In a tense New Bern courtroom on Tuesday, a panel of North Carolina judges delved into the heart of a high-stakes legal challenge against the state’s controversial health law, questioning whether restrictions on certain ophthalmology procedures violate constitutional protections. The case, centered in the U.S. District Court for the Eastern District of North Carolina, could reshape access to specialized eye care for millions across the state, pitting patient safety concerns against claims of professional overreach.
Attorneys for the plaintiffs, including the North Carolina Optometric Society and several independent eye care providers, argued that the law—enacted in 2022 as part of House Bill 684—unfairly limits optometrists from performing advanced procedures like laser-assisted cataract surgery and intravitreal injections. These restrictions, they claim, infringe on due process rights and equal protection under the 14th Amendment, while stifling competition in a field desperate for more providers amid a national eye care shortage.
New Bern Hearing Exposes Deep Rifts in Eye Care Regulation
The three-hour hearing in New Bern drew a standing-room-only crowd of ophthalmologists, optometrists, patients, and policymakers. U.S. District Judge Terrence Boyle, presiding alongside Judges Richard Myers and Robert Numbers, peppered both sides with pointed questions about the law’s scope and its real-world effects. “Does this health law truly protect patients, or does it merely shield one profession from another?” Judge Boyle asked plaintifss’ lead counsel, Sarah Jenkins of the Raleigh-based firm Jenkins & Associates.
Jenkins responded forcefully: “Your Honor, North Carolina’s rural communities are losing eye care access daily because of these artificial barriers. We’ve got waiting lists stretching six months for basic procedures that trained optometrists could handle competently.” She cited data from the American Optometric Association showing that North Carolina ranks 42nd nationally in eye care providers per capita, with over 2.5 million residents in underserved areas.
State attorneys, represented by Deputy Attorney General Mark Davis, countered that the restrictions are rooted in evidence-based medicine. “Ophthalmology procedures like YAG laser capsulotomy require surgical precision that optometrists’ training doesn’t match,” Davis argued, referencing a 2021 study by the American Academy of Ophthalmology that reported complication rates 15% higher in non-MD hands for similar interventions. The judges took no immediate action, signaling a ruling could come within weeks.
Spotlight on House Bill 684: The Law Fueling the Firestorm
At the epicenter of this constitutionality battle is House Bill 684, signed into law by Governor Roy Cooper in July 2022 amid lobbying from the North Carolina Medical Society. Dubbed the “Patient Safety and Scope of Practice Act,” it amends existing statutes to confine over a dozen ophthalmology services—ranging from diagnostic fluorescein angiography to therapeutic injections for macular degeneration—to board-certified ophthalmologists only.
Proponents hailed it as a victory for public health, pointing to incidents like a 2020 optometrist-led procedure in Charlotte that led to a patient’s permanent vision loss. “This isn’t about turf wars; it’s about lives,” said Dr. Elena Vasquez, president of the NC Ophthalmology Alliance, in a pre-hearing statement. The law also imposes hefty fines—up to $50,000 per violation—on violators, effectively halting expansion of optometric practices in urban hubs like Raleigh and Charlotte.
Critics, however, decry it as protectionism. A 2023 economic analysis by the Mercatus Center estimated the restrictions could drive up eye care costs in North Carolina by 12-18%, adding $250 million annually to consumer expenses. Rural counties like Hyde and Tyrrell, where the nearest ophthalmologist is over 100 miles away, face the brunt, with optometrists reporting a 30% drop in procedure volumes since implementation.
- Key Restricted Procedures: Laser trabeculoplasty for glaucoma, corneal cross-linking for keratoconus, and anti-VEGF injections for retinal diseases.
- Training Disparity: Optometrists undergo 4 years of specialized school plus residencies; ophthalmologists add 4 years of medical school and 3-4 years residency.
- Enforcement Stats: 47 citations issued in the first year, per NC Board of Optometry records.
Plaintiffs’ Constitutional Arsenal Targets Equal Protection Flaws
The legal challenge, filed in March 2023 by a coalition including Dr. Marcus Hale, a Wilmington optometrist who shuttered his laser suite post-law, hinges on multiple constitutional claims. Foremost is the equal protection clause, alleging the law irrationally discriminates against equally qualified non-MD providers without substantial justification.
“We’ve presented peer-reviewed studies from states like Oklahoma and Kentucky, where optometrists perform these procedures safely with outcomes matching ophthalmologists,” Jenkins told reporters outside court. A landmark 2019 Journal of the American Optometric Association study tracked 5,000 cases, finding no statistical difference in efficacy or safety.
Plaintiffs also invoke the dormant commerce clause, arguing the law hampers interstate telemedicine flows. Dr. Hale testified via video: “Patients from Virginia cross state lines virtually for my care, but now HB 684 blocks that, violating federal commerce protections.” Economic ripple effects include job losses—over 200 optometric positions statewide—and clinic closures in the Piedmont region.
Amicus briefs from the FTC and 15 other states bolster the case, warning of a chilling effect on healthcare innovation. “North Carolina‘s approach risks a provider desert,” read the FTC filing, echoing national trends where scope expansions have boosted access by 22%, per a 2022 RAND Corporation report.
State Defenders Lean on Safety Data and Precedent
Not to be outmatched, the state’s defense wove a tapestry of safety imperatives and judicial precedent. Davis invoked the rational basis review standard, long upheld in cases like Williamson v. Lee Optical (1955), where the Supreme Court deferred to states on medical regulations.
“Even if optometrists are capable, the legislature’s choice to err on caution is constitutional,” he asserted, brandishing NC Department of Health data showing a 7% rise in adverse eye events post-2018 scope expansions elsewhere. Dr. Raj Patel, an ophthalmologist expert witness, detailed procedural complexities: “Intravitreal injections risk endophthalmitis—one wrong move, and a patient goes blind.”
The defense highlighted bipartisan support for HB 684, passing 72-44 in the House and 32-15 in the Senate. Governor Cooper, a Democrat, signed it despite optometric pushback, citing input from 20+ medical boards. “Public trust in healthcare demands these guardrails,” Cooper tweeted post-signing.
Comparative analysis shows North Carolina aligns with conservative states like Texas and Florida, while progressive ones like California grant broader optometric privileges. A table of state variances underscores the patchwork:
| State | Laser Procedures Allowed for Optometrists? | Injections? |
|---|---|---|
| North Carolina | No | No |
| California | Yes (supervised) | Yes |
| Texas | No | No |
| Oklahoma | Yes | Yes |
Patient Stories and Economic Ripples Amplify Stakes
Beyond legalese, human stories dominated sidebars. Testifier Linda Ramirez, a 68-year-old retiree from Greenville, described driving 3 hours to Raleigh for injections now delayed by HB 684. “My vision’s deteriorating while I wait— this law isn’t protecting me,” she lamented.
Economically, the health law reverberates. A University of North Carolina Chapel Hill study projects 15,000 fewer annual procedures by 2025, exacerbating Medicare backlogs where 40% of beneficiaries need eye care. Small practices like Hale’s report 25% revenue dips, threatening closures in high-need areas.
National eyes watch closely; a favorable ruling could embolden challenges in 12 similar states. Optometry groups pledge appeals to the 4th Circuit if needed, potentially reaching the Supreme Court.
Looking ahead, stakeholders brace for impact. If struck down, optometrists could resume services within months, flooding underserved zones. Upholding it might spur legislative tweaks or federal intervention via HR 382, the Protecting Patient Access Act. Either way, North Carolina‘s ophthalmology landscape hangs in the balance, with access hanging by a judicial thread. Court watchers predict a decision by mid-November, setting the stage for appeals that could redefine health law boundaries nationwide.
