Article Date: 12/1/2008

A Call to Co-management
surgical care

A Call to Co-management

How to deliver eye care when patients undergo refractive surgery.

LOUIS J. PHILLIPS, O.D., F.A.A.O., Sewickley, Pa.

As an optometrist, you manage the refractive care of your patients. Therefore, you shouldn't cease delivering that care, should any of your patients elect to undergo refractive surgery for two reasons: First, doing so is a great disservice to the patient. As the patient's primary-care optometrist, no eyecare practitioner knows his ocular health and refractive needs better. Therefore, he may receive less-than-adequate care elsewhere. Second, losing the patient inflicts harm to the financial health of your practice.

Your legal role

Despite what some of you may have heard or possibly read, co-management is neither illegal nor under siege by the government. In 1999, the Office of Inspector General (OIG), in redefining Safe Harbors simply said that co-management of cataract surgery is no longer a Safe Harbor. This means that the government can review co-management on a case-by-case basis to ensure that co-managing practitioners are performing their individual roles properly, and that these practices aren't in violation of the federal anti-kickback statute. Essentially, this means that each practitioner must actually deliver care, communicate the delivery of that care to the other practitioner, inform the patient of each practitioner's role and allow for an exception when it's in the best interest of the patient. This would include situations in which the patient requires specialized care by the surgical practice, such as after the patient undergoes combined glaucoma or corneal surgery. (To access the OIG text of the 1999 Safe Harbor Regulations, visit You can also review the American Optometric Association's 2004 Bulletin on this topic.1)

Here, I explain why your role in the care of refractive surgery patients is crucial to their ocular and mental health and how you can integrate co-management into your practice.

Your significance

Refractive surgery is, without question, refractive care. It is physiological optics involving concerns, such as aberrations, glare, pupil size, contrast sensitivity, angles kappa and alpha, prolate vs. oblate shape and much more. In addition, refractive care consists of using your relationship with the patient as a means of gauging their expectations, vision needs and mental health regarding the surgery.

Specifically, refractive care consists of:

► making an evaluation of the refractive stability of the patient's visual system.

► determining the most appropriate procedure for the viable candidate.

► accurately informing the patient of the benefits and risks of the procedure.

► prescribing a refractive correction to fit the viable refractive surgery candidate's ocular and lifestyle needs.

► managing patient expectations by educating him about both the pre- and postoperative steps of the procedure, particularly the recovery process, to minimize anxiety.

► managing the healing process.

► accurately assessing the patient's visual response to the surgery.

All of these points unquestionably fall under the jurisdiction of you, the optometrist. Why? Because your optometry training and subsequent continuing education have made you an expert in optics, refraction and vision care. Even ophthalmologists, during our many battles for prescription rights, have acknowledged that optometrists possess a superior expertise in optics and refractive care. In addition, you, not the surgeon, have a relationship with the patient as their primary-eyecare practitioner.

To successfully integrate co-management into your practice, follow these six steps:

1 Maintain a current competence in refractive surgery.

Refractive surgery has become a great deal more complicated through the last few years, as it's expanded from corneal refractive procedures to clear lens exchange, phakic intraocular lenses (IOLs) and cataract surgery. Within these categories are the issues of surface laser treatment vs. LASIK; femtosecond vs. mechanical microkeratome; presbyopic vs. standard IOL; multifocal vs. accommodative IOL; astigmatic vs. spherical IOL and much more. Therefore, if you want to provide the best care to refractive surgery candidates, it's critical you invest the time and effort to stay abreast of the latest happenings in this ever-expanding area. This includes learning (through the various optometric and ophthalmic journals, continuing education courses and related meetings) about what, specifically, is involved in managing any surgery postoperatively, so you understand and can monitor the healing process.

2 Provide internal marketing regarding your skills.

The advertising that patients see and hear, via billboards, the radio, television and the Internet, sends the message that they should go directly to a refractive surgery center, and possibly one with the lowest price, for their total care. Unless we actively communicate our expertise and the need for our involvement in refractive surgery, this message continues unabated.

To counteract this very pervasive message, provide internal marketing regarding your refractive surgery care skills. You can accomplish this through displaying posters and brochures in your exam area that highlight available options and the customized pre- and postoperative care you can provide to ensure a successful outcome.

Also, include the question: "Are you interested in refractive surgery?" on your patient in-take form to make patients aware that you, the optometrist, play a significant role in refractive surgery. Then, make a point of rating his interest in refractive surgery during patient history taking, so you can direct your exam and discussion. A simple one through four rating system works well. If the patient's interest appears low, then complete the exam, and prescribe the necessary contact lenses or spectacles. If the exam results reveal he's indeed a candidate for refractive surgery, inform him of that option. Tell him to return to you should he decide to pursue it, as you have the expertise to guide and support him through the process. (Even if the patient takes a year or two to choose surgery, he'll remember your recommendation.) These few seconds pay huge dividends as patients begin to return for your guidance and care.

If, however, the patient expresses a significant interest (i.e. he's ready to move forward with surgery) and his exam reveals he's a viable candidate, you now know that you may not need to fit the patient for new contact lenses or a pair of spectacles. Spend this time informing the patient about refractive surgical care.

Because there isn't enough time during a regular exam to cover all the necessary bases concerning refractive surgery, have the patient schedule a separate refractive surgery appointment, at which you'll perform additional testing and patient education.

A more recent need is to bring the cataract patient back once the patient has decided to undergo cataract surgery. At the time the patient presents for his yearly exam, you cannot predict whether you will need to refer him for surgery. And, as with standard refractive surgery, more options exist today so that such a discussion takes more time than what is available during the initial exam.

More options and higher expectations make it imperative that your patient education cover lens options and patient expectations vs. realistic outcomes. After all, a disappointed patient is an unhappy patient.

For instance, if the cataract patient expects to be free of spectacles, you should discuss presbyopic IOLs or monovision. Also, you need to evaluate corneal astigmatism and discuss correcting it with an astigmatic IOL or limbal relaxing incisions.

3 Make a specific referral.

Because of your expertise in eye care and eye health, you're in the best position to evaluate the skill level of the ophthalmic surgeons in your community, enabling you to recommend a specific surgeon for a specific type of refractive surgery — a fact of which you should make your patients aware. You can assist the patient by making the appointment before he leaves the office. Many optometrists offer patients a choice of several surgeons. Don't do this. The patient is looking for your guidance.

4 Make a specific treatment recommendation.

Once the patient has made the appointment with your chosen surgeon, provide the surgeon with a concise report that contains information that will help him deliver the requested care. My practice's cataract consult request form includes the patient's name; date of birth; referring doctor (me); date of referral; eye health history (i.e. oldest and most recent refraction of both eyes with visual acuity); vision difficulty (i.e. reading, driving or other) caused by cataract; diagnosis; recommendations; suggested refractive goals and the patient's desire to have me co-manage the surgical care.

5 Maintain communication with the surgeon.

Letting the surgeon know that the patient wants you to comanage the surgical care informs him that he is to consider you a partner in care. You've shared your recommendations for the patient's treatment. Now, the M.D. must keep you abreast of all the intricacies of the procedure and his decision-making.

Something to keep in mind: Just because you make a specific recommendation, that doesn't mean the surgeon must deliver only the prescribed care. If the surgeon feels another approach is better, you should expect communication explaining the difference, so further discussion can take place. You shouldn't expect the surgeon to proceed with care he doesn't believe is appropriate. A unilateral decision to deliver other than the requested care, however, suggests he doesn't respect your opinion, which could cause problems in terms of your partnership in the patient's care.

Remember: If no communication exists between providers, the patient's insurance carrier can deny payment to you, the co-managing optometrist.

6 Deliver the postoperative care.

Postoperative care consists of acting as a reassuring counselor to the patient and delivering the ongoing refractive and ocular care relative to the specific surgery, whether you're prescribing corrective eyewear or advising the patient about the need for an additional surgery.

Also, you know your patient, in terms of whether he'll be anxious and need reassurance or whether he'll be overly confident and likely be non-compliant with postoperative instructions.

Avoid failure

When a prospective refractive surgery patient leaves our practice for care elsewhere, we've failed in two ways: First, we have failed as a healthcare advocate for our patients. This is because the patient has lost our expertise, guidance and support regarding the intricacies of refractive surgery. Since we've formed a relationship with the patient as his primary-care optometrist, this means he may receive less-than-adequate care elsewhere. Second, as a small business owner, we have lost the revenue that the patient brings to our practice as well as the referrals to his friends and family.

I hope I have helped you understand that co-management is in the best interest of the patient and you, if carried out properly. Also, I hope this article will help you better integrate co-management into your practice. OM

1. Co-Management Responsibilities. American Optometric Association Bulletin; Oct. 2004; Vol. 63:11.

Dr. Phillips is president of SightLine Laser and Ophthalmic Associates in Pittsburgh. He ‘s past president of the Pennsylvania Optometric Association and a founding member and past president of the Optometric Council on Refractive Technology. You can e-mail him at

Optometric Management, Issue: December 2008