Comanagement of cataract surgery has become an integral part of thousands of OD practices, with 78% of optometrists reporting that they comanage, on average, six cataract patients per month.1 It is essential for the delivery of care in hundreds of surgical practices, and also a benefit cherished by a significant number of patients for reasons of comfort, convenience and continuity of care.
Although comanagement can be described by several models, this article provides an updated perspective from one particular type: relatively comprehensive peri-surgical care by an optometrist working within a surgical center.2 (For the perspective of a referring OD, see “Questions to Ask Your Surgeon, and Yourself,” below.)
The Job of a Surgical Center OD
Practicing within a surgical center has developed into an increasingly popular subspecialty of optometry. As with any profession, this subspecialty represents a spectrum of practice types, so the responsibilities of an OD working within a surgical facility may vary from center to center.
The role of optometry within a surgical practice, though it may be diverse, is perfectly suited through our education and training to be an essential element in the collaboration of care required in modern cataract surgery protocols. In addition, optometry’s role can also bolster the success of the practice as a business by increasing efficiency, communication, access to care and effectiveness of care.
The truth is that today’s peri-operative process—often anchored by the OD and support staff—usually demands significantly more time to complete than the surgical event itself. In a recent survey, 93% of ophthalmologists reported spending 20 minutes or less with each patient.3 For this reason, many patients report that the clinic experience with the OD is one of the major factors influencing their overall experience and impression of the surgery center’s care.
To allow the surgeon maximum time in the OR, the OD may take on nearly all non-surgical responsibility (see "Typical Pre-surgical OD Responsibilities"), collecting pre- and post-op data, educating the patient and caregivers, and being the point-person who coordinates care at several levels. Good communication with the patient, the staff, the surgeon, the referring OD and other health care providers is essential to ensure that the surgery and perioperative care are seamless.
Technical Data
Data acquisition and analysis has become a key component of modern cataract surgery (see "Possible Technical Data Acquired During Pre-op Exam"). Where a patient may have sat in front of one or possibly two diagnostic tools during a preoperative exam just a few years ago, it is now common to employ at least five or six devices to complete the pre-surgical evaluation.
Typical Pre-surgical OD Responsibilities
1. Acquisition of technical data
2. Extensive history review
3. Informed consent
4. Ocular evaluation
5. Plan for care
6. Pre-op calculations
7. Communication/education
Precise testing and biometry are absolutely essential to accurately calculate the IOL formulas. Technicians are key team members of a surgical center’s support staff and a great asset to the practice. However, the licensed health care professionals are the ones who ultimately “put it all together”—assessing, diagnosing, planning, treating and managing the patient.
History
The information gathered preoperatively in the review of systems, past history and present history is as valuable as the technical information gathered during the evaluation. In the context of planning a potential surgical procedure, certain elements become significant and contribute to a successful surgical process (see "Factors in the History Relevant to Planning Cataract Surgery").
Each case presents as unique, and often patients do not understand why seemingly unrelated history can be important to eye surgery. The more that is known about a patient’s specific history, the more effectively the care can be tailored in an effort to reduce potential complications and maximize comfort for the patient.
Possible Technical Data Acquired During Pre-op Exam
1. Corneal analysis (keratometry, topography, pachymetry, endothelial cell count)
2. Biometry (axial length, anterior chamber depth, lens thickness, white to white)
3. Acuity metrics (auto-refraction, BCVA, potential acuity measure, glare, pupil size)
4. Macular imaging
5. Nerve fiber imaging
6. Angle imaging
7. Visual field testing
8. General health measures (e.g., blood pressure, blood sugar, weight)
Informed Consent
Today’s informed consent process requires significant attention to the discussion of a patient’s lifestyle, level of vision impairment, surgical options, IOL designs, desired outcome, risks, possible complications and postoperative instructions/restrictions.
With such a volume of information presented in a relatively short period, repetition can be beneficial, especially employing multiple media (e.g., video presentations, web-based productions, printed documents).
With the complexities of insurance plan coverage, eligibility, comanagement fee allocation, out-of-pocket expenses (i.e., deductibles, optional IOL premiums, medication costs) and possible multiple procedures planned, patients must also be made fully aware of the financial ramifications and total fees of the care provided and proposed.
Financial consideration is now often a topic the OD must address with the patient. Again, the center’s support staffs for scheduling, billing, financing and insurance verification are invaluable team members.
Ocular Evaluation
Although it may seem redundant if the patient has recently been seen by a referring OD, it is necessary for the surgical center to confirm and evaluate the current ocular status in the context of a potential surgical treatment. Conversely, if there is a period of time between surgeries, the evaluation and testing must often be repeated and the information brought up to date.
The ocular evaluations and refractions completed by the OD team members within a surgical center are not meant to simply repeat the evaluation completed by the referring doctor, but rather to provide the surgeon the most complete and accurate ocular/visual information so that a surgical plan may be developed.
a. Diabetes (insulin, oral medication or diet control)
2. Complete ocular history (including but not limited to): a. Rx history (habitual wear for distance, near or both; recent change)
3. Complete medication and treatment history, including but not limited to: a. Any prior/present/planned use of alpha1-adrenergic
antagonist meds: Flomax (tamsulosin, Boehringer Ingelheim), Hytrin
(terazosin, Abbott), Cardura (doxazosin mesylate, Pfizer), Uroxatral
(alfuzosin, Sanofi-Aventis)
4. Complete procedures history with dates, including but not limited to: a. All surgeries and procedures
5. Allergic/adverse reaction history, including but not limited to:
a. Sulfa
6. Other
Factors in the History Relevant to Planning Cataract Surgery
1. Complete systemic history, including but not limited to:
b. Cardiac history
c. Kidney conditions
d. Lung disease
e. Systemic inflammatory conditions
f. Recent infections (including dental)
g. Seizure disorders/tremors (e.g., Parkinson’s, epilepsy)
h. Communicable diseases (HIV, MRSA, hepatitis, TB)
b. Contact lens wear
c. Amblyopia/strabismus/diplopia
d. Prior acute or chronic conditions (i.e., blepharitis,
conjunctivitis, keratitis, dry eye, corneal dystrophies, iritis, PXF,
floaters, glaucoma, retinal/macular conditions)
e. Current ocular medications (including non-prescription meds)
f. Prior trauma
g. Prior ocular surgery (muscle, lid, corneal, pterygium, refractive, lenticular, glaucoma)
h. Vitreoretinal history (injections, laser treatment, membrane peel, vitrectomy, scleral buckle, gas bubble, silicone oil)
i. Other periocular injections (Botox, fillers)
b. Anti-coagulation or anti-platelet therapy:
Coumadin (warfarin, Bristol-Myers Squibb), Paradaxa (dabigatran
etexilate, Boehringer Ingelheim), Plavix (clopidogrel bisulfate,
Bristol-Myers Squibb), aspirin, other NSAIDs and vitamin E
b. Cardiac procedures
c. Dental procedures
d. Treatments (dialysis, chemotherapy, radiation, hyperbaric, physical therapy)
b. Iodine
c. Latex
d. Adhesives
e. Silicone
f. Anesthesia/epinephrine
g. Steroid responder
h. Keloid formation
a. Claustrophobia
b. Anxiety
c. Mobility issues
d. Prone intolerance
e. Oxygen dependence
f. Language translation required
g. Care facility orders
h. Dementia
i. Syncope (vaso-vagal reaction)
Plan for Care
With a well-orchestrated plan and delivery of a high level of care, the surgery event can be a milestone of positive change in the patient’s visual status.
Although proposed plans for treatment of cataracts are now quite individualized (see "Points to Consider in Cataract Surgery Planning"), even the best plans must be amenable to change if concerns or complications arise. Surgical center practice requires patient access to emergency care and personnel if concerns or questions arise. The center’s OD staff may participate in on-call services to manage problems and, if necessary, escalate care to an appropriate provider (e.g., the operating surgeon, retina specialist, etc.).
Completing the surgical plan will often require information to be obtained from an array of other health care providers. Such information may include a recent physical, blood work, EKG, platelet levels, blood pressure, blood glucose level, significant recovery time from other recent procedures or treatments, general well-being of the patient, and data on any prior ocular surgery.
Points to Consider in Cataract Surgery Planning
1. Which eye is first
2. Tentative timing for second eye
a. Anisometropia and refractive state between
surgery
b. Postoperative progress of the first eye
3. All ocular diagnoses
4. Targeted refractive outcome for both eyes
a. Reduction of myopia/hyperopia
b. Reduction of cylinder (toric IOL/incisional plan)
c. Monovision/multifocal/pseudo-accommodative
5. Planned multiple or secondary procedures (e.g., refractive, glaucoma, corneal, pterygium, retinal)
6. Preferred IOL choice
7. Special surgical considerations
8. Transportation or travel
9. Postoperative instructions/restrictions
10. Pre- and postoperative medications
11. Schedule of comanaged care
IOL Calculations
The surgical center’s optometric staff—with optometry’s inherent extensive knowledge of optics—can contribute significantly to IOL calculations and analysis. It is necessary to calculate not only suggestions for the primary lens of choice, but also secondary lens choices in the event of a complex surgery (e.g., an anterior chamber, sulcus-placed, or sutured IOL; a monofocal IOL instead of a planned premium lens).
The increasing population of individuals who have undergone prior refractive procedures poses a particular challenge to accurate IOL calculation. An ever-evolving gamut of formulas and methods help to predict the optimal lens choice for these patients.
While rare, refractive surprises occur after cataract extraction and there is an entirely different set of tools and calculations used to remedy the situation of erroneous power if warranted.
Communications
With the wealth of information gathered and the multitude of individuals involved, clear communication, often directed by the OD, is the lifeblood of a successful cataract comanagement program. Information must flow freely between the ODs and surgeons. Expectations of care, understanding of the planned or executed procedures and comfort in raising concerns or questions are all important aspects of integrated care.
Patients can present with extremely complex ocular histories, unrealistic expectations and complicated health issues. The center-based OD can be a liaison between the referring OD and operating surgeon, as the practitioner who understands the perspective of both.
The relationship and communication between the center OD and referring OD is just as crucial, and is quite a unique opportunity for varied modes of optometry to work together in the care of a mutual patient. Center ODs often serve as liaisons between the surgical center and the referring OD network, acting as a resource for information and education in a peer-to-peer capacity.
Communication with other professionals within a practice, such as nursing and anesthesia staff, is also essential. The ancillary support staff forms a collective team and are a tremendous resource for patient care (see "Comanagement Center Team Members"). Often, the ODs in a surgical center act to coordinate activity among the clinical, non-clinical and surgical staff within the practice. The voluminous information now available from evaluations and calculations can be very complex and time-consuming to review. The OD is in a keen position to understand the clinical case, manage the flow and serve the varying needs of the entire organization.
Comanagement Center Team Members
1. Surgical staff
2. Optometric staff
3. Anesthesia staff
4. Nursing staff
5. Administrative and management staff
6. Operating room staff
7. Technicians
8. Scheduling staff
9. Billing/patient finance staff
10. Counselors
11. Marketing staff
12. IT/health informatics staff
Lastly, clear and complete communication with the patient is obviously crucial. The center OD staff can professionally educate the patient, address questions and concerns, assist with the consent process, and convey the outcome and expected course of recovery. It is important to stress that the patient’s best interest will always dictate the course of care. The program of care may change from the anticipated game plan, but there is a true collaboration of care providers working as a team to provide the best for each patient.
The comanagement center–based OD is often the “point guard” of this cooperative team that includes the primary eye care optometrist who entrusted the patient to the surgical center. For the referring OD to understand the process above and provide as much information as possible will only improve the ultimate care of their patient.
Dr. Calnan-Holt is an optometric physician at the Pacific Cataract and Laser Institute in Spokane, Wash., a referral center founded in 1985.
1. AOA Clinical Practice of Optometry, Executive Summary. Available at:
www.aoa.org/documents/ric/2011_clinical_practice_of_optometry-executive_summary.pdf. Accessed January 5, 2013.
2. Cunningham D, Whitley W. What is integrated eye care? Rev Optom. 2012 Mar;149(3):64-71.
3. Ophthalmologist Compensation Report 2011. Available at:
www.medscape.com/features/slideshow/compensation/2011/ophthalmology. Accessed January 5, 2013.
Careful
consideration is required long before a patient is referred to a
surgical comanagement center. In my opinion, a common pitfall of the
referring primary eye care provider (PECP) is to give surgical
comanagement too little thought. Successful surgical comanagement
requires serious consideration of all steps, even those that occur
outside of your exam room.
The
most important aspect of surgical comanagement is communication. Ask
yourself the following questions about your current surgical comanaging
facility and/or surgeon:
• Do they communicate their ability to perform a full spectrum of surgeries relevant to their specialty?
The
PECP must consider the expertise and skill of the surgeon. I have
observed that ophthalmologists dedicating themselves solely to surgery
have far better outcomes, with fewer complications, than those who
perform surgery secondary to their non-surgical practice.
If
the above considerations are favorable, then I would recommend the PECP
step back and consider the comanaging philosophy of the surgeon or
surgical group. I expect the surgeon or surgical group to respect my
role as the patient’s PECP. This is especially critical when the
referring doctor is an optometrist. In general, the most successful
comanaging relationships are those where both referring and consulting
providers are striving to meet the patient’s vision needs while working
closely as a team.
The
approach to comanagement should always be about how to provide the best
possible care for your patient. Carefully selecting a comanaging
surgeon or surgical group will result in extremely satisfied patients
with improved vision and quality of life, generating positive
word-of-mouth that will speak highly of all parties involved in the
delivery of care.
Questions to Ask Your Surgeon, and Yourself
By Nathan Scott, OD
• Do they disclose their success and complication rates in writing for you and your patients to review and compare?
• Do they provide professional patient literature regarding the
various procedures performed for you to pass along to your patients?
• Do they provide information about fees and insurance billing that you may pass along to your patients?
• Are you invited to visit their facility and observe care provided to surgical patients?
• Are you informed, in a timely manner, of the surgical outcome and recommended postoperative treatment?
• Do they properly bill and/or submit claims indicating comanagement so that you may be properly reimbursed in a timely manner?
