The Latanoprost Prescription
Dr. Alan Cho, OD, holds Pennsylvania therapeutic pharmaceutical agent certification. He does not hold the separate Board certification required to diagnose and treat glaucoma. A 58-year-old established patient presents with blurred distance vision. Dr. Cho measures intraocular pressure of 28 mmHg OD and 26 mmHg OS, cup-to-disc ratios of 0.7 OD and 0.65 OS, and a nasal step on 24-2 visual field in the right eye. He diagnoses primary open-angle glaucoma, prescribes latanoprost nightly OU, and schedules a 3-month follow-up. He documents “glaucoma suspect, rule out” but does not refer. The patient asks whether Dr. Cho can treat glaucoma and whether she should see an ophthalmologist. The practice’s policy says the optometrist may treat any condition covered by the TPA certificate.
1. Did Dr. Cho exceed his scope of practice? Explain the difference between TPA certification and glaucoma treatment authority.
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Yes. Pennsylvania’s therapeutic pharmaceutical agent certification authorizes an optometrist to use specified drugs for conditions within the optometric scope, but glaucoma diagnosis and treatment is a separate authority that requires additional Board-recognized certification. Holding a TPA certificate does not automatically include glaucoma. Dr. Cho’s findings-elevated pressure, cupping, and a visual field defect-are not a borderline screening issue; they support a glaucoma diagnosis. By diagnosing primary open-angle glaucoma and starting latanoprost without the glaucoma credential, he practiced outside his lawful scope even though latanoprost is a drug he could otherwise use. The practice policy is wrong because it treats the TPA certificate as unlimited.
2. What should Dr. Cho have done at this visit?
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He should have recognized the glaucomatous findings, documented them, discussed the suspicion with the patient, and referred her promptly to an ophthalmologist or a glaucoma-certified optometrist for diagnosis and treatment. He could have repeated pressure and fields if clinically appropriate, but he should not have initiated chronic glaucoma therapy or scheduled a routine three-month follow-up as if he were managing the disease. The referral should be timely and documented, with a copy of the findings sent to the receiving clinician. He should also clarify his own certification status to the patient and avoid ambiguous chart language such as “glaucoma suspect, rule out” when he has already prescribed treatment.
3. What risks does the current course create for the patient and for Dr. Cho?
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The patient is exposed to untreated or undertreated glaucoma with possible progressive optic nerve damage, and she is not receiving the monitoring that a glaucoma diagnosis requires. For Dr. Cho, prescribing outside his certification creates Board exposure for practicing beyond scope, possible civil penalties, and malpractice risk if the patient deteriorates. The chart is internally inconsistent: it calls the case a “rule out” while prescribing definitive therapy. Insurance claims for the latanoprost may also be questioned if the prescriber lacks the credential. The practice should arrange an immediate transfer of care, document the patient’s current status, and not simply continue the prescription until the referral occurs.