodiatristss) can prescribe certain medicines within agreed Clinical Management Plans60

Supplementary prescribing

Under the supplementary prescriber program Patient Specific Direction is the traditional written instruction from a doctor dentist nurse or pharmacist independent prescriber for medicines to be supplied or administered to a named patient Under the Exemption62

Prescription only Medicines (POMs) which are not for parenteral administration and which- (a) are eyes drops and are POMs by reason only that they contain not more than 05

List63

57 Medicines (Designated Prescriber Optometrists) Regulations 2005 (SR 2005256) Schedule 58 Medicines (Designated Prescriber Optometrists) Amendment Regulations 2007 (SR 2007183) Explanatory Note 59 Exemptions from the general rules are permitted for optometrists These are provided for in the Prescription Only Medicine (Human Use Order) 1997 SI No 1830 (The ldquoPOM Orderrdquo) the Medicines (Pharmacy and General Sale-Exemption) Order 1980 SI No 1924 and the Medicines ( Sale or Supply) (Miscellaneous Provisions) Regulations 1980 SI No 1923 60 Department of Health Supplementary Prescribing httpwwwdhgovukenHealthcareMedicinespharmacyandindustryPrescriptionsTheNon-MedicalPrescribingProgrammeSupplementaryprescribingindexhtm 61 Department of Health Medicine Matters A guide to mechanisms for the prescribing supply and administration of medicines httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_064325IdcService=GET_FILEampdID=116051ampRendition=Web 62 Department of Health Medicines Matters A guide to mechanisms for the prescribing supply and administration of medicines July 2006 Appendix Prescribing supply and administration of medicines 63 Exemption Level 2 Drugs

is a voluntary prescribing partnership between the independent prescriber (doctor or dentist) and supplementary prescriber to implement an agreed patient-specific clinical management plan (CMP) with the patientrsquos agreement Following agreement of the CMP the supplementary prescriber may prescribe any medicine for the patient that is referred to in the plan until the next review by the independent prescriber61

Chloramphenicol or (b) are eye ointments and are POMs by reason only that they contain not more than 1 Chloramphenicol or (c) are POMs by reason only that they contain any of the following substances Atropine sulphate Bethanecol chloride Carbachol Cyclopentolate hydrochloride Homatropine hydrobromide Naphazoline hydrochloride Naphazoline nitrate Physostigmine salicylate Physostigmine Pilocarpine hydrochloride Pilocarpine nitrate Tropicamide Sale or supply shall be only- (a) in the course of their professional practice and (b) in an emergency

3 Authority to Prescribe andor Administer Drugs in United States Jurisdictions This table was provided by the Ontario Association of Optometrists Note Some restrictions apply on medications used to treat glaucoma in some states

SUMMARY ndash LEGEND DRUG PRESCRIPTIVE AUTHORITY FOR OPTOMETRISTS

Medications Used To Treat ALLERGIES

Medications Used To Treat INFECTIONS

Medications Used To Treat GLAUCOMA

Medications Used To Treat

INFLAMMATION

Medications Used To Treat PAIN (oral)

Alabama T O T O T O T O O Alaska T T T T Arizona T O T O T T Osup1 O Arkansas T O T O T O T O O California T O T O T T Osup1 O Colorado T O T O T O T Osup1 O Connecticut T O T O T O T O O Delaware T O T O T O T Osup2 DC T O T O T O T Osup1 Osup2 Florida T T T T Georgia T T T T O Guam T O T O T O T O O Hawaii T O T O T O T O Osup2 Idaho T O T O T O T O O Illinois T T T T Osup2 Indiana T O T O T O T O Osup2 Iowa T O T O T O T O O Kansas T O T O T O T O O Kentucky T O T O T O T O O Louisiana T O T O T T O Maine T O T O T T Osup1 O Maryland T T O T T Massachusetts T T T Michigan T O T O T O T Osup1 O Minnesota T O T O T O T Osup1 O Mississippi T T O T O T Osup1 O Missouri T O T O T O T O O Montana T O T O T O T O O

Nebraska T O T O T T Osup1 O Nevada T O T O T O T O New Hampshire T O T O T O T Osup1 O New Jersey T O T O T O T O O New Mexico T O T O T O T Osup1 O New York T T T T North Carolina T O T O T O T O O North Dakota T O T O T O T O O Ohio T O T O T O T Osup1 Osup2 Oklahoma T O T O T O T O O Oregon T O T O T O T O O Pennsylvania T T O T T O O Rhode Island T T T T South Carolina T O T O T O T O South Dakota T O T O T O T O O Tennessee T O T O T O T O O Texas T O T O T O T Osup1 O Utah T O T O T O T O O Vermont T O T O T O T O O Virginia T O T O T O T O O Washington T O T O T O T Osup1 O West Virginia T O T O T O T O O Wisconsin T O T O T O T O O Wyoming T O T O T O T Osup1 O

T Topical Legend Drugs GLAUCOMA Tx = 49 states + DC + Guam

O Oral Legend Drugs ORAL Rx AUTHORITY = 45 states + DC + Guam

sup1 No Oral Steroids CONTROLLED SUBSTANCE Rx AUTHORITY = 39 states + Guam

sup2 No Controlled Narcotic Substances INJECTABLES AUTHORITY = 28 states + DC

The information contained in this chart represents a summary as of May 27 2005 of the state optometry statutesboard regulations In some states situations for legend drug prescriptive authority may vary The key ldquoTrdquo or ldquoOrdquo in many instances represents every topical andor oral legend drug available under a specific heading For more complete information please contact Sherry L Cooper Manager of the American Optometric Associationrsquos State Government Relations Center at 314-991-4100800-365-2219 Ext 4266 or SLCooperAOAorg

Glaucoma Medications HPRAC has reviewed a number of medications that are currently in use to treat glaucoma and medications that are intended to reduce elevated intraocular pressure and prevent damage to the optic nerve The Glaucoma Research Foundation64 through its pubished reports and advisory newletters was a major source of advice to the Council Specific reports on drugs available for glaucoma treatment follow

bull Adrenergic

bull Alpha Agonist

bull Beta Blockers

bull Carbonic Anhydrase Inhibitors

bull Cholinergic (Miotic)

bull Combined

bull Prostaglandin Analogs

bull Overview

bull All

Certification or Legislative Requirements in Selected United States Jurisdications for Glaucoma Medications

Texas Optometry Board65

65 httpwwwtobstatetxusogshtm

License Requirements

To apply for an Optometric Glaucoma Specialist License applicants must take an approved course complete a skills evaluation by an ophthalmologist and submit an application

with fee to the Optometry Board Approved 30 hour courses are listed on the Boards website Use the find feature of your Internet browser to search for Optometric Glaucoma

Specialist Course Rules Rules defining the responsibilities and authority of Optometric Glaucoma Specialists including specific drug prescribing and administration authority

and required procedures for the treatment of glaucoma may be found at these links 28010 Optometric Glaucoma Specialist Administration and Prescribing of Oral Medications

and Anti-Glaucoma Drugs 28011 Treatment of Glaucoma by an Optometric Glaucoma Specialist

The statutory provisions governing Optometric Glaucoma Specialists may be found at this link See Sections 351358 and 3513581 of the Texas Optometry Act

Oral Medications Only therapeutic optometrists licensed as Optometric Glaucoma Specialists may prescribe and administer oral medications Only those oral medications listed may be prescribed and administered Each medication has a time period that may not be exceeded All therapeutic optometrists may administer topical anti-virals

New Hampshire Board of Optometry66 The New Hampshire Board of Optometry lists all optometrists who are authorized to treat glaucoma pursuant to the Optometry Practice Act Licensure Requirements An optometrist certified to use pharmaceutical agents in the practice of optometry must complete a minimum of 50 hours of continuing education every year in order to maintain pharmaceutical certification A minimum of 20 hours shall be by participation in formal courses and the remainder by independent study An optometrist certified to treat glaucoma shall complete a minimum of 10 of the required hours in glaucoma specific education A minimum of 7 hours shall be by participation in formal courses and 3 hours may be by independent study The Joint Pharmaceutical Formulary and Credentialing Committee in November 2006 authorized the general formulary of approved therapeutical pharmaceutical agents for TPA certified optometrists to write prescriptions andor to dispense samples

Pharmaceutical Agents For TPA Certified Optometrists The following edition of the TPA Certified Optometrist Formulary was approved to authorize certified optometrists to write and pharmacists to fill prescriptions for drugs listed in the Formulary provided that such drugs are for the exclusive diagnosis or treatment of disease or conditions of the human eye adnexa or eyelids No optometrist is authorized to possess administer prescribe or dispense controlled substances in Schedules I or II Certified optometrists who wish to write prescriptions for controlled substances in Schedules III IV or V must first obtain a DEA permit A certified optometrist may dispense a formulary-listed pharmaceutical agent to a patient if no charge is imposed for the drug(s) ie samples and the amount dispensed does not exceed a 24 hour supply except that if the minimum available quantity for dispensing is greater than a 24-hour supply the optometrist may dispense the minimum available quantity 66 httpwwwnhgovoptometryglaucomaindexhtm

Pharmaceutical Agents Approved By The New Hampshire Joint Pharmaceutical Formulary and Credentialing Committee As Of November 2006

Anti Infectives Topical Use Oral Use Amoxicillin Yes Yes AmoxicillinPotassium Clavulanate Yes Yes

Amikacin Yes No Ampicillin Yes Yes Azithromycin Yes Yes Bacitracin Yes Yes Cefaclor Yes Yes Cefuroxime Yes Yes Cephalexin Yes Yes Anti-Infectives

Cefazolin Yes No Ciprofloxacin

Yes Yes

Clarithromycin Yes Yes Clindamycin Yes No

Dicloxacillin Yes Yes Doxycycline Yes Yes Cloxacillin Yes Yes Erythromycin Yes Yes Gatifloxacin Solution Yes No Gentamycin Yes Yes Gramacidin Yes Yes Levofloxacin Yes Yes Minocycline Yes Yes

Moxifloxacin HCI Solution 5 Yes No Norfloxacin Yes No Nafcillin Yes Yes Neomycin Yes Yes Ofloxacin Yes Yes Oxacillin Yes Yes Oxytetracycline Yes Yes Penicillin V Yes Yes Piperacillin Yes No Polymyxin B Yes Yes Sodium Sulfacetamide Yes Yes Sulfamethoxazole Yes Sufisoxazole Yes Yes Tetracycline Yes Yes Ticarcillin Yes No Trimethoprim Yes No Tobramycin Yes Yes Antiviral Agents Famvir (Famciclovir) No Yes Valtrex (Valacyclovir HCl)) No Yes Zovirax (Acyclovir) No No Yes Immunologic Agents Cyclosporine Ophthalmic Emulsion 05 Yes No Analgesics Acetaminophen with Codeine Not to exceed 30mg

No Yes

Codeine300mg Acetaminophen No Yes

Propoxyphene Hydrochloride No Yes Propoxyphene Hydrochloride with Acetaminophen Combination

No Yes

Non Steroidal Anti-Inflammatory Agents

Bromfenac Yes Diclofenac Sodium Yes Yes Etodolac Yes Yes Fenoprofen Yes Yes Flurbiprofen Sodium Yes Ibuprofen Yes Yes Ketoprofen Yes Yes Ketorolac Yes Yes Meclofenamate Yes Yes Mefenamic Acid Yes Yes Naproxen Yes Yes Naproxen Sodium Yes Yes Nepafenac Yes Corticosteroids (alone or in combination)

Dexamethasone 01 Yes No Dexamethasone Sodium Phosphate 005 01

Yes No

Fluorometholone 01025 Yes No Fluorometholone Acetate 01 Yes No Loteprednol Etabonate 02 05 Yes No Medrysone 1 Yes No Prednisolone Acetate 012 0125 1 Yes No Prednisolone Sodium Phosphate 0125 Yes No

1 Rimexolone 1 Miotics (alone or in combination)

(These agents for use in accommodative esotropia only the diagnosis to be indicated on any prescription written)

Demecarium Bromide Yes No Echothiophate Iodide Yes No Isoflurophate Yes No Agents Approved By Statute All topical pharmaceutical agents that are within the scope of optometric practice including but not limited to the following All mydriatic amp cycloplegic agents which are topically applied Anti-allergy medications including but not limited to antihistamines decongestants amp mast-cell stabilizers which ar All anesthetics dyes ocular lubricants amp hypertonic agents which are topically applied All non-legend over-the-counter agents e topically appliedAll oral analgesics which are used for the treatment of eye diseases amp which are not Controlled Substances Diphenhydramine (Benadryl) epinephrine or equivalent medications to counter anaphylaxis or anaphylactic reactions No No Yes All topical agents used for diagnostic purposes Anti-glaucoma agents which are topically applied if the TPA certified optometrist has met the requirements of RSA 3276-c (in

which case the optometrist shall indicate on the prescription Glaucoma Prescriptive Authority Granted) Topical and oral anti-glaucoma agents for the emergency treatment of acute angle closure glaucoma with immediate referral to an ophthalmologist Topically applied anti-viral agents (the TPA certified optometrist shall consult with an ophthalmologist prior to dispensing or prescribing)

New Hampshire Occupations and Professions Chapter 7 OPT0METRY Examinations and Licenses Section 3276 - c 3276-c Treatment of Glaucoma ndash I (a) Optometrists seeking authorization to treat glaucoma shall complete at least 40 hours of classroom education approved by the board incorporating epidemiology of the glaucomas genetics of the glaucomas anatomy physiology and mechanics of aqueous inflow and aqueous outflow optic nerve anatomy and pathophysiology neurotoxicity and neuroprotectants receptor biology pharmacology clinical use and toxic effects of alpha and beta adrenergic agents carbonic anhydrase inhibitors prostanoids and cholinergic agents (b) Optometrists shall pass an examination approved by the board that covers the educational components listed in subparagraph (a) Upon passage of such exam an optometrist shall have prescriptive authority during the clinical management period pursuant to RSA 3276-a (c) The board shall waive the requirements of this paragraph and of paragraph II for optometrists who have either graduated after 2002 or who have proof of 12 months of credentialed privileges to treat glaucoma by the United States Department of Defense or Department of Veteran Affairs or the national Indian Health Service verified by the board II (a) To be authorized to initiate treatment of glaucoma for patients 18 years of age or older a therapeutic pharmaceutical agent certified optometrist shall complete the educational requirements in paragraph I and provide evidence of written referrals and consultations with an ophthalmologist For purposes of this section glaucoma means primary open-angle glaucoma and ophthalmologist means a physician licensed under RSA 329 with a specialty in ophthalmology The joint pharmaceutical formulary and credentialing committee shall review evidence of glaucoma co-management submitted pursuant to subparagraph (b) (b) Except as provided in subparagraph I(c) or paragraph III therapeutic pharmaceutical agent certified optometrists are required to provide evidence of successful collaborative treatment and co-management of 25 glaucoma patients up to 5 of which may be established patients during a period of not less than 18 months for each patient to ophthalmologists according to the following criteria

(1) A new or existing glaucoma patient is examined and diagnosed by the optometrist (2) The optometrist develops a proposed treatment plan and forwards the plan with examination documentation to an ophthalmologist for consultation (3) The ophthalmologist examines the patient and reviews the optometrists examination documentation and proposed treatment plan (4) The ophthalmologist optometrist and patient mutually agree to and document a treatment plan (5) The optometrist shall consult with the co-managing ophthalmologist when any of the following occurs the patients target pressure is not reached within 90 days the patient is experiencing documented progression of optic nerve damage the patient develops documented and repeated progression of visual field loss or the patient develops angle-closure or other secondary glaucoma and (6) For each successfully co-managed glaucoma patient the optometrist and co-managing ophthalmologist shall complete a glaucoma credentialing reporting form and submit the form to the joint pharmaceutical formulary and credentialing committee upon completion of the 18 months of treatment III The joint pharmaceutical formulary and credentialing committee may waive or reduce the requirements of RSA 3276-c I and II for the following categories of optometrists (a) Optometrists with a license and proof of practice for 12 months treating glaucoma patients in another state that currently authorizes the treatment of glaucoma by optometrists or (b) Optometrists who have proof of successful completion of a 12-month accredited optometric residency program or its equivalent IV Upon certification to treat glaucoma patients (a) For a period of 24 months optometrists shall consult with an ophthalmologist within 30 days for each new glaucoma patient for confirmation of diagnosis and review of treatment plan (b) An optometrist shall consult with an ophthalmologist within 30 days when any of the following occurs (1) The patient is experiencing documented progression of optic nerve damage or the patient develops documented and repeated progression of visual field loss on maximum tolerated medical therapy or (2) The patient develops angle-closure or other secondary glaucoma

Source 2002 2743 eff July 17 2002 2006 1824 eff July 24 2006

Kansas Board of Examiners in Optometry Co-management of Adult Open Angle Glaucoma67

To qualify for glaucoma treatment licensing currently certified diagnostic and therapeutic licensees in Kansas must co-manage open angle glaucoma patients with a board certified Ophthalmologist The diagnosis must be confirmed by an Ophthalmologist and a treatment plan signed by the Ophthalmologist submitted to the Board of Examiners in Optometry Prescription of topical ocular pharmaceuticals for treatment of adult open angle glaucoma is allowed only if an approved treatment plan is a part of the patient record

The process for applying for glaucoma licensing includes co-managing at least twenty (20) patients for at least two years The two-year co-management period begins when the first treatment plan is submitted to the Board The twenty (20) patients must be a mix of glaucoma suspects and at least (10) confirmed cases of adult open angle glaucoma The treatment plans must be submitted to the Board on the approved reporting form In each year of co-management an annual report must be submitted on May 31st on the approved reporting form listing each case submitted to the Board The annual reporting form should reflect all cases that have been co-managed within that calendar year beginning with case number one (1) A twenty-four (24) hour course in the treatment and co-management of adult open-angle glaucoma is also required for licensing This is in addition to the twenty-four hours of continuing education required each year for license renewal By the end of the co-management period proof must be furnished to the Board that professional liability insurance in the amount of $1000000 is maintained The Board of Examiners in Optometry will review the glaucoma co-management file for license approval when two years has lapsed since submittal of the first case twenty (20) cases have been submitted to the board and an application with license fee is submitted

State Board of Licensing Pennsylvania68 Under Act 225 of 2002 the Board may grant certification to treat glaucoma to therapeutically certified licensees There are two ways a licensee can obtain therapeutic certification 1) by successfully completing 100 hours in the prescription and administration of pharmaceutical agents for therapeutic purposes as a condition of graduation from optometry school and by passing the National Board of Examiners in Optometry (NBEO) examination (which examination included the prescription and administration of pharmaceutical agents) - OR - 2) by successfully completing a Board-approved 100-hour course in the prescription and administration of pharmaceutical agents for therapeutic purposes and passing the National Board of Examiners in Optometry examination on the prescription and administration of pharmaceutical agents for therapeutic purposes (the Treatment and Management of Ocular Diseases TMOD examination) In order to qualify for certification to treat glaucoma the new language allows optometrists to apply according to the category under which they qualified for therapeutic certification Optometrists who obtained their therapeutic certification under (2) must also complete 18 hours of Board-approved continuing education in glaucoma Please complete the information in 1 or 2 on the next page

67 httpwwwkssbeocomGLCcomanagementhtm

68 wwwdosstatepaus

New York (Article 143 Optometry Education Law)69 Optometrists are authorized to prescribe Diagnostic pharmaceuticals Diagnostic pharmaceuticals shall mean those drugs which shall be limited to topical applications to the surface of the eye for the purpose of diagnostic examination of the eye and shall be limited to Anesthetic agents Mydriatics Cycloplegics Cycloplegics Miotics Disclosing agents and other substances used in conjunction with these drugs as part of a diagnostic procedure

Phase one therapeutic pharmaceutical agents Phase one pharmaceutical agents shall mean those drugs which shall be limited to topical application to the surface of the eye for therapeutic purposes and shall be limited to antibioticantimicrobials decongestantsanti-allergenics non-steroidal anti-inflammatory agents steroidal anti-inflammatory agents antiviral agents hyperosmotichypertonic agents cycloplegics artificial tears and lubricants

Phase two therapeutic pharmaceutical agents Phase two pharmaceutical agents shall mean those drugs which shall be limited to topical application to the surface of the eye and shall be limited to beta blockers alpha agonists direct acting cholinergic agents

Standard of care An optometrist authorized to use pharmaceutical agents for use in the diagnosis treatment or prevention of ocular disease shall be held to the same standard of care in diagnosis use of such agents and treatment as that degree of skill and proficiency commonly exercised by a physician in the same community

Before using or prescribing phase one therapeutic pharmaceutical agents each optometrist shall have completed at least three hundred hours of clinical training in the diagnosis treatment and management of patients with ocular disease other than glaucoma and ocular hypertension Before using or prescribing phase two therapeutic pharmaceutical agents an optometrist must be certified for diagnostic and phase one therapeutic agents and have completed an additional one hundred hours of clinical training in the diagnosis treatment and management of patients with glaucoma and ocular hypertension

Consultation After the initial diagnosis of glaucoma or ocular hypertension and before initiating treatment of any patient an optometrist shall engage in a written consultation with a licensed physician specializing in diseases of the eye A consultation shall be required for a period of three years or until the optometrist has examined and diagnosed seventy-five patients having glaucoma or ocular hypertension which examinations require a written consultation in accordance with paragraph (a) of this subdivision whichever occurs later The consultation provisions shall not apply to a graduate of an appropriate program approved by the department who successfully passed an examination in the use of diagnostic and therapeutic pharmaceutical agents approved by the department and graduated such school subsequent to January first nineteen hundred ninety-nine and who has had at least seventy-five documented examinations and diagnosis of patients with glaucoma or ocular hypertension which examinations were part of their training and were under physician supervision

69 httpwwwopnysedgovarticle143htm

Continuing education Each optometrist certified to use phase one or phase two therapeutic pharmaceutical agents shall complete a minimum of thirty-six hours of continuing education per triennial registration period The education shall be in the area of ocular disease and pharmacology and may include both didactic and clinical components

Notice to patient An optometrist prescribing steroids or antiviral medication shall inform each patient that in the event the condition does not improve within five days a physician of the patients choice will be notified An optometrist engaged in a written consultation with an ophthalmologist shall inform a patient diagnosed with glaucoma that the optometrist will have the diagnosis confirmed and co-managed with an ophthalmologist of the patients choice or one selected by the optometrist In addition each optometrist certified to prescribe and use therapeutic drugs shall have posted conspicuously in the office reception area the following notice Dr (Name) OD is certified by New York State to use drugs to diagnose and treat diseases of the eye In the event your condition requires the use of steroids or antiviral medication and your condition does not improve within five days a physician of your choice will be notified In the event you are diagnosed with glaucoma the optometrist will have your diagnosis confirmed and treatment co-managed with an ophthalmologist (MD) of your choice or if you wish one selected by Dr (Name) The second paragraph of such notice is required during the period when the optometrist is engaged in a required written consultation

California In order to receive a glaucoma certification California licensed optometrists must demonstrate that they have collaboratively treated 50 primary open angle glaucoma patients who are over 18 years of age for a period of two years Documentation of the collaborative treatment must accompany this application Such documentation may be provided by completing the ldquoDocumentation of Collaborative Treatment of Glaucoma Patientsrdquo form provided by the Board70

After an optometrist has been issued a license to practice optometry in the State of California heshe may obtain certifications that allow the optometrist to provide certain additional optometric procedures and services Such certifications are listed immediately to the right of the doctors license number The five different certification designations and their meanings are listed below

DPA The DPA designation indicates that the optometrist is certified to use diagnostic pharmaceutical agents for examination purposes only

TPA The TPA designation indicates that the optometrist is certified to use therapeutic pharmaceutical agents and the optometrist may treat certain conditions of the human eye or any of its appendages with therapeutic pharmaceutical agents The optometrist may also perform certain procedures on the eye The therapeutic pharmaceutical agents that may be prescribed the conditions of the eye and the authorized procedures are listed in California Business and Professions Code Section 3041

TPL The TPL designation indicates that in addition to the optometric services described in the TPA section above the optometrist is also certified to perform lacrimal irrigation and dilation procedures for patients over the age of 12 years

70 httpwwwoptometrycagovformspubsglaucoma-certndoc-apppdf

TPG The TPG designation indicates that in addition to the optometric services described in the TPA section above the optometrist is also certified to diagnose and treat primary open angle glaucoma in patients over the age of 18 years

TLG The TLG designation indicates that in addition to the optometric services described in the TPA section above the optometrist is also certified to perform lacrimal irrigation and dilation procedures for patients over the age of 12 years and diagnose and treat primary open angle glaucoma in patients over the age of 18 years

Maryland On July 1 2004 the Maryland General Assembly71 made changes in optometristsrsquo scope of practice under the State Board of Examiners in Optometry including adding continuing education and certification requirements altering what an optometrist can administer and prescribe repealing the treatment plan requirement for a therapeutically certified optometrist to administer and prescribe topical therapeutic pharmaceutical agents for glaucoma only and changing what pharmaceutical agents can be prescribed The bill also repeals the requirement that before a therapeutically certified optometrist may administer and prescribe topical therapeutic pharmaceutical agents for glaucoma the optometrist must jointly and promptly develop a written individualized treatment plan with the ophthalmologist to whom a patient with primary open-angle glaucoma is referred Instead the optometrist must consult with the ophthalmologist regarding the patientrsquos treatment Additionally it repeals the requirement that the patient must be referred to an ophthalmologist at least once a year after the initial mandatory referral If the optometrist consults with an ophthalmologist the optometrist must provide the tests or photos for the ophthalmologistrsquos review RHODE ISLAND72 In December 2007 Rhode Island amended its definition of ldquoamplified optometristrdquo to mean an optometrist licensed to practice optometry and authorized by the Board of Examiners for Optometry to administer and prescribe all topical pharmaceutical agents in the treatment of conditions of the human eye and its appendages including anterior uveitis and glaucoma without surgery or other invasive techniques and in accordance with the requirements herein No optometrist shall perform any surgery for the purpose of detecting any diseased or pathological condition of the eye Only licensed optometrists who have satisfactorily completed a course in pharmacology as it applies to optometry with particular emphasis on the topical application of drugs to the eye for the purposes of detecting any diseased or pathological condition of the eye or the effects of any disease or pathological condition of the eye are permitted to apply pharmaceutical agents topically to the eye for the purpose of detecting any diseased or pathological condition of the eye or the effects of any disease or pathological condition of the eye

71 2004 Session House Bill 1091 72 httpwww2secstateriusdarregdocsreleasedpdfDOH4991pdf STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Department of Health RULES AND REGULATIONS PERTAINING TO OPTOMETRISTS

Therapeutic Pharmaceutical Requirements Related to Amplification of Privileges to Treat Anterior Uveitis and Glaucoma 32 All applicants for initial licensure or any licensed applicant who seek certification to use all topical therapeutic pharmaceuticals used in the treatment of conditions of the human eye and its appendages including but not limited to the removal of superficial foreign bodies from the eye and the treatment of the diseases of anterior uveitis and glaucoma without the use of surgery or other invasive techniques shall have completed the International Association of Boards of Optometry examination in The Treatment and Management of Ocular Disease administered after January 1 1999 Therapeutic Pharmaceutical Requirements to Treat Glaucoma322 Submit a completed form for each patient providing evidence that the applicant has performed written consultations which satisfy the following requirements i) The applicant has consulted with an ophthalmologist or optometrist with amplified privileges to treat glaucoma who is licensed in good standing and who has been treating glaucoma for no less than three (3) years regarding no less than twenty (20) glaucoma-related patients and the ophthalmologist or optometrist with amplified privileges to treat glaucoma who is licensed in good standing and who has been treating glaucoma for no less than three (3) years has provided written confirmation of this consultation ii) Up to ten (10) of these glaucoma-related patients may have been diagnosed as glaucoma-related up to one (1) year prior to completion of the requirements in subsection 321 above All twenty (20) glaucoma-related patients shall be followed for a minimum of one (1) year or until the patient is stabilized (ie symptoms controlled vision loss arrested medication changes not required) whichever is longer and iii) For each glaucoma-related patient the applicant shall develop in consultation with the ophthalmologist or optometrist with amplified privileges to treat glaucoma who is licensed in good standing and who has been treating glaucoma for no less than three (3) years the following A) A confirmatory evaluation and diagnosis by the ophthalmologist or optometrist with amplified privileges to treat glaucoma who is licensed in good standing and who has been treating glaucoma for no less than three (3) years B) A written plan for diagnostic workup for each patient This workup shall be in accordance with the prevailing community standard of care and C) A treatment plan for each patient which shall take into account the assessment of the optic nerve the level of the intraocular pressure and stability of the clinical course iv) The methodology of consultation required in sections 322 (i) and 32 (ii) shall be left to the professional discretion of the ophthalmologist or optometrist with amplified privileges to treat glaucoma who is licensed in good standing and who has been treating glaucoma for no less than three (3) years and the applicant provided however the applicant may submit to the Board of Examiners in Optometry the completed form once the patient has reached the agreed upon treatment plan (including target pressure and compliance with medications)

South Dakota73 Each optometrist certified before July 1 1994 for diagnostic and therapeutic pharmaceutical agents seeking certification for the treatment and management of glaucoma and ocular hypertension must present satisfactory evidence of having achieved a passing score as determined by the institution on an oral or written examination over course work on the treatment and management of glaucoma and ocular hypertension provided by one of the institutions listed in this section and taken after April 30 1994 Satisfactory evidence is a certificate of completion with a passing score from the institution

73 httplegisstatesdusrulesDisplayRuleaspxRule=2050020406

ALLERGIES

INFECTIONS

GLAUCOMA

INFLAMMATION

Kansas Board of Examiners in Optometry

Co-management of Adult Open Angle Glaucoma

New York (Article 143 Optometry Education Law) Optometrists are authorized to prescribe Diagnostic pharmaceuticals Diagnostic pharmaceuticals shall mean those drugs which shall be limited to topical applications to the surface of the eye for the purpose of diagnostic examination of the eye and shall be limited to Anesthetic agents Mydriatics Cycloplegics Cycloplegics Miotics Disclosing agents and other substances used in conjunction with these drugs as part of a diagnostic procedure

Maryland On July 1 2004 the Maryland General Assembly made changes in optometristsrsquo scope of practice under the State Board of Examiners in Optometry including adding continuing education and certification requirements altering what an optometrist can administer and prescribe repealing the treatment plan requirement for a therapeutically certified optometrist to administer and prescribe topical therapeutic pharmaceutical agents for glaucoma only and changing what pharmaceutical agents can be prescribed The bill also repeals the requirement that before a therapeutically certified optometrist may administer and prescribe topical therapeutic pharmaceutical agents for glaucoma the optometrist must jointly and promptly develop a written individualized treatment plan with the ophthalmologist to whom a patient with primary open-angle glaucoma is referred Instead the optometrist must consult with the ophthalmologist regarding the patientrsquos treatment Additionally it repeals the requirement that the patient must be referred to an ophthalmologist at least once a year after the initial mandatory referral If the optometrist consults with an ophthalmologist the optometrist must provide the tests or photos for the ophthalmologistrsquos review

South Dakota Each optometrist certified before July 1 1994 for diagnostic and therapeutic pharmaceutical agents seeking certification for the treatment and management of glaucoma and ocular hypertension must present satisfactory evidence of having achieved a passing score as determined by the institution on an oral or written examination over course work on the treatment and management of glaucoma and ocular hypertension provided by one of the institutions listed in this section and taken after April 30 1994 Satisfactory evidence is a certificate of completion with a passing score from the institution