The following opinion is presented on-line for informational use only and does not replace the official version. (Mich Dept of Attorney General Web Site - www.ag.state.mi.us) STATE OF MICHIGAN FRANK J. KELLEY, ATTORNEY GENERAL Opinion No. 6846 May 8, 1995 PUBLIC HEALTH CODE: Optometrists treating glaucoma OPTOMETRISTS: Optometrists treating glaucoma Optometrists are not authorized to treat glaucoma under the Public Health Code. Honorable Michael J. Griffin State Representative The Capitol Lansing, Michigan You have asked if optometrists are authorized to treat glaucoma under the Public Health Code. Your question arises because of 1994 PA 384, which amended the Public Health Code, 1978 PA 368, MCL 333.1101 et seq, MSA 14.15(1101) et seq. to expand the practice of optometry. 1994 PA 384 took effect on March 30, 1995. Before its effective date, section 17401(1) of the Public Health Code allowed specially licensed optometrists to administer two diagnostic drugs in examining the human eye to measure vision and adapt lenses to aid vision. One of those two drugs, Proparacaine HCL 0.5%, is a topical anesthetic used in detecting glaucoma. David Paton & John A. Craig, Glaucomas: Diagnosis and Management, 28 Clinical Symposia, No 2, p 15 (1976), updated and reprinted, 1981. But optometrists were not authorized to use any therapeutic drugs. House Legislative Analysis, HB 4331, January 3, 1995, at p 1. The goal of statutory construction is to discover and effectuate legislative intent. This goal may be achieved by examining both the language of a statute and its legislative history, including legislative bill analyses. In re Forfeiture of $5,264, 432 Mich 242, 248-258; 439 NW2d 246 (1989). 1994 PA 384 expanded the definition of practice of optometry in section 17401(1)(b)(iii) of the Public Health Code to include: [T]he use of therapeutic pharmaceutical agents to correct, remedy, or relieve a defect or abnormal condition or to correct, remedy, or relieve the effect of a defect or abnormal condition of the human eye. 1994 PA 384 also added the following definition of therapeutic pharmaceutical agent to section 17401(1)(d) of the Public Health Code: "Therapeutic pharmaceutical agent" means a topically administered prescription drug or other topically administered drug used for the purpose of correcting, remedying, or relieving a defect or abnormal condition of the anterior segment of the human eye or for the purpose of correcting, remedying, or relieving the effects of a defect or abnormal condition of the anterior segment of the human eye. [Emphasis added.] The Public Health Code does not specify which conditions and diseases optometrists may treat. The answer to your question, therefore, turns on the definition of therapeutic pharmaceutical agent found in section 17401(1)(d) of the Public Health Code. If anti-glaucoma topically administered drugs fall within that definition, then optometrists may use them to treat glaucoma. Thus, we must determine whether these drugs correct a defect or the effects of a defect of the anterior segment of the eye. The Legislature did not define the term anterior segment of the human eye in section 17401(1)(d) of the Public Health Code. Moreover, research has failed to reveal any precise medical definition of this term. But it is clear that glaucoma affects the entire eye, and not the anterior segment alone. Glaucoma is a condition in which the pressure of the eye exceeds the tolerance of the eye, eventually resulting in blindness. Paton & Craig, supra, at 3. The increase in pressure is due to an imbalance in the production and outflow of the fluid contained in the front of the eye. Id. at 5-6. The increase in pressure results in damage to the optic nerve, which is located at the posterior of the eye. Id. at 6-10. Topically administered anti-glaucoma medications restore the balance in the production and outflow of fluid, decreasing the pressure of the eye and preventing further damage to the optic nerve. Id. at 34. Since glaucoma is not limited to the anterior segment of the human eye, topically administered drugs used to treat glaucoma do not come within the definition of therapeutic pharmaceutical agent in section 17401(1)(d) of the Public Health Code. Thus, they may not be administered by optometrists to treat glaucoma. A legislative analysis of HB 4331 as enrolled, which became 1994 PA 384, supports this proposition: The bill is an attempt to work out a compromise between optometrists, non-physicians who favor expanding their scope of practice to include the prescription of therapeutic drugs to treat such conditions as "pink eye," and ophthalmologists, physicians who oppose what they see as further encroachments on medical practice by non-physicians. Currently, optometrists, who may not diagnose disease, must refer all of their patients to physicians for diagnosis and treatment -- even such common and easily treatable diseases such as "pink eye." This not only is inconvenient to optometric patients, it unnecessarily increases health care costs by requiring patients (or their medical insurers) to pay for medical consultations even in cases where their condition could be safely and easily treated by the optometrist. The bill still would not allow optometrists to diagnose disease, but it would allow qualified optometrists to prescribe and use therapeutic drugs to treat certain conditions (such as "pink eye"), which would benefit optometric patients while also reducing health care costs. Optometrists would continue to have to refer patients to ophthalmologists whenever the optometrists detected signs of other than localized eye disease. [Emphasis added.] This legislative analysis never mentions the treatment of glaucoma. It demonstrates that 1994 PA 384 allows optometrists to treat minor conditions, such as pink eye, but not glaucoma. This conclusion is also supported by controlling case law of the Michigan Supreme Court concerning the interpretation of statutes defining the scope of practice of health care professions. In Attorney General v Beno, 422 Mich 293; 373 NW2d 544 (1985), the court rejected a chiropractor's claim that he was authorized to take diagnostic x-rays of his patient's elbow. In reaching that result, the court stated, at p 312, the following: Where there are hazy lines between the jurisdiction of health-care professions, we think the public health and safety is best protected by more strictly construing the jurisdiction of the more specialized and limited health profession in favor of the more comprehensively trained and licensed profession. It would seem to be more in keeping the public protection to have the broader discipline making diagnostic observations about those things within the specialties of the narrower discipline, rather than vice versa. [Emphasis added.] In light of Beno, 1994 PA 384 must be construed in favor of the broader, more comprehensively trained discipline of ophthalmology, which is a speciality within the practice of medicine, and against the more limited discipline of optometry. Thus, section 17401(1)(d) of the Public Health Code must be construed to allow optometrists to use topically administered drugs only to correct a defect or the effects of a defect of the anterior segment of the eye. Since glaucoma results in blindness because of damage to the optic nerve, located at the posterior of the eye, the treatment of glaucoma is beyond the scope of optometric practice. An attempt was made to amend HB 4331 by inserting specific language prohibiting optometrists from diagnosing or treating glaucoma and requiring optometrists who suspect that a patient has glaucoma to refer the patient to a physician who specialized in the diagnosis and treatment of diseases of the human eye. 1994 Journal of the House 2817 (No. 70, December 8, 1994). This proposed amendment was rejected by a 31-59 vote. Id. at 2818. The courts of this state have found the rejection of a proposed amendment to be persuasive evidence of legislative intent. Liquor Control Comm'n v Fraternal Order of Eagles, Aerie No. 629, 286 Mich 32, 43-44; 281 NW 427 (1938). Nonetheless, the rejection of a proposed amendment to a bill is not always conclusive evidence of legislative intent. 2A Sutherland Statutory Construction (5th ed), Sec. 48.18, p 369. The House of Representatives may have rejected the amendment as unnecessary, believing that the treatment of glaucoma was already prohibited under the language of the bill. Moreover, the Legislature is presumed to be aware of the standard tenets of statutory construction. People v Jones, 190 Mich App 509, 513; 476 NW2d 646 (1991) lv den, 439 Mich 937 (1992). One of these tenets is "expressio unius est exclusio alterius," i.e., the expression of one thing in a statute implies the exclusion of other similar things. United States Fidelity & Guarantee Co v Amerisure Ins Co, 195 Mich App 1, 6; 489 NW2d 115 (1992). The House of Representatives may have rejected the proposed amendment in order to avoid naming specific diseases that optometrists are prohibited from treating, so as not to invoke the tenet of "expressio unius" with regard to other diseases. Thus, in view of the statutory language, other legislative history and the controlling canons of statutory construction, rejection of the amendment is not determinative on this issue. In sum, since anti-glaucoma topically administered drugs relieve defects that extend beyond the anterior segment of the eye, they fall outside the definition of therapeutic pharmaceutical agent found in section 17401(1)(d) of the Public Health Code, as amended by 1994 PA 384. Thus, the Public Health Code does not authorize optometrists to treat glaucoma. If an optometrist detects signs or symptoms of glaucoma in a patient, the optometrist must advise the patient to see a physician for diagnosis and possible treatment and must not attempt to treat the condition in any way, in accordance with section 17432(l) of the Public Health Code. It is my opinion, therefore, that optometrists are not authorized to treat glaucoma under the Public Health Code. Frank J. Kelley Attorney General