Surgeons and optometrists often work together to provide care to cataract patients during the entire peri-operative period — which includes both pre-operative and post-operative care. This is to ensure both of the providers are on the same page, so the patient can achieve the best possible outcome from their cataract surgery.

Here I detail the responsibilities of the referring optometrist in these patients’ care.

COMPLETE THE PRE-OP EVALUATION

O.D.s should conduct a thorough evaluation of the patient to determine whether the patient is ready for the referral to the surgeon. This evaluation includes screening for ocular surface disease (OSD), AMD and surface wrinkling retinopathy, among other retinal pathology. Data collected from the pre-op evaluation is then communicated to the surgeon. It should include: diagnostic findings and any treatments.

Regarding OSD, issues with the ocular surface can push the referral period down the road, as the ocular surface must heal prior to cataract surgery. The reason for this is two-fold: A healthy ocular surface is needed for accurate measurements for the IOL the patient and the surgeon decide on. Additionally, an unhealthy ocular surface that undergoes surgery can result in prolonged patient discomfort, post-surgery.

O.D.s should prescribe a treatment regimen, appropriate to the ocular surface findings, and schedule follow-up visits to ensure the ocular surface is healthy prior to the referral to the surgeon.

Other issues, such as surface wrinkling retinopathy or AMD, also screened for in the pre-op evaluation via examination of the macula, can rule out the patient as a candidate for high-technology IOLs.

COUNSEL THE PATIENT

Although the ultimate decision of what type of IOL the patient will receive during surgery will be determined by the surgeon and the patient, O.D.s should use patients’ data regarding refraction and lifestyle to educate them about the IOLs for which they would make good candidates. The education the optometrist provides in advance can assist in making that decision.

Whether patients benefit from a toric IOL, an EDOF IOL, a trifocal, multifocal or monofocal technology, patients who know their choices ahead of time are put at ease. Also, counseling the patient prior to the referral may save the surgeon time, which is appreciated.

Additionally, the O.D. should review with pa-tients the cataract evaluation process they will encounter in the surgical practice. This is because the cataract evaluation day for the patient in the surgery practice can be an intimidating time. Specifically, the optometrist should inform patients of the typical length of the visit; that they will be moved room to room; the tests, such as biometry, OCT, topography, ray tracing and brightness acuity, that will be performed on them; that their eyes will be dilated; and that they may meet with multiple doctors, which can be the case of many practices. The visit can last up to three hours, with counseling included.

The patient counseling information the optometrist needs to communicate to the surgeon is the interest a patient has regarding the type of IOL. This communication needs to reviewed by the surgical practice in a timely manner prior to the encounter with the patient.

EDUCATE THE PATIENT ON CO-MANAGEMENT

One of the most important aspects of co-management is to have the proper consent documentation signed by all parties that the care of the patient will be shared between providers.

In our practice, the patient is aware of who will be providing what care, and that the care will be transferred between providers when medical stability of the procedure is achieved.

The training and the regulatory boards over each profession is in the consent. Also, at my practice, we advise the patient of the financial remuneration involved in the various levels of care that will be provided by each provider, so he or she agrees to the co-management.

It is so important to have discussed the co-managed care with the patient prior to the referral. When this occurs, patients are fully aware of how the care will be provided and have signed an agreement that they acknowledge the care will be given in that manner, and that they can see the operating surgeon anytime they wish. This crucial step prevents awkward moments that can occur if a patient is not aware of the intended transfer of care.

Projections for Cataract in 2010-2030-2050 (in millions)

 

 

RECEIVE PATIENT VIA TRANSFER OF CARE

The transfer of care, which can vary from patient to patient, should take place when the patient is medically stable and following a normal healing pattern. The date the surgical practice releases the care to the optometrist, the specifics of the type of IOL implanted and, in the case of toric IOLs, the axis in which the lens was implanted should be included in the surgeon’s transfer of care letter. This is critical to the co-managing optometrist and the post-operative care process. Without this information, the optometrist would not know the intended axis that the lens was placed and, therefore, have no baseline data.

The surgeon’s transfer of care letter should also contain the medication the patient is taking and the instructions provided to the patient. This ensures the patient that all parties involved in the care are on the same page.

The role of the optometrist when complications are incurred is to manage what can be managed within the office — such as iatrogenic IOP spikes or persistent inflammation — and to refer any condition that needs immediate attention — such as leaking wounds, a dislocated IOL or endophthalmitis.

CONTINUITY OF CARE

My practice has found that co-management between the referring O.D. and surgeon leads to excellent patient care, when each side is aware of their responsibility. When communication is clear and processes are in place to collaborate, the patient receives the best care and has the best possible outcome available to them. OM

DR. DEVRIES has a degree in financial management from the University of Nevada School of Business, and is co-founder of Eye Care Associates of Nevada, a medical/surgical co-management referral practice. He has relationships with Allergan, Bio-Tissue, Bruder, BVI Medical, Bausch + Lomb, Eyes 4 Lives, Eyegate Pharmaceuticals, Johnson & Johnson Vision, OcuSoft, Ophthalmic Resources, Revision Optics, RPS, RySurg, ScienceBased Health, Shire, Sun Pharmaceutical, TearLab and Tear Science. Email him at drdevries@nveyelaser.com.