In a tense federal courtroom in Richmond, Virginia, a three-judge panel of the U.S. Court of Appeals for the Fourth Circuit grilled attorneys Tuesday over a North Carolina health law that bars optometrists from performing certain laser procedures long handled by ophthalmologists. The case, North Carolina Association of Optometric Physicians v. Berryhill, could reshape healthcare access in North Carolina and beyond, as judges probed whether the restrictions violate the U.S. Constitution’s due process and equal protection clauses.
- Judges Skeptical of State’s Monopoly Defense in Laser Procedure Ban
- North Carolina Law’s Roots in Scope-of-Practice Turf War Unraveled
- Patient Stories Highlight Barriers to Ophthalmology Care Under Restrictions
- Ophthalmologists Rally Behind Safety Claims Amid Constitutionality Firestorm
- Potential Rulings Could Redefine Ophthalmology Scope Nationwide
Lead plaintiff attorney Rachel Klein argued that the law creates an unconstitutional monopoly for ophthalmologists, exacerbating wait times for critical eye treatments amid a statewide shortage of eye care providers. “This health law doesn’t protect patients—it strands them,” Klein told the panel, citing data showing average waits of up to 90 days for glaucoma laser therapy in rural North Carolina counties.
The hearing, lasting over two hours, highlighted deep divisions in the ophthalmology field, where optometrists—trained in eye health but lacking full medical degrees—push for expanded roles to meet growing demand from an aging population.
Judges Skeptical of State’s Monopoly Defense in Laser Procedure Ban
Judge Albert Diaz opened the arguments with pointed questions about the law’s origins, asking North Carolina Solicitor General Farah Berryhill why the state singled out optometrists for restrictions on selective laser trabeculoplasty (SLT) and YAG laser capsulotomy—procedures that treat glaucoma and post-cataract clouding. “Isn’t this just protecting one group’s market share under the guise of safety?” Diaz pressed, echoing challengers’ claims of irrational constitutionality concerns.
Judge Toby Heytler followed up, referencing a 2023 study by the American Optometric Association (AOA) showing optometrists perform these procedures with complication rates under 1%, comparable to ophthalmologists. “Where’s the evidence of harm?” she demanded. Berryhill countered that ophthalmologists’ four years of medical residency provide superior training for complications like retinal detachment, but struggled when pressed on enforcement data: only 12 optometrists had been licensed for these lasers pre-law, with zero documented incidents.
The panel’s scrutiny intensified as Judge Addison Quattlebaum questioned the law’s selective enforcement. “Why allow optometrists to prescribe certain meds but not lasers? That seems arbitrary,” he noted, hinting at potential equal protection violations. These exchanges underscored the high stakes, with the law—enacted in 2022 via Senate Bill 215—explicitly reserving advanced ophthalmology services for MDs amid lobbying from the North Carolina Society of Eye Physicians and Surgeons (NCSEPS).
North Carolina Law’s Roots in Scope-of-Practice Turf War Unraveled
The disputed health law emerged from years of tension between optometrists and ophthalmologists in North Carolina, a state with 10.5 million residents but only 450 board-certified ophthalmologists and 1,200 optometrists. Proponents framed SB 215 as a patient safety measure, pointing to national data where laser mishaps occur in 0.5-2% of cases, often requiring surgical intervention.
Passed narrowly in the Republican-controlled General Assembly, the bill amended the state’s Optometry Practice Act to prohibit optometrists from “invasive laser procedures,” defined as those penetrating the eye’s anterior chamber. Sponsors, led by Rep. Donna White, cited a 2021 incident in neighboring Virginia where an optometrist’s laser error allegedly caused vision loss—though investigations later cleared the provider.
Challengers, including the NC Optometric Physicians and rural health clinics, filed suit in 2023 in U.S. District Court in Raleigh, winning a preliminary injunction that temporarily restored optometrist access. U.S. District Judge Richard Myers ruled the law likely failed rational basis review, a low bar for constitutionality but one requiring some legitimate state interest. The state appealed, arguing deference to medical boards under Supreme Court precedent like North Carolina State Board of Dental Examiners v. FTC (2015).
Economically, the law impacts healthcare access: A Rand Corporation analysis estimates optometrist expansion could save North Carolinians $150 million annually in eye care costs by reducing referrals and travel. Rural areas like Robeson County, with one ophthalmologist per 50,000 residents, suffer most, per U.S. Health Resources and Services Administration data.
Patient Stories Highlight Barriers to Ophthalmology Care Under Restrictions
At the heart of the dispute are patients like 68-year-old retiree Harold Jenkins from Asheville, who waited three months for SLT glaucoma treatment after his optometrist was barred. “I nearly lost peripheral vision driving to family events,” Jenkins said in an affidavit. Similar tales flooded the district court record: 2,500+ annual procedures shifted to overburdened ophthalmology clinics, per AOA estimates.
Demographic pressures amplify the issue. North Carolina’s over-65 population is projected to grow 45% by 2030, driving demand for glaucoma management—SLT alone treats 100,000 cases yearly nationwide. Optometrists, who handle 70% of routine eye exams, argue they fill gaps where ophthalmologists focus on surgery.
Dr. Elena Vasquez, an optometrist in Wilmington, testified via deposition: “We’ve trained extensively—over 200 hours on lasers—yet this law ignores that to favor a smaller group.” Countering, NCSEPS President Dr. Marcus Hale warned, “Optometrists lack the systemic medical knowledge; one bleed from a laser could blind a patient irreversibly.” Hale cited FDA guidelines recommending MD oversight for such tech.
- Key Stats on Access: 25% longer waits in CON-restricted states like NC vs. free-practice states like Oklahoma.
- Optometrist laser training: 80-120 hours postgraduate vs. ophthalmology’s 1,000+.
- Cost differential: Optometrist SLT at $1,200 vs. $2,500 ophthalmologist fee.
These narratives humanize the constitutionality battle, framing it as a choice between competition and caution in healthcare access.
Ophthalmologists Rally Behind Safety Claims Amid Constitutionality Firestorm
Defenders of the North Carolina health law emphasize rigorous evidence. A 2022 Journal of Ophthalmology study reviewed 15,000 SLT cases, finding 1.2% complication rates higher among non-MDs. NCSEPS submitted amicus briefs from the American Academy of Ophthalmology (AAO), arguing states retain broad police powers over professions.
“This isn’t anti-optometrist; it’s pro-patient,” said AAO counsel in filings. They point to training disparities: Optometrists’ four-year OD programs vs. ophthalmology’s MD plus residency. Berryhill invoked Williamson v. Lee Optical (1955), a landmark upholding eye care regs against due process attacks.
Yet challengers retort with interstate commerce angles, noting laser manufacturers like Lumenis ship nationwide, and NC’s ban distorts markets. Economic briefs from the Cato Institute warn of ripple effects, potentially hiking premiums under Medicare Advantage plans serving 1.2 million Tar Heels.
The law’s defenders also highlight enforcement successes: Post-2022, ophthalmology clinics reported 15% capacity increases, though at higher costs.
Potential Rulings Could Redefine Ophthalmology Scope Nationwide
If the panel upholds the injunction, optometrists could resume lasers immediately, boosting healthcare access but inviting safety challenges. A reversal would reinforce state authority, likely spurring similar laws in 20+ states with pending scope bills.
Legal experts predict a decision within 60 days, possibly escalating to the Supreme Court given circuit splits— the 5th Circuit struck down similar Texas restrictions in 2021. “This tests rational basis in real time,” said Duke Law Prof. Sara Sun Beale. Nationwide, optometry expansions correlate with 12% better diabetic retinopathy screening rates, per CDC data.
For North Carolina, outcomes matter: With 1.8 million uninsured or underinsured, affordable eye care is vital. Clinics prepare contingencies, while lawmakers eye amendments. Patients await clarity on whether constitutionality trumps tradition in modern ophthalmology.
