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Opinion: Safe eye surgery requires more than a Golden Ticket

Optometrists aren’t eye surgeons. Yet Colorado lawmakers have printed up a new law that allows them to do surgery, with minimal training

The classic film “Willy Wonka & the Chocolate Factory” has Gene Wilder as the title character nonchalantly warning, “Stop. Don’t,” as various children try unknown confections and experience unanticipated “complications.” Of course, each instance ends with predictably unfortunate results.

Craig H. Kliger, M.D.

In what seems a move worthy of Wonka’s caveat, the Colorado General Assembly has allowed optometrists to do eye surgery with lasers and scalpels despite the fact the legislation has no clear requirement for training on live human patients, and realistically no meaningful amount of such training will occur.

I will give the optometrists and bill sponsors points for political savvy. They successfully countered eye physicians’ (ophthalmologists) suggestions that seven years of additional training were needed to do a small subset of eye surgeries by painting those procedures as “non-dangerous.” They did this by using terms such as “non-thermal” for lasers, and “lumps and bumps” for eyelid lesions instead of “tumors.”

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In short, the General Assembly — which, for the most part, is composed of those without expertise in surgery — wasn’t buying the need for such extensive training. Yet, the ability to render potentially sight-threatening surgical care without at least reasonable training shouldn’t be a political “prize.” 

Indeed, the bill requires new graduates from schools where the procedures are “taught” to simply pass a standardized examination that the Colorado State Board of Optometry deems “tests the qualifications of the applicant to practice optometry…” Note that a single such examination testing surgical skills currently exists and is performed completely on plastic or rubber models.

However, that test could simply be forgone by the board in lieu of “multiple choice” ones already taken. Furthermore, since only about 90 of the 1,650 annual U.S. optometric graduates attend a school where actual human training is currently legal (two of 23), it seems naïve to think the vast majority could have meaningful human experience.

Those currently out in practice would seemingly be no better qualified. They would complete an “approved” course (existing ones are typically 16 hours each for eyelid and laser eye surgery and include about 4 hours of lab experience that can’t possibly allow meaningful human experience), as well as a “proctored clinical session” — that might not require such experience, either.

Interestingly, before the bill was finalized, the term “non-thermal” as applied to laser treatment was deleted. Proponents likely realized eye surgery lasers use heat to alter or even destroy tissue to achieve the needed effect. However, given that change, it then seems legitimate to ask what other safety issues may have been downplayed that will only be discovered upon implementation of the law?

You might wonder why anyone would want to do surgery without training on live humans? Having done all these procedures myself, I have no answer other than a lack of understanding of what is involved due to inexperience.

Living eyes – unlike plastic models – actually blink and move, as do related tissues, making treatment that much more difficult (and increasing the odds of causing unpredictable damage). Furthermore, living human tissue actually responds to treatment, and that response can vary significantly among patients.

For example, when treating glaucoma, the intent is to lower eye pressure by stimulating fluid drainage out of the eye. Overtreatment, however, can— for lack of a better word — “cook” the involved delicate eye structures, rendering them non-functional and actually raising eye pressure, making glaucoma worse. Meanwhile, undertreatment may have no effect, wasting both a patient’s time and scarce healthcare dollars to perform a procedure of no value.

There are also complications — in some cases potentially sight-threatening ones — which optometrists also tend to downplay. Yes, these can happen to anyone, including the well-trained. It’s just that the well trained are actually better prepared to avoid them, and to manage them when they do (and will) happen.

I recognize by now you may be asking why Coloradans should care about what someone from California thinks. While it has been said all politics are local, the skills required to do surgical procedures are no different in our two states.

I further recognize that proponents of the bill will label me — an ophthalmologist — as intrinsically biased. But, would you or a loved one want to undergo eye surgery by optometrists “trained” this way, particularly when it is very possible the first “real” surgery they perform will be in their own office where no one will be available to come to the rescue should something go wrong?

Mark Twain said, “It is better to deserve honors and not have them, than to have them and not deserve them.” Surgical privileges are no different. Had I been allowed to do any surgery with the “training” called for in this bill, not only would I have been incompetent, I would have been terrified.

Colorado patients should be similarly afraid.

So, before the governor approves this less-than-fully-cooked idea, he might heed Wonka’s warning to young Violet Beauregarde as she started chewing a piece of gum that ended up having the unanticipated “complication” of turning her into a giant blueberry: “Oh! I wouldn’t do that. I really wouldn’t.”


Craig H. Kliger, M.D., of San Francisco, is executive vice president of the California Academy of Eye Physicians and Surgeons.


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