Comanaging Cataract Patients: The New Role of the Primary Care Optometrist.
technologies and techniques, as well as changes in scope of practice, mean
O.D.s can take a more active role in comanaging these patients.
C. AJAMIAN, O.D., F.A.A.O.
in the management of the cataract patient has changed dramatically over the past
two decades. Armed with more clinical experience and confidence, doctors of optometry
are on the front line gathering critical information, diagnosing the condition,
and guiding the patient's decision as to when to undergo surgery. Once a surgical
referral is made, the optometrist's involvement with the patient's care continues.
Always remember that these are our patients, and we take responsibility for all
aspects of their care from start to finish. Our involvement during the postoperative
period may begin as early as one day or as late as three months after the surgery.
Our level of participation depends on many factors, with the foremost
consideration being the wishes and care of the patient. Another important factor
is the confidence of the surgeon in his/her technical abilities. Some surgeons may
want to follow patients for a longer period of time. When we note this trend, we
should probably steer our patients in a different direction. The high-volume cataract
specialists are usually very comfortable releasing their patients after surgery,
because they have a track record of consistent results. There will always be cases
where complications occur, and we respect the surgeon for wanting to follow these
patients for a longer period of time.
Your practice setting can also determine whether you are involved
in comanagement. Some O.D.s in busy corporate settings may not have the time or
financial incentive to see post-op patients until the global period (typically three
months) has ended. Others make their decisions based on insurance reimbursement.
Yet others may not have the option to comanage, based on the surgeon's desire to
keep the fee to himself in an era of declining reimbursement.
This article is about doing what is best for your cataract patients.
How? By performing a careful pre-op exam, including detailed refractive and eye
health findings, sending that information along with input on the best correction
options and referring your patients to the most experienced surgeons who are secure
enough in their technical skills to work cooperatively with the primary care doctor
Pearls for Cataract Comanagement
your documentation. In addition to documenting patient complaints, make specific
remarks, such as, "Patient can no longer drive at night." These can help justify
the surgery in the event of an audit.
all data clearly and pass on to the surgeon in written form.
that the patient will see you for post-op care. Patients generally sign a consent
form in the surgeon's office, but it's wise to mention this to the patient beforehand.
first-hand knowledge of your surgeon. Don't just go by word of mouth, visit and
spend time with your surgeon. Be aware of the materials and lens platforms the surgeon
into surgery, preferable when one of your patients is scheduled, and follow him
or her through the process. This is will enable you to fully answer any questions
about the procedure.
patient preferences to the surgeon well ahead of the surgery.
on observations that might alter the way surgery is performed. For example, if the
patient is overly sensitive, the surgeon will need to prepare a retrobulbar or peribulbar
those with preexisting conditions. Patients with AMD, diabetic retinopathy or glaucoma
will likely not achieve 20/20 vision even after surgery. Patients and family members
should be well-prepared.
Document, document, document
There is more to the preoperative exam than just taking a history,
acuity, and looking at the crystalline lens. First and foremost, we must document
the patient's visual complaints and be sure that a functional impairment exists.
Yes, the record should clearly state the chief complaint of "gradual progressive
acuity loss OD greater than OS for six months," but should go on to record how this
is interfering with the patient's life. Documentation such as, "Patient can no longer
drive at night," or Problems sewing and knitting," or "Patient would like to read
her Bible but is unable to see the print," go a long way toward justifying surgery
in the event of an audit. With more and more pressure on surgeons and surgery centers
to include adequate rationale for treatment in the chart, you could save the patient
a lot of unhappiness by sending them only when they are truly ready.
The following scenario serves to illustrate the point: A 69-year-old
female presented to her optometrist for a routine exam with no visual complaints.
She was 20/30-2 OD and 20/25 OS. Her doctor told her she had cataracts and scheduled
her for same-day surgery one week later. Her daughter took the day off to drive
her mother to the surgery center. They got up at 5:30am for a 7:30am appointment.
The surgery had to be canceled because she still had no complaints and no functional
impairment had been elicited. The patient and daughter were, for obvious reasons,
quite upset with everyone involved.
situation could have easily been avoided. If there are no visual and lifestyle complaints,
schedule the patient back for a six-month follow-up, not surgery! If the patient
complains of the inability to read, check near acuity. If there is a complaint of
glare while driving at night, do room lights-on acuity or a Brightness Acuity Test
(BAT) to confirm the problem. Record everything clearly and pass on the information
to the surgeon in written form.
Finally, document that the patient has been given the choice of
whom they will see for the post-op care. The patient will generally sign a consent
form in the surgeon's office stating they wish to see their O.D. for post-op care,
but it is wise for you to mention it to your patient and document such in your chart.
Now you are ready to send the patient for surgery... but to whom?
Choose or lose
Let's assume you just began practicing in a new city or town.
You want to establish a good relationship with a reputable cataract surgeon who
will send your patients back. Where do you begin? The best way to start is to talk
to colleagues and ask them who they work with. Hopefully they will steer you to
a surgeon who is personable, has skilled hands and works cooperatively with optometrists.
But is that recommendation enough? First-hand knowledge is always best, so visit
with the surgeon and spend time with him or her in the operating room. The true
personality of the individual will only be revealed under "battle conditions," not
over lunch. A half a day is all that is necessary to tell the tale. Scrub in to
surgery, don't just watch a monitor from another room. Ideally, come on a day when
one of your patients is scheduled, and follow that patient through the entire process
from check-in to recovery. How much time does the patient spend at the surgery center
from start to finish? What is the average length of each case? Is the surgeon calm
and controlled with patients and staff? How are unexpected complications handled?
How are the patient and family treated in the recovery area? The patient will be
extremely grateful and comforted to know that you are there, and you will have an
"eyewitness account" of the experience.
being familiar with the surgery center and protocols, you will be better equipped
to give future patients a clear picture of what their surgery will entail. By knowing
what techniques are used, the kind of equipment the ASC has invested in, and the
demeanor of the surgeon, you can make your decision on whom to refer patients to
in the future. For the many doctors that already have an established relationship
with a surgeon, but have never seen them operate, try to carve out some time to
watch them. With surgical technology always changing, a yearly trip to the O.R.
is a nice change of pace and a learning experience as well.
The optometrist's role in cataract comanagement extends well beyond
determining the presence of a lens opacity. After all, no one knows your patient's
visual system better than you do! Be their advocate and make sure the surgeon has
all necessary information prior to surgery day. there are too many factors such
as nerves, hunger and forgetfulness, to rely on the patient to convey meaningful
information. They will often change their story and forget to tell the specialist
about difficulties reading or driving at night. A monovision contact lenses patient
who wants to remain so postoperatively may not know how to express that, and as
a result it may not get done.
Patients are more informed on lens implant options, so have an
open discussion with them about the materials your surgeon uses. With variables
like silicone vs. acrylic material, edge design and blue-blockers, it's important
to understand what will be placed in your patient's eye and why.
With new IOL options and procedures such as limbal relaxing incisions
(LRI) to reduce astigmatism, it is critical that you convey your patient's preferences
to the surgeon. Mention the new multifocal IOL's to all your patients, so that they
are aware this option exists. With direct-to-consumer advertising ready to launch
this summer, it is imperative that you be proactive in mentioning these new lenses,
and ready to answer their questions. Many will not choose these surgical alternatives
due to cost or goals, but they should be able to make the choice. Likewise, a patient
with 3.00D of astigmatism who has a chance to shed some or all of their cylinder
with an LRI should have that option. Don't leave it up to the surgeon alone to introduce
this concept. Be proactive and discuss all options that will benefit that particular
Also, be sure to pass along to the surgeon any of your observations
about the patient that might alter the way surgery is performed. One example: the
overly-sensitive patient who squeezes tight when drops are instilled or Goldmann
tonometry is attempted. In cases such as these, the surgeon will need to be prepared
to do a retrobulbar or peribulbar block. Pseudo-exfoliation patients are another
category of patient that you should flag for the surgeon. This condition can dramatically
alter the surgical technique due to often unstable zonules, requiring iris hooks
for capsular support.
Yet another example, tied in with taking a good history, is a
male patient on Flomax (tamsulosin, Boehringer Ingelheim), the most commonly prescribed
alpha-1 blocker for benign prostatic hyperplasia (BPH). Unfortunately, the drug
may have a similar yet undesirable effect on the iris during cataract surgery. Specifically,
tamsulosin has been linked to intra-operative floppy iris syndrome (IFIS). The surgeon
can be better prepared to use iris retractors, a pupil expansion ring or a viscoadaptive
agents to maintain pupil dilation if you notify him or her in advance.
Finally, if the patient has any coexisting condition such as AMD,
diabetic retinopathy or glaucoma, he or she may still be a good candidate for cataract
surgery, but needs to know (along with family members) that the visual result probably
won't be 20/20. Risks of cystoid macular edema increase significantly, so know your
surgeon's protocol for non-steroidal anti-inflammatory (NSAID) use, both before
surgery and after. Today NSAIDs are much more commonly used as part of the pre-
and postoperative routine, with or without retinal problems, so be informed and
be ready to explain this to your patients.
technology changing, a yearly trip to the O.R. is a nice change of pace and a learning
Just as cataract surgery has matured into a sophisticated procedure
with consistent outcomes in the right hands, comanagement of these patients has
evolved due to the convenient, cost-effective and quality care provided by doctors
of optometry around the country. As with any primary care doctor, we are the quarterbacks,
and need to coordinate the plays by carefully selecting our surgeons, providing
them with complete information, and expecting detailed information back. The days
of the "patient out the door mission accomplished" mentality are long over!
We are primary-care doctors of optometry, and we must carry out
our responsibilities as such. Primary-care doctors give firm counsel on the best
referral source for a particular problem. Primary-care doctors send their patients
to colleagues who respect them, confer with them, and support their decisions and
their profession at all levels. Primary-care doctors provide meaningful, detailed
information to the surgeon and expect the same back.
With this system in place, our patients will always be on the
Ajamian currently serves as Center
Director for Omni Eye Services in Atlanta, the first optometric comanagement center
in the country. He is also General Chairman of the Education Committee for SECO
International as well as an adjunct faculty member for 12 schools and colleges of
optometry. Send e-mail to PAjamian@novamed.com.
Optometric Management, Issue: March 2006