Article Date: 3/1/2006

comanagement
Comanaging Cataract Patients: The New Role of the Primary Care Optometrist.
New 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.
PAUL C. AJAMIAN, O.D., F.A.A.O.

Optometry's role 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 of optometry.

Clinical Pearls for Cataract Comanagement

Expand 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.

Record all data clearly and pass on to the surgeon in written form.

Document 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.

Have 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 prefers.

Scrub 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.

Convey patient preferences to the surgeon well ahead of the surgery.

Pass 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 block.

Council 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.

This 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. 

By 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.

Communication rules

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 patient.

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.

Two-way street

With technology changing, a yearly trip to the O.R. is a nice change of pace and a learning experience.

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 winning team!

Dr. 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