Scope of Practice: Orthoptist Asked to Perform a Procedure Outside Training
You are a certified orthoptist working in a busy ophthalmology clinic. The supervising ophthalmologist is running 45 minutes behind and asks you to perform a botulinum toxin injection into the extraocular muscles of a patient with acute sixth nerve palsy, saying 'you've done the measurements, just do the injection, I'll sign off.' You have never performed injections and your certification and institutional privileging do not include intraocular or periocular injection. The patient is anxious and has been waiting two hours. A second ophthalmologist is available in the adjacent clinic but has not been asked.
1. What is the appropriate response, and what professional standards apply?
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Decline to perform the injection. Orthoptic scope of practice covers assessment, measurement, and non-surgical management of binocular vision and ocular motility; it does not include performing botulinum toxin injections or other procedures for which the orthoptist is not trained, credentialed, and privileged. Performing an injection outside one's scope and training exposes the patient to risk and the clinician to liability, and violates professional standards regardless of the supervising physician's request. The appropriate action is to state clearly that this is outside your scope, and to facilitate care by involving the available second ophthalmologist or rescheduling with the supervising physician. Document the request and your response per institutional policy.
2. How would you handle the conversation with the patient and with the supervising physician to preserve the therapeutic relationship?
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With the patient: acknowledge the wait, explain that the injection will be performed by the ophthalmologist (or the covering ophthalmologist) and that you will stay involved in the measurements and follow-up. Avoid implying the physician is unavailable or that care is compromised; focus on who is qualified to do the procedure. With the physician: be direct and non-confrontational-'I'm not credentialed or trained for injections, so I can't do this one; Dr. X is available next door, or we can reschedule.' Offer to complete the motility measurements and prepare the patient. If the physician pressures you, escalate to the clinic manager or medical director per policy. Document the interaction factually.
3. What does this scenario illustrate about the orthoptist's role in a team, and how should such situations be prevented?
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It illustrates that the orthoptist is a credentialed professional with a defined scope, not a generic extension of the physician. Clear role boundaries protect patients and preserve trust. Prevention: ensure written scope-of-practice and privileging documents are current and shared with the team; clarify at onboarding which procedures are and are not within the orthoptist's role; build scheduling buffers and a backup physician plan for high-volume clinics; and encourage a culture where declining an out-of-scope request is supported rather than penalized. Revisit the policy if the physician repeatedly makes such requests.