Should Optometry Play a Bigger Role in Wet AMD Monitoring?

As U.S. optometrists push to expand their scope of practice, a recent British randomized trial suggested that community optometrists could safely play a large role in the monitoring of neovascular (wet) age-related macular degeneration (AMD).

In the FENETRE trial published in JAMA Network Open, community optometrists were able to monitor patients with quiescent wet AMD about as well as hospital-based clinicians supervised by ophthalmologists, reported Konstantinos Balaskas, MD, of University College London Institute of Ophthalmology, and colleagues.

In interviews with MedPage Today, optometrists said the findings support giving optometry a larger stake in AMD care. However, an accompanying commentary warned that the results of the study “should not be extrapolated to support independent optometrist therapeutic decision-making or intravitreal injection administration.”

Optometrists Push for Wider Scopes of Practice

Like specialists in other fields such as physician assistants and nurse anesthetists, optometrists have sparked controversy by trying to expand their scope of practice so they can provide more types of medical care.

Optometrists have gained the right to perform certain ophthalmic laser procedures in at least 16 states, according to the American Optometric Association, and their scope of practice has also expanded to include surgery in some states. But these efforts have faced resistance from ophthalmologists, and there have been several failed legislative efforts to prevent optometrists from being called doctors or physicians.

Mark T. Dunbar, OD, of Bascom Palmer Eye Institute at the University of Miami, told MedPage Today that optometrists can diagnose and manage non-vascular (dry) AMD. And while they can monitor wet AMD cases between visits to retinal specialists, he said, no states allow them to provide the standard treatment of intravitreal injections.

Community Versus Hospital-Based Care

The FENETRE trial examined what happened in the U.K. when community optometrists took on the responsibility of monitoring wet AMD.

Researchers recruited 704 adults ages 55 and older with quiescent wet AMD in at least one eye following anti-VEGF therapy. They were randomly assigned to a year of monitoring every 2 months in either hospitals or community optometrist practices with the aim of detecting progression that required treatment.

A total of 635 patients completed at least one follow-up. Mean age was 80-81, and the majority were women.

In hospitals, patients were monitored by multidisciplinary teams under consultant ophthalmologist oversight (medical retina fellows, trainees, hospital optometrists, and/or nurses). In the community, specially chosen and trained optometrists provided the monitoring services.

Comparable Results

Per the primary outcome, false-negative clinical management decisions were more common in hospitals (7.8%) than in the community setting (3.8%), meeting noninferiority criteria. False-positive clinical management decisions occurred in 3.5% of hospital participants versus 8.4% of community participants.

Trained community optometrists can monitor quiescent wet AMD “with a level of safety comparable to specialist hospital clinics,” the authors noted. “The consistently low rate of missed reactivations” suggests that both hospital-based and community monitoring strategies “can support safe [neovascular] AMD monitoring.”

Ophthalmologist Warns About Moving Too Fast

In the accompanying commentary, ophthalmologist Sally S. Ong, MD, and medical student Isaiah J. Miller, of Wake Forest University School of Medicine in Winston-Salem, North Carolina, noted that wet AMD care requires frequent clinic visits. They highlighted a study that found that patients averaged 8.1 clinic visits per eye in the first 12 months of care.

“The high burden of disease monitoring and treatment creates an enormous strain on specialist clinics and hospitals,” Ong and Miller wrote.

However, they cautioned that the study did not prove that all community optometrists can safely monitor wet AMD since participants were specially chosen and trained. Furthermore, the study wasn’t designed to pit ophthalmologists against optometrists, they added.

Ong and Miller contended that the study only provides support for wet AMD monitoring by optometrists within the specific context of the research, which took place in a country, unlike the U.S., with national optometrist credentialing and a single-payer system.

“The results of this trial must not be overinterpreted to promote unsupervised clinical decision-making by optometrists outside an integrated care pathway to perform intravitreal injections,” they noted.

They also pointed out that the American Academy of Ophthalmology (AAO) opposes expanding the scope of practice of optometrists to include intravitreal injections.

Optometrists Weigh In

In an interview, Teri Geist, OD, president of the American Optometric Association, said the study “supports a larger role for doctors of optometry in monitoring appropriately selected patients with dormant neovascular AMD.”

The research shows that “optometrists tended to err on the side of patient safety,” she told MedPage Today. “The community group had more false positives, and 16% of participants received a ‘suspicious’ classification that prompted referral. The authors correctly characterize that as a safety-first approach rather than missed disease.”

Dunbar, the Miami optometrist, said he was “a little insulted” by the commentary and its focus on the qualifications of ophthalmologists. He added that talk of expanding the scope of practice of optometrists to include intravitreal injections is a “scare tactic” by the AAO.

In the U.S., each state determines the scope of practice for optometrists. There doesn’t appear to be any significant movement to grant optometrists the right to give intravitreal injections. In 2025, a bill in Minnesota aimed to do just that, but it failed to progress in the state legislature.

It makes sense for optometrists to monitor patients with wet AMD for signs of worsening, Dunbar said, especially in light of the current patient burden on retinal specialists. Moreover, optometrists now routinely rely on optical coherence tomography, which helps the monitoring process, he pointed out.