Few topics in optometry generate as much debate as scope of practice expansion. Supporters argue that expanded authority improves access to care, particularly in underserved areas.
Critics, meanwhile, have raised concerns that allowing optometrists to perform procedures such as injections, laser treatments, and expanded medication management could increase patient safety risks and expose practitioners to greater malpractice liability.
- See here for the latest in scope of practice legislative news.
At the same time, optometry itself has changed dramatically over the past few decades. Therapeutic prescribing authority has expanded nationwide, oral medications are now permitted in all 50 states, and several states have authorized procedures that were once outside the profession’s scope.
So with all of this in mind—what’s our topic of conversation?
A recent study published in Optometry and Vision Science set out to examine whether those changes have translated into greater malpractice risk.
Using nearly three decades of National Practitioner Data Bank (NPDB) records, researchers analyzed malpractice payments involving optometrists across the United States and compared trends in states with expanded scope laws to national patterns.
- To note: The NPDB is a federal database that tracks malpractice payments and certain adverse actions involving healthcare providers throughout the United States.
Why has optometric scope expansion become such a heated issue?
The scope of optometric practice in the United States has changed dramatically since the 1990s.
According to the study authors, optometrists could prescribe therapeutic medications in only about half of states in 1990.
Fast forward to 2024: All 50 states allow therapeutic and oral prescribing authority, while additional states have begun to authorize procedures such as injections, lesion removal, and laser treatments.
And what specific arguments have risen from this?
Those expansions have frequently generated debate surrounding patient safety and procedural competency.
But despite the policy discussions, relatively little national data has examined whether expanded optometric privileges actually translate into increased malpractice exposure.
The researchers noted that understanding malpractice trends could help inform:
- Legislation
- Clinical training
- Patient safety discussions
- Risk mitigation strategies
They also pointed out that perceived malpractice risk can influence clinical decision-making itself.
So what exactly did they investigate?
The researchers performed a retrospective analysis of publicly available NPDB data from 1996 through 2023, examining:
- Number of malpractice payments
- Payment amounts
- Provider age
- Patient demographics
- Allegation categories
- Geographic distribution
- Long-term liability trends
The team also conducted a separate analysis focused on states that had expanded optometric scope before 2023.
Among those states: Oklahoma, Kentucky, Louisiana, Alaska, Wisconsin, Arkansas, Indiana, Mississippi, Wyoming, Colorado, and Virginia.
They then compared malpractice patterns before and after scope expansion within those states.
What participants did the study actually analyze?
Across the full study period, researchers identified 1,040 malpractice payments made on behalf of optometrists in the United States.
That averaged roughly 38 to 39 paid malpractice events per year nationwide.
Additional findings included:
- Mean payment amount: approximately $220,918 inflation-adjusted
- Provider average age: 43 years
- 56% of cases involved patients older than 50
- Some claims involved multiple providers simultaneously
The study also evaluated allegation categories attached to malpractice claims.
… and what did the researchers find?
One of the clearest findings: Malpractice payments involving optometrists remained relatively uncommon overall.
Researchers found no statistically significant increase in annual malpractice case numbers over time, and—perhaps more importantly—expanded-scope states generally mirrored national trends.
According to the analysis, there was no statistically significant increase in malpractice cases after scope expansion in nearly all evaluated states; Indiana was the lone exception in reaching statistical significance.
Tell me more.
The study also found that:
- Most claims were diagnostic rather than procedural
- “Failure to diagnose” accounted for roughly 40% of allegations
- Procedure-related allegations represented a much smaller proportion of claims
The authors specifically noted that the data did not support claims that expanded procedural authority had compromised patient safety.
Did they give a reason for why malpractice rates have stayed relatively stable?
The discussion section explored several possible reasons malpractice trends may have remained relatively stable despite expanding clinical responsibilities.
One major theme: education.
The authors described how optometric education has evolved substantially over the past few decades, shifting from a primarily refraction-focused curriculum toward broader systemic disease management, pharmacology, and interdisciplinary care.
They also highlighted:
- Increased residency participation
- Stronger continuing education systems
- Expanded communication training
- Evidence-based clinical practice models
Anything else?
Technology may also be contributing.
The paper discussed how tools such as optical coherence tomography (OCT) and widefield imaging have improved early disease detection and strengthened clinical documentation.
Researchers suggested those advances may reduce liability exposure by improving diagnostic accuracy and objective disease monitoring.
The study additionally noted that laser-related malpractice claims did not appear to rise in states where optometrists gained laser privileges.
- The authors suggested formalized credentialing and procedural training programs may partially explain that finding.
Are there any important limitations here?
The authors acknowledged several important limitations.
First, malpractice payments involving optometrists remain relatively rare events overall, which limits statistical power for some state-level analyses.
The NPDB also does not provide highly granular clinical details. Researchers could not determine:
- Specific diseases involved
- Exact procedures tied to claims
- Severity of outcomes
- Whether claims directly stemmed from injections, prescribing, or lasers
As a result, the findings reflect broader malpractice patterns rather than procedure-specific risk profiles.
The paper also noted that malpractice databases likely underrepresent the true number of adverse clinical events overall because not every complication results in litigation or formal payment reporting.
What are clinicians saying about the findings?
The study authors argued that the results challenge a common assumption in scope-of-practice debates: that broader procedural authority leads to increased malpractice exposure.
The authors suggested that advances in education, credentialing requirements, continuing education, and diagnostic technology may have helped support patient safety as optometrists assumed greater clinical responsibilities.
What else stood out?
Although the study focused on historical malpractice data, the authors noted that future liability patterns may not look exactly the same.
Case in point: Healthcare delivery continues to evolve through increased use of electronic health records (EHRs), artificial intelligence (AI)-assisted imaging, telehealth, and changing communication models.
- Each of those developments could influence how care is delivered, documented, and evaluated in future malpractice claims.
For that reason, the authors believe ongoing monitoring will remain important as scope expansion laws mature and longer-term data become available.
And lastly—the take home.
This NPDB analysis found that malpractice payments involving optometrists remained relatively uncommon from 1996 through 2023.
To summarize:
- Researchers found no evidence that expanded authority involving lasers, injections, or oral medications broadly increased malpractice risk.
- Most claims continued to involve diagnostic issues rather than procedural complications, and states with expanded scope laws generally mirrored national trends.
Taken together, the findings suggest that advances in education, training, technology, and clinical oversight may be helping maintain patient safety as optometry's role continues to change.