Today's Law As Amended


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AB-407 Optometry: assistants and scope of practice.(2021-2022)



As Amends the Law Today


SECTION 1.

 The heading of Chapter 5.4 (commencing with Section 2540) of Division 2 of the Business and Professions Code is amended to read:

CHAPTER  5.4. Prescription Lenses and Ophthalmic and Optometric Assistants

SEC. 2.

 Section 2544 of the Business and Professions Code is amended to read:

2544.
 (a) Notwithstanding any other provision of law, an assistant in any setting where optometry or ophthalmology is practiced who is acting under the direct responsibility and supervision of a physician and surgeon or optometrist may fit prescription lenses. Under the direct responsibility and supervision of an ophthalmologist or optometrist, an assistant in any setting where optometry or ophthalmology is practiced may also do the following:
(1) Prepare patients for examination.
(2) Collect preliminary patient data, including taking a patient history.
(3) Perform simple noninvasive testing of visual acuity, pupils, and ocular motility.
(4) Perform automated visual field testing.
(5) Perform ophthalmic photography and digital imaging.
(6) Perform tonometry.
(7) Perform lensometry.
(8) Perform nonsubjective auto refraction.
(8) (9)  Perform nonsubjective auto preliminary subjective  refraction procedures  in connection with finalizing  subjective refraction procedures performed by an ophthalmologist or optometrist. optometrist, subject to the following conditions: 
(A) The assistant shall have at least 45 hours of documented training in subjective refraction procedures acceptable to the supervising ophthalmologist or optometrist.
(B) Any preliminary subjective refraction procedures shall be performed as follows:
(i) When the supervising physician and surgeon or optometrist is physically present at the location where the procedures are being performed, and not involving telehealth services.
(ii) In conjunction with an in-person examination being performed by the supervising physician and surgeon or optometrist.
(iii) With a supervisory ratio of no more than three assistants per supervising ophthalmologist or optometrist during the supervisor’s work shift.
(C) An assistant performing preliminary subjective refraction procedures may utilize appropriate related equipment, including, but not limited to, a phoropter, trial lenses, and a retinoscope, solely for the purpose of performing those procedures.
(D) An assistant may not prescribe glasses or contact lenses, and nothing in this section shall be interpreted as authorizing those activities.
(9) (10)  Administer cycloplegiacs, cycloplegics,  mydriatics, and topical anesthetics that are not controlled substances, for ophthalmic purposes.
(10) (11)  Perform pachymetry, keratometry, A scans, B scans,  scan and B scan ultrasound testing,  and electrodiagnostic testing.
(b) For the purposes of this section, “setting” includes, but is not limited to, any facility licensed by the State Department of Public Health or the State Department of Social Services.
(c) Nothing in this section shall be construed to authorize activities that corporations and other artificial legal entities are prohibited from conducting by Section 2400.

SEC. 2.1.

 Section 2544 of the Business and Professions Code is amended to read:

2544.
 (a) Notwithstanding any other provision of law, an assistant in any setting where optometry or ophthalmology is practiced who is acting under the direct responsibility and supervision of an optometrist or  a physician and surgeon or optometrist  may fit prescription lenses. Under the direct responsibility and supervision of an ophthalmologist optometrist  or optometrist, ophthalmologist,  an assistant in any setting where optometry or ophthalmology is practiced may also do the following:
(1) Prepare patients for examination.
(2) Collect preliminary patient data, including taking a patient history.
(3) Perform simple noninvasive testing of visual acuity, pupils, and ocular motility.
(4) Perform automated visual field testing.
(5) Perform ophthalmic photography and digital imaging.
(6) Perform tonometry.
(7) Perform lensometry.
(8) Perform nonsubjective auto refraction.
(8) (9)  Perform nonsubjective auto preliminary subjective  refraction procedures  in connection with finalizing  subjective refraction procedures performed by an ophthalmologist or optometrist. optometrist, subject to the following conditions: 
(A) The assistant shall have at least 45 hours of documented training in subjective refraction procedures acceptable to the supervising ophthalmologist or optometrist.
(B) Any preliminary subjective refraction procedures shall be performed as follows:
(i) When the supervising physician and surgeon or optometrist is physically present at the location where the procedures are being performed, and not involving telehealth services.
(ii) In conjunction with an in-person examination being performed by the supervising physician and surgeon or optometrist.
(iii) With a supervisory ratio of no more than three assistants per supervising ophthalmologist or optometrist during the supervisor’s work shift.
(C) An assistant performing preliminary subjective refraction procedures may utilize appropriate related equipment, including, but not limited to, a phoropter, trial lenses, and a retinoscope, solely for the purpose of performing those procedures.
(D) An assistant may not prescribe glasses or contact lenses, and nothing in this section shall be interpreted as authorizing those activities.
(9) (10)  Administer cycloplegiacs, cycloplegics,  mydriatics, and topical anesthetics that are not controlled substances, for ophthalmic purposes.
(10) (11)  Perform pachymetry, keratometry, A scans, B scans,  scan and B scan ultrasound testing,  and electrodiagnostic testing.
(b) For the purposes of this section, “setting” includes, but is not limited to, any facility licensed by the State Department of Public Health or the State Department of Social Services.
(c) Nothing in this section shall be construed to authorize activities that corporations and other artificial legal entities are prohibited from conducting by Section 2400.

SEC. 3.

 Section 3041 of the Business and Professions Code is amended to read:

3041.
 (a) The practice of optometry includes the prevention and diagnosis diagnosis, prevention, treatment, and management  of disorders and dysfunctions of the visual system, and the treatment and management of certain disorders and dysfunctions of the visual system, as  as authorized by this chapter, as  well as the provision of habilitative or rehabilitative optometric services, and is the doing of any or all of the following:
(1) The examination of the human eye or eyes, or its or their appendages, and  eyes and their adnexa, including through the use of all topical and oral diagnostic pharmaceutical agents that are not controlled substances, and  the analysis of the human vision system, either subjectively or objectively.
(2) The determination of the powers or range of human vision and the accommodative and refractive states of the human eye or  eyes, including the scope of its or  their functions and general condition.
(3) The prescribing  prescribing, using,  or directing the use of, or using,  of  any optical device in connection with ocular exercises, visual training, vision training, or orthoptics.
(4) The prescribing of contact and spectacle lenses for, or the fitting or  prescribing, fitting, or  adaptation of contact and spectacle lenses to, the human eye, eyes,  including lenses that may be classified as drugs or devices by any law of the United States or of this state. state, and diagnostic or therapeutic contact lenses that incorporate a medication or therapy the optometrist is certified to prescribe or provide. 
(5) The use of topical pharmaceutical agents for the purpose of the examination of the human eye or eyes for any disease or pathological condition.
(b) (5)  (1) For  An optometrist who is certified to use therapeutic pharmaceutical agents,   an optometrist certified  pursuant to Section 3041.3, may also diagnose and treat the human eye or eyes, or any of its or their appendages, for all of the following conditions: diagnosing and preventing conditions and diseases of the human eyes and their adnexa, and treating nonmalignant conditions and diseases of the anterior segment of the human eyes and their adnexa, including ametropia and presbyopia: 
(A) Through medical treatment, infections of the anterior segment and adnexa, excluding the lacrimal gland, the lacrimal drainage system, and the sclera in patients under 12 years of age.
(B) Ocular allergies of the anterior segment and adnexa.
(C) Ocular inflammation, nonsurgical in cause except when comanaged with the treating physician and surgeon, limited to inflammation resulting from traumatic iritis, peripheral corneal inflammatory keratitis, episcleritis, and unilateral nonrecurrent nongranulomatous idiopathic iritis in patients over 18 years of age.
(D) Traumatic or recurrent conjunctival or corneal abrasions and erosions.
(E) Nonmalignant ocular surface disease and dry eye disease.
(F) Ocular pain, nonsurgical in cause except when comanaged with the treating physician and surgeon, associated with conditions optometrists are authorized to treat.
(G) Hypotrichosis and blepharitis.
(H) Pursuant to subdivision (e), glaucoma in patients over 18 years of age, as described in subdivision (k).
(2) For purposes of this section, “treat” means the use of therapeutic pharmaceutical agents, as described in subdivision (c), and the procedures described in subdivision (d).
(c) (A)  In diagnosing and treating the conditions listed in subdivision (b), an optometrist certified to use therapeutic pharmaceutical agents pursuant to Section 3041.3 may use or prescribe, including for rational off-label purposes, all of the following therapeutic pharmaceutical agents: Using or prescribing, including for rational off-label purposes, topical and oral prescription and nonprescription therapeutic pharmaceutical agents that are not controlled substances and are not antiglaucoma agents or limited or excluded by subdivision (b). For purposes of this section, “controlled substance” has the same meaning as used in the California Uniform Controlled Substances Act (Division 10 (commencing with Section 11000) of the Health and Safety Code) and the United States Uniform Controlled Substances Act (21 U.S.C. Sec. 801 et seq.).  
(1) Topical pharmaceutical agents for the examination of the human eye or eyes for any disease or pathological condition, including, but not limited to, topical miotics.
(2) Topical lubricants.
(3) Antiallergy agents. In using topical steroid medication for the treatment of ocular allergies, an optometrist shall consult with an ophthalmologist if the patient’s condition worsens 21 days after diagnosis.
(4) Topical and oral anti-inflammatories.
(5) Topical antibiotic agents.
(6) Topical hyperosmotics.
(7) Topical and oral antiglaucoma agents pursuant to the certification process defined in subdivision (e).
(8) Nonprescription medications used for the rational treatment of an ocular disorder.
(9) Oral antihistamines.
(10) Prescription oral nonsteroidal anti-inflammatory agents.
(11) Oral antibiotics for medical treatment of ocular disease.
(12) Topical and oral antiviral medication for the medical treatment of herpes simplex viral keratitis, herpes simplex viral conjunctivitis, periocular herpes simplex viral dermatitis, varicella zoster viral keratitis, varicella zoster viral conjunctivitis, and periocular varicella zoster viral dermatitis.
(13) Oral analgesics that are not controlled substances.
(14) (B)  Codeine  Prescribing the oral analgesic controlled substance codeine  with compounds, hydrocodone with compounds, and tramadol as listed in the California Uniform Controlled Substances Act (Division 10 (commencing with Section 11000) of the Health and Safety Code) and the United States Uniform Controlled Substances Act (21 U.S.C. Sec. 801 et seq.). The use of these agents shall be  seq.),  limited to three days, with a  referral to an ophthalmologist if the pain persists.
(15) Additional therapeutic pharmaceutical agents pursuant to subdivision (f).
(d) (C)  An optometrist who is certified to use therapeutic pharmaceutical agents pursuant to Section 3041.3 may also perform all of the following procedures: If also certified under subdivision (c), using or prescribing topical and oral antiglaucoma agents for the medical treatment of all primary open-angle, exfoliation, pigmentary, and steroid-induced glaucomas in persons 18 years of age or over. In the case of steroid-induced glaucoma, the prescriber of the steroid medication shall be promptly notified if the prescriber did not refer the patient to the optometrist for treatment. 
(1) Corneal scraping with cultures.
(2) Debridement of corneal epithelia.
(3) Mechanical epilation.
(4) Collection of blood by skin puncture or venipuncture for testing patients suspected of having diabetes.
(5) (D)  Suture removal, with prior consultation with the treating physician and surgeon. If also certified under subdivision (d), administration of immunizations for influenza, herpes zoster virus, pneumococcus, and SARS-CoV-2 in compliance with individual Advisory Committee on Immunization Practices (ACIP) vaccine recommendations published by the federal Centers for Disease Control and Prevention (CDC) in persons 18 years of age or over. 
(6) Treatment or removal of sebaceous cysts by expression.
(7) Administration of oral fluorescein to patients suspected as having diabetic retinopathy.
(8) Use of an auto-injector to counter anaphylaxis.
(9) (E)  Ordering of smears, cultures, sensitivities, complete blood count, mycobacterial culture, acid fast stain, urinalysis, tear fluid analysis, and X-rays Utilizing the following techniques and instrumentation  necessary for the diagnosis of conditions or and  diseases of the eye or adnexa. An optometrist may order other types of images subject to prior consultation with an ophthalmologist or appropriate physician and surgeon. and adnexa: 
(i) Laboratory tests or examinations ordered from an outside facility.
(10) (ii)  A clinical laboratory test or examination  Laboratory tests or examinations performed in an office  classified as waived under the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA) (42 U.S.C. Sec. 263a; Public Law 100-578) and designated in paragraph (9) necessary for the diagnosis of conditions and diseases of the eye or adnexa, or if otherwise specifically authorized by this chapter. 100-578), which shall also be allowed for detecting indicators of possible systemic disease that manifests in the eye for the purpose of facilitating appropriate referral to or consultation with a physician and surgeon. 
(iii) Skin testing performed in an office to diagnose ocular allergies, limited to the superficial layer of the skin.
(iv) X-rays ordered from an outside facility.
(v) Other imaging studies ordered from an outside facility subject to prior consultation with an appropriate physician and surgeon.
(vi) Other imaging studies performed in an office, including those that utilize laser or ultrasound technology, but excluding those that utilize radiation.
(F) Performing the following procedures, which are excluded from restrictions imposed on the performance of surgery by paragraph (6) of subdivision (b), unless explicitly indicated:
(i) Corneal scraping with cultures.
(ii) Debridement of corneal epithelium not associated with band keratopathy.
(iii) Mechanical epilation.
(iv) Collection of blood by skin puncture or venipuncture for laboratory testing authorized by this subdivision.
(11) (v)  Punctal occlusion by plugs, excluding laser, diathermy, cryotherapy, or other means constituting surgery as defined in this chapter. Suture removal subject to comanagement requirements in paragraph (7) of subdivision (b). 
(vi) Treatment or removal of sebaceous cysts by expression.
(12) (vii)  The use or prescription of diagnostic or therapeutic contact lenses, including lenses or devices that incorporate a medication or therapy  Lacrimal punctal occlusion using plugs, or placement of a stent or similar device in a lacrimal canaliculus intended to deliver a medication  the optometrist is certified to prescribe or provide.
(13) (viii)  Removal of foreign bodies  Foreign body and staining removal  from the cornea, eyelid, and conjunctiva with any appropriate instrument other than a scalpel. Corneal foreign bodies shall be nonperforating, be  instrument. Removal of corneal foreign bodies and any related stain shall, as relevant, be limited to that which is nonperforating,  no deeper than the midstroma, and require no surgical repair upon removal. not reasonably anticipated to require surgical repair. 
(14) (ix)  For patients over  Lacrimal irrigation and dilation in patients  12 years of age, lacrimal irrigation and dilation,  age or over,  excluding probing of the nasal lacrimal  nasolacrimal  tract. The board shall certify any optometrist who graduated from an accredited school of optometry before May 1, 2000, to perform this procedure after submitting proof of satisfactory completion of 10 procedures under the supervision of an ophthalmologist as confirmed by the ophthalmologist. Any optometrist who graduated from an accredited school of optometry on or after May 1, 2000, shall be exempt from the certification requirement contained in this paragraph.
(x) Administration of oral fluorescein for the purpose of ocular angiography.
(15) (xi)  Intravenous injection for the purpose of performing ocular angiography at the direction of an ophthalmologist as part of an active treatment plan in a setting where a physician and surgeon is immediately available.
(16) (xii)  Skin testing to diagnose ocular allergies, limited to the superficial layer of the skin. Use of noninvasive devices delivering intense pulsed light therapy or low-level light therapy that do not rely on laser technology, limited to treatment of conditions and diseases of the adnexa. 
(xiii) Use of an intranasal stimulator in conjunction with treatment of dry eye syndrome.
(G) Using additional noninvasive medical devices or technology that:
(i) Have received a United States Food and Drug Administration-approved indication for the diagnosis or treatment of a condition or disease authorized by this chapter. A licensee shall successfully complete any clinical training imposed by a related manufacturer prior to using any of those noninvasive medical devices or technologies.
(ii) Have been approved by the board through regulation for the rational treatment of a condition or disease authorized by this chapter. Any regulation under this paragraph shall require a licensee to successfully complete an appropriate amount of clinical training to qualify to use each noninvasive medical device or technology approved by the board pursuant to this paragraph.
(b) Exceptions or limitations to the provisions of subdivision (a) are as follows:
(1) Treatment of the following is excluded from the practice of optometry in a patient under 18 years of age, unless explicitly allowed otherwise:
(A) Anterior segment inflammation, which shall not exclude treatment of:
(i) The conjunctiva.
(ii) Nonmalignant ocular surface disease, including dry eye syndrome.
(iii) Contact lens-related inflammation of the cornea.
(iv) An infection of the cornea.
(B) Conditions or diseases of the sclera.
(2) Use of any oral prescription steroid anti-inflammatory medication for a patient under 18 years of age shall be done pursuant to a documented, timely consultation with an appropriate physician and surgeon.
(3) Use of any nonantibiotic oral prescription medication for a patient under five years of age shall be done pursuant to a documented, prior consultation with an appropriate physician and surgeon.
(4) The following classes of agents are excluded from the practice of optometry unless they have an explicit United States Food and Drug Administration-approved indication for treatment of a condition or disease authorized under this section:
(A) Antiamoebics.
(B) Antineoplastics.
(C) Coagulation modulators.
(D) Hormone modulators.
(E) Immunomodulators.
(5) The following are excluded from authorization under subparagraph (G) of paragraph (5) of subdivision (a):
(A) A laboratory test or imaging study.
(17) (B)  Use of any noninvasive medical  Any noninvasive  device or technology authorized pursuant to subdivision (f). that constitutes surgery under paragraph (6). 
(6) Performing surgery is excluded from the practice of optometry. “Surgery” means any act in which human tissue is cut, altered, or otherwise infiltrated by any means. It does not mean an act that solely involves the administration or prescribing of a topical or oral therapeutic pharmaceutical.
(7) (A) Treatment with topical and oral medications authorized in subdivision (a) related to an ocular surgery shall be comanaged with the ophthalmologist that performed the surgery, or another ophthalmologist designated by that surgeon, during the customary preoperative and postoperative period for the procedure. For purposes of this subparagraph, this may involve treatment of ocular inflammation in a patient under 18 years of age.
(B) Where published, the postoperative period shall be the “global” period established by the federal Centers for Medicare and Medicaid Services, or, if not published, a reasonable period not to exceed 90 days.
(C) Such comanaged treatment may include addressing agreed-upon complications of the surgical procedure occurring in any ocular or adnexal structure with topical and oral medications authorized in subdivision (a). For patients under 18 years of age, this subparagraph shall not apply unless the patient’s primary care provider agrees to allowing comanagement of complications.
(e) (c)  An optometrist certified pursuant to Section 3041.3 shall be certified for the treatment of glaucoma, as described in subdivision (k), in patients over 18 years of age after the optometrist meets the following applicable  to medically treat authorized glaucomas under this chapter after meeting the following  requirements:
(1) For licensees who graduated from an accredited school of optometry on or after May 1, 2008, submission of proof of graduation from that institution.
(2) For licensees who were certified to treat glaucoma under this section prior to January 1, 2009, submission of proof of completion of that certification program.
(3) For licensees who completed a didactic course of not less than 24 hours in the diagnosis, pharmacological, and other treatment and management of glaucoma, submission of proof of satisfactory completion of the case management requirements for certification established by the board.
(4) For licensees who graduated from an accredited school of optometry on or before May 1, 2008, and who are not described in paragraph (2) or (3), submission of proof of satisfactory completion of the requirements for certification established by the board under Chapter 352 of the Statutes of 2008.
(f) (1) Any topical or oral therapeutic pharmaceutical agent, which is not a controlled substance, or noninvasive medical device or technology that is not expressly authorized for use or prescription by an optometrist certified to use therapeutic pharmaceutical agents pursuant to Section 3041.3 shall be deemed to be authorized if it has received a United States Food and Drug Administration approved indication for the diagnosis or treatment of a condition authorized by this chapter. A licensee shall successfully complete any clinical training imposed by a related manufacturer prior to using any of those therapeutic pharmaceutical agents or noninvasive medical devices or technologies.
(2) Any other topical or oral therapeutic pharmaceutical agent, which is not a controlled substance, or noninvasive medical device or technology that is not expressly authorized for use or prescription by an optometrist certified to use therapeutic pharmaceutical agents pursuant to Section 3041.3 and does not meet the requirements in paragraph (1) shall be deemed authorized if approved by the board through regulation for the rational treatment of a condition authorized by this chapter. Any regulation under this paragraph shall require a licensee to successfully complete an appropriate amount of clinical training to qualify to use each topical or oral therapeutic pharmaceutical agent or noninvasive medical device or technology approved by the board pursuant to this paragraph.
(3) This subdivision shall not be construed to authorize any of the following:
(A) Any therapeutic pharmaceutical agent, medical device, or technology involving cutting, altering, or otherwise infiltrating human tissue by any means.
(B) A clinical laboratory test or imaging study not authorized by paragraphs (1) to (16), inclusive, of subdivision (d).
(C) Treatment of any disease or condition that could not be treated by an optometrist before January 1, 2018.
(g) (d)  (1)  An optometrist certified pursuant to Section 3041.3 shall be certified for the administration of immunizations  to administer authorized immunizations, as described in subparagraph (D) of paragraph (5) of subdivision (a),  after the optometrist meets all of the following requirements:
(A) (1)  Completes an immunization training program endorsed by the federal Centers for Disease Control and Prevention (CDC) or the Accreditation Council for Pharmacy Education that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and maintains that training.
(B) (2)  Is certified in basic life support.
(C) (3)  Complies with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient’s primary care provided and entering information in the appropriate immunization registry designated by the immunization branch of the State Department of Public Health.
(D) (4)  Applies for an immunization certificate on a board-approved form.
(2) For the purposes of this section, “immunization” means the administration of immunizations for influenza, herpes zoster virus, and pneumococcus in compliance with individual Advisory Committee on Immunization Practices (ACIP) vaccine recommendations published by the CDC for persons 18 years of age or older.
(h) (e)  Other than for prescription ophthalmic devices described in subdivision (b) of Section 2541, any dispensing of a therapeutic pharmaceutical agent by an optometrist shall be without charge.
(i) The practice of optometry does not include performing surgery. “Surgery” means any procedure in which human tissue is cut, altered, or otherwise infiltrated by mechanical or laser means. “Surgery” does not include those procedures specified in paragraphs (1) to (15), inclusive, of subdivision (d). This subdivision does not limit an optometrist’s authority to utilize diagnostic laser and ultrasound technology within his or her scope of practice.
(j) (f)  An optometrist licensed under this chapter is subject to the provisions of Section 2290.5 for purposes of practicing telehealth.
(k) (g)  For the  purposes of this chapter, “glaucoma” means either  all  of the following: following definitions shall apply: 
(1) All primary open-angle glaucoma. “Adnexa” means the eyelids and muscles within the eyelids, the lacrimal system, and the skin extending from the eyebrows inferiorly, bounded by the medial, lateral, and inferior orbital rims, excluding the intraorbital extraocular muscles and orbital contents. 
(2) Exfoliation and pigmentary glaucoma. “Anterior segment” means the portion of the eye anterior to the vitreous humor, including its overlying soft tissue coats. 
(3) (A) “Ophthalmologist”  Steroid induced glaucoma.  means a physician and surgeon, licensed under Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code, specializing in treating eye disease. 
(B) (4)  If an optometrist treats a patient for steroid induced glaucoma the optometrist shall promptly notify the prescriber of the steroid medication if the prescriber did not refer the patient to the optometrist for treatment. “Physician and surgeon” means a physician and surgeon licensed under Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. 
(l) (5)  For purposes of this chapter, “adnexa” means ocular adnexa. “Prevention” means use or prescription of an agent or noninvasive device or technology for the purpose of inhibiting the development of an authorized condition or disease. 
(m) (6)  In an emergency, an optometrist shall stabilize, if possible, and immediately refer any patient who has an acute attack of angle closure to an ophthalmologist. “Treatment” means use of or prescription of an agent or noninvasive device or technology to alter the course of an authorized condition or disease once it is present. 

SEC. 3.1.

 Section 3041 of the Business and Professions Code is amended to read:

3041.
 (a) The practice of optometry includes the prevention and diagnosis diagnosis, prevention, treatment, and management  of disorders and dysfunctions of the visual system, and the treatment and management of certain disorders and dysfunctions of the visual system, as  as authorized by this chapter, as  well as the provision of habilitative or rehabilitative optometric services, and is the doing of any or all of the following:
(1) The examination of the human eye or eyes, or its or their appendages, and  eyes and their adnexa, including through the use of all topical and oral diagnostic pharmaceutical agents that are not controlled substances, and  the analysis of the human vision system, either subjectively or objectively.
(2) The determination of the powers or range of human vision and the accommodative and refractive states of the human eye or  eyes, including the scope of its or  their functions and general condition.
(3) The prescribing  prescribing, using,  or directing the use of, or using,  of  any optical device in connection with ocular exercises, visual training, vision training, or orthoptics.
(4) The prescribing of contact and spectacle lenses for, or the fitting or  prescribing, fitting, or  adaptation of contact and spectacle lenses to, the human eye, eyes,  including lenses that may be classified as drugs or devices by any law of the United States or of this state. state, and diagnostic or therapeutic contact lenses that incorporate a medication or therapy the optometrist is certified to prescribe or provide. 
(5) The use of topical pharmaceutical agents for the purpose of the examination of the human eye or eyes for any disease or pathological condition.
(b) (5)  (1) For  An optometrist who is certified to use therapeutic pharmaceutical agents,   an optometrist certified  pursuant to Section 3041.3, may also diagnose and treat the human eye or eyes, or any of its or their appendages, for all of the following conditions: diagnosing and preventing conditions and diseases of the human eyes and their adnexa, and treating nonmalignant conditions and diseases of the anterior segment of the human eyes and their adnexa, including ametropia and presbyopia: 
(A) Through medical treatment, infections of the anterior segment and adnexa, excluding the lacrimal gland, the lacrimal drainage system, and the sclera in patients under 12 years of age.
(B) Ocular allergies of the anterior segment and adnexa.
(C) Ocular inflammation, nonsurgical in cause except when comanaged with the treating physician and surgeon, limited to inflammation resulting from traumatic iritis, peripheral corneal inflammatory keratitis, episcleritis, and unilateral nonrecurrent nongranulomatous idiopathic iritis in patients over 18 years of age.
(D) Traumatic or recurrent conjunctival or corneal abrasions and erosions.
(E) Nonmalignant ocular surface disease and dry eye disease.
(F) Ocular pain, nonsurgical in cause except when comanaged with the treating physician and surgeon, associated with conditions optometrists are authorized to treat.
(G) Hypotrichosis and blepharitis.
(H) Pursuant to subdivision (e), glaucoma in patients over 18 years of age, as described in subdivision (k).
(2) For purposes of this section, “treat” means the use of therapeutic pharmaceutical agents, as described in subdivision (c), and the procedures described in subdivision (d).
(c) (A)  In diagnosing and treating the conditions listed in subdivision (b), an optometrist certified to use therapeutic pharmaceutical agents pursuant to Section 3041.3 may use or prescribe, including for rational off-label purposes, all of the following therapeutic pharmaceutical agents: Using or prescribing, including for rational off-label purposes, topical and oral prescription and nonprescription therapeutic pharmaceutical agents that are not controlled substances and are not antiglaucoma agents or limited or excluded by subdivision (b). For purposes of this section, “controlled substance” has the same meaning as used in the California Uniform Controlled Substances Act (Division 10 (commencing with Section 11000) of the Health and Safety Code) and the United States Uniform Controlled Substances Act (21 U.S.C. Sec. 801 et seq.). 
(1) Topical pharmaceutical agents for the examination of the human eye or eyes for any disease or pathological condition, including, but not limited to, topical miotics.
(2) Topical lubricants.
(3) Antiallergy agents. In using topical steroid medication for the treatment of ocular allergies, an optometrist shall consult with an ophthalmologist if the patient’s condition worsens 21 days after diagnosis.
(4) Topical and oral anti-inflammatories.
(5) Topical antibiotic agents.
(6) Topical hyperosmotics.
(7) Topical and oral antiglaucoma agents pursuant to the certification process defined in subdivision (e).
(8) Nonprescription medications used for the rational treatment of an ocular disorder.
(9) Oral antihistamines.
(10) Prescription oral nonsteroidal anti-inflammatory agents.
(11) Oral antibiotics for medical treatment of ocular disease.
(12) Topical and oral antiviral medication for the medical treatment of herpes simplex viral keratitis, herpes simplex viral conjunctivitis, periocular herpes simplex viral dermatitis, varicella zoster viral keratitis, varicella zoster viral conjunctivitis, and periocular varicella zoster viral dermatitis.
(13) Oral analgesics that are not controlled substances.
(14) (B)  Codeine  Prescribing the oral analgesic controlled substance codeine  with compounds, hydrocodone with compounds, and tramadol as listed in the California Uniform Controlled Substances Act (Division 10 (commencing with Section 11000) of the Health and Safety Code) and the United States Uniform Controlled Substances Act (21 U.S.C. Sec. 801 et seq.). The use of these agents shall be  seq.),  limited to three days, with a  referral to an ophthalmologist if the pain persists.
(15) Additional therapeutic pharmaceutical agents pursuant to subdivision (f).
(d) (C)  An optometrist who is certified to use therapeutic pharmaceutical agents pursuant to Section 3041.3 may also perform all of the following procedures: If also certified under subdivision (c), using or prescribing topical and oral antiglaucoma agents for the medical treatment of all primary open-angle, exfoliation, pigmentary, and steroid-induced glaucomas in persons 18 years of age or over. In the case of steroid-induced glaucoma, the prescriber of the steroid medication shall be promptly notified if the prescriber did not refer the patient to the optometrist for treatment. 
(1) Corneal scraping with cultures.
(2) Debridement of corneal epithelia.
(3) Mechanical epilation.
(4) Collection of blood by skin puncture or venipuncture for testing patients suspected of having diabetes.
(5) (D)  Suture removal, with prior consultation with the treating physician and surgeon. If also certified under subdivision (d), administration of immunizations for influenza, herpes zoster virus, pneumococcus, and SARS-CoV-2 in compliance with individual Advisory Committee on Immunization Practices (ACIP) vaccine recommendations published by the federal Centers for Disease Control and Prevention (CDC) in persons 18 years of age or over. 
(6) Treatment or removal of sebaceous cysts by expression.
(7) Administration of oral fluorescein to patients suspected as having diabetic retinopathy.
(8) Use of an auto-injector to counter anaphylaxis.
(9) (E)  Ordering of smears, cultures, sensitivities, complete blood count, mycobacterial culture, acid fast stain, urinalysis, tear fluid analysis, and X-rays Utilizing the following techniques and instrumentation  necessary for the diagnosis of conditions or and  diseases of the eye or adnexa. An optometrist may order other types of images subject to prior consultation with an ophthalmologist or appropriate physician and surgeon. and adnexa: 
(i) Laboratory tests or examinations ordered from an outside facility.
(10) (ii)  A clinical laboratory test or examination  Laboratory tests or examinations performed in an office  classified as waived under the federal Clinical Laboratory Improvement Amendments of 1988 (CLIA) (42 U.S.C. Sec. 263a; Public Law 100-578) and designated in paragraph (9) necessary for the diagnosis of conditions and diseases of the eye or adnexa, or if otherwise specifically authorized by this chapter. 100-578), which shall also be allowed for: 
(I) Detecting indicators of possible systemic disease that manifests in the eye for the purpose of facilitating appropriate referral to or consultation with a physician and surgeon.
(II) Detecting the presence of SARS-CoV-2 virus.
(iii) Skin testing performed in an office to diagnose ocular allergies, limited to the superficial layer of the skin.
(iv) X-rays ordered from an outside facility.
(v) Other imaging studies ordered from an outside facility subject to prior consultation with an appropriate physician and surgeon.
(vi) Other imaging studies performed in an office, including those that utilize laser or ultrasound technology, but excluding those that utilize radiation.
(F) Performing the following procedures, which are excluded from restrictions imposed on the performance of surgery by paragraph (6) of subdivision (b), unless explicitly indicated:
(i) Corneal scraping with cultures.
(ii) Debridement of corneal epithelium not associated with band keratopathy.
(iii) Mechanical epilation.
(iv) Collection of blood by skin puncture or venipuncture for laboratory testing authorized by this subdivision.
(11) (v)  Punctal occlusion by plugs, excluding laser, diathermy, cryotherapy, or other means constituting surgery as defined in this chapter. Suture removal subject to comanagement requirements in paragraph (7) of subdivision (b). 
(vi) Treatment or removal of sebaceous cysts by expression.
(12) (vii)  The use or prescription of diagnostic or therapeutic contact lenses, including lenses or devices that incorporate a medication or therapy  Lacrimal punctal occlusion using plugs, or placement of a stent or similar device in a lacrimal canaliculus intended to deliver a medication  the optometrist is certified to prescribe or provide.
(13) (viii)  Removal of foreign bodies  Foreign body and staining removal  from the cornea, eyelid, and conjunctiva with any appropriate instrument other than a scalpel. Corneal foreign bodies shall be nonperforating, be  instrument. Removal of corneal foreign bodies and any related stain shall, as relevant, be limited to that which is nonperforating,  no deeper than the midstroma, and require no surgical repair upon removal. not reasonably anticipated to require surgical repair. 
(14) (ix)  For patients over  Lacrimal irrigation and dilation in patients  12 years of age, lacrimal irrigation and dilation,  age or over,  excluding probing of the nasal lacrimal  nasolacrimal  tract. The board shall certify any optometrist who graduated from an accredited school of optometry before May 1, 2000, to perform this procedure after submitting proof of satisfactory completion of 10 procedures under the supervision of an ophthalmologist as confirmed by the ophthalmologist. Any optometrist who graduated from an accredited school of optometry on or after May 1, 2000, shall be exempt from the certification requirement contained in this paragraph.
(x) Administration of oral fluorescein for the purpose of ocular angiography.
(15) (xi)  Intravenous injection for the purpose of performing ocular angiography at the direction of an ophthalmologist as part of an active treatment plan in a setting where a physician and surgeon is immediately available.
(16) (xii)  Skin testing to diagnose ocular allergies, limited to the superficial layer of the skin. Use of noninvasive devices delivering intense pulsed light therapy or low-level light therapy that do not rely on laser technology, limited to treatment of conditions and diseases of the adnexa. 
(xiii) Use of an intranasal stimulator in conjunction with treatment of dry eye syndrome.
(G) Using additional noninvasive medical devices or technology that:
(i) Have received a United States Food and Drug Administration-approved indication for the diagnosis or treatment of a condition or disease authorized by this chapter. A licensee shall successfully complete any clinical training imposed by a related manufacturer prior to using any of those noninvasive medical devices or technologies.
(ii) Have been approved by the board through regulation for the rational treatment of a condition or disease authorized by this chapter. Any regulation under this paragraph shall require a licensee to successfully complete an appropriate amount of clinical training to qualify to use each noninvasive medical device or technology approved by the board pursuant to this paragraph.
(b) Exceptions or limitations to the provisions of subdivision (a) are as follows:
(1) Treatment of the following is excluded from the practice of optometry in a patient under 18 years of age, unless explicitly allowed otherwise:
(A) Anterior segment inflammation, which shall not exclude treatment of:
(i) The conjunctiva.
(ii) Nonmalignant ocular surface disease, including dry eye syndrome.
(iii) Contact lens-related inflammation of the cornea.
(iv) An infection of the cornea.
(B) Conditions or diseases of the sclera.
(2) Use of any oral prescription steroid anti-inflammatory medication for a patient under 18 years of age shall be done pursuant to a documented, timely consultation with an appropriate physician and surgeon.
(3) Use of any nonantibiotic oral prescription medication for a patient under five years of age shall be done pursuant to a documented, prior consultation with an appropriate physician and surgeon.
(4) The following classes of agents are excluded from the practice of optometry unless they have an explicit United States Food and Drug Administration-approved indication for treatment of a condition or disease authorized under this section:
(A) Antiamoebics.
(B) Antineoplastics.
(C) Coagulation modulators.
(D) Hormone modulators.
(E) Immunomodulators.
(5) The following are excluded from authorization under subparagraph (G) of paragraph (5) of subdivision (a):
(A) A laboratory test or imaging study.
(17) (B)  Use of any noninvasive medical  Any noninvasive  device or technology authorized pursuant to subdivision (f). that constitutes surgery under paragraph (6). 
(6) Performing surgery is excluded from the practice of optometry. “Surgery” means any act in which human tissue is cut, altered, or otherwise infiltrated by any means. It does not mean an act that solely involves the administration or prescribing of a topical or oral therapeutic pharmaceutical.
(7) (A) Treatment with topical and oral medications authorized in subdivision (a) related to an ocular surgery shall be comanaged with the ophthalmologist that performed the surgery, or another ophthalmologist designated by that surgeon, during the customary preoperative and postoperative period for the procedure. For purposes of this subparagraph, this may involve treatment of ocular inflammation in a patient under 18 years of age.
(B) Where published, the postoperative period shall be the “global” period established by the federal Centers for Medicare and Medicaid Services, or, if not published, a reasonable period not to exceed 90 days.
(C) Such comanaged treatment may include addressing agreed-upon complications of the surgical procedure occurring in any ocular or adnexal structure with topical and oral medications authorized in subdivision (a). For patients under 18 years of age, this subparagraph shall not apply unless the patient’s primary care provider agrees to allowing comanagement of complications.
(e) (c)  An optometrist certified pursuant to Section 3041.3 shall be certified for the treatment of glaucoma, as described in subdivision (k), in patients over 18 years of age after the optometrist meets the following applicable  to medically treat authorized glaucomas under this chapter after meeting the following  requirements:
(1) For licensees who graduated from an accredited school of optometry on or after May 1, 2008, submission of proof of graduation from that institution.
(2) For licensees who were certified to treat glaucoma under this section prior to January 1, 2009, submission of proof of completion of that certification program.
(3) For licensees who completed a didactic course of not less than 24 hours in the diagnosis, pharmacological, and other treatment and management of glaucoma, submission of proof of satisfactory completion of the case management requirements for certification established by the board.
(4) For licensees who graduated from an accredited school of optometry on or before May 1, 2008, and who are not described in paragraph (2) or (3), submission of proof of satisfactory completion of the requirements for certification established by the board under Chapter 352 of the Statutes of 2008.
(f) (1) Any topical or oral therapeutic pharmaceutical agent, which is not a controlled substance, or noninvasive medical device or technology that is not expressly authorized for use or prescription by an optometrist certified to use therapeutic pharmaceutical agents pursuant to Section 3041.3 shall be deemed to be authorized if it has received a United States Food and Drug Administration approved indication for the diagnosis or treatment of a condition authorized by this chapter. A licensee shall successfully complete any clinical training imposed by a related manufacturer prior to using any of those therapeutic pharmaceutical agents or noninvasive medical devices or technologies.
(2) Any other topical or oral therapeutic pharmaceutical agent, which is not a controlled substance, or noninvasive medical device or technology that is not expressly authorized for use or prescription by an optometrist certified to use therapeutic pharmaceutical agents pursuant to Section 3041.3 and does not meet the requirements in paragraph (1) shall be deemed authorized if approved by the board through regulation for the rational treatment of a condition authorized by this chapter. Any regulation under this paragraph shall require a licensee to successfully complete an appropriate amount of clinical training to qualify to use each topical or oral therapeutic pharmaceutical agent or noninvasive medical device or technology approved by the board pursuant to this paragraph.
(3) This subdivision shall not be construed to authorize any of the following:
(A) Any therapeutic pharmaceutical agent, medical device, or technology involving cutting, altering, or otherwise infiltrating human tissue by any means.
(B) A clinical laboratory test or imaging study not authorized by paragraphs (1) to (16), inclusive, of subdivision (d).
(C) Treatment of any disease or condition that could not be treated by an optometrist before January 1, 2018.
(g) (d)  (1)  An optometrist certified pursuant to Section 3041.3 shall be certified for the administration of immunizations  to administer authorized immunizations, as described in subparagraph (D) of paragraph (5) of subdivision (a),  after the optometrist meets all of the following requirements:
(A) (1)  Completes an immunization training program endorsed by the federal Centers for Disease Control and Prevention (CDC) or the Accreditation Council for Pharmacy Education that, at a minimum, includes hands-on injection technique, clinical evaluation of indications and contraindications of vaccines, and the recognition and treatment of emergency reactions to vaccines, and maintains that training.
(B) (2)  Is certified in basic life support.
(C) (3)  Complies with all state and federal recordkeeping and reporting requirements, including providing documentation to the patient’s primary care provided and entering information in the appropriate immunization registry designated by the immunization branch of the State Department of Public Health.
(D) (4)  Applies for an immunization certificate on a board-approved form. in accordance with Section 3041.5. 
(2) For the purposes of this section, “immunization” means the administration of immunizations for influenza, herpes zoster virus, and pneumococcus in compliance with individual Advisory Committee on Immunization Practices (ACIP) vaccine recommendations published by the CDC for persons 18 years of age or older.
(h) (e)  Other than for prescription ophthalmic devices described in subdivision (b) of Section 2541, any dispensing of a therapeutic pharmaceutical agent by an optometrist shall be without charge.
(i) The practice of optometry does not include performing surgery. “Surgery” means any procedure in which human tissue is cut, altered, or otherwise infiltrated by mechanical or laser means. “Surgery” does not include those procedures specified in paragraphs (1) to (15), inclusive, of subdivision (d). This subdivision does not limit an optometrist’s authority to utilize diagnostic laser and ultrasound technology within his or her scope of practice.
(j) (f)  An optometrist licensed under this chapter is subject to the provisions of Section 2290.5 for purposes of practicing telehealth.
(k) (g)  For the  purposes of this chapter, “glaucoma” means either  all  of the following: following definitions shall apply: 
(1) All primary open-angle glaucoma. “Adnexa” means the eyelids and muscles within the eyelids, the lacrimal system, and the skin extending from the eyebrows inferiorly, bounded by the medial, lateral, and inferior orbital rims, excluding the intraorbital extraocular muscles and orbital contents. 
(2) Exfoliation and pigmentary glaucoma. “Anterior segment” means the portion of the eye anterior to the vitreous humor, including its overlying soft tissue coats. 
(3) (A) “Ophthalmologist”  Steroid induced glaucoma.  means a physician and surgeon, licensed under Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code, specializing in treating eye disease. 
(B) (4)  If an optometrist treats a patient for steroid induced glaucoma the optometrist shall promptly notify the prescriber of the steroid medication if the prescriber did not refer the patient to the optometrist for treatment. “Physician and surgeon” means a physician and surgeon licensed under Chapter 5 (commencing with Section 2000) of Division 2 of the Business and Professions Code. 
(l) (5)  For purposes of this chapter, “adnexa” means ocular adnexa. “Prevention” means use or prescription of an agent or noninvasive device or technology for the purpose of inhibiting the development of an authorized condition or disease. 
(m) (6)  In an emergency, an optometrist shall stabilize, if possible, and immediately refer any patient who has an acute attack of angle closure to an ophthalmologist. “Treatment” means use of or prescription of an agent or noninvasive device or technology to alter the course of an authorized condition or disease once it is present. 
SEC. 4.
 No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.
SEC. 5.
 Section 2.1 of this bill incorporates amendments to Section 2544 of the Business and Professions Code proposed by both this bill and Assembly Bill 1534. That section of this bill shall only become operative if (1) both bills are enacted and become effective on or before January 1, 2022, (2) each bill amends Section 2544 of the Business and Professions Code, and (3) this bill is enacted after Assembly Bill 1534, in which case Section 2 of this bill shall not become operative.
SEC. 6.
 (a) Section 3.1 of this bill shall become operative only if (1) this bill and Assembly Bill 691 of the 2021–22 Regular Session are enacted and become effective on or before January 1, 2022, and (2) Assembly Bill 691 adds Section 3041.5 to the Business and Professions Code, in which case Section 3 of this bill shall not become operative.
(b) Section 3 of this bill shall become operative only if Assembly Bill 691 is not enacted and does not become effective on or before January 1, 2022, in which case Section 3.1 of this bill shall not become operative.