CLEVELAND AMBULATORY CENTER DELINEATION OF CLINICAL PRIVILEGES Ophthalmology

Applicant's Signature Date

The granting, reviewing and changing of clinical privileges will be in accordance with the Medical Staff Bylaws. Assignment of such clinical privileges must be based upon education, clinical training, demonstrated skills and capacity to manage procedurally related complications.

Indicate procedures for which you do and do not wish to be credentialed. Return this form with your Application.

Recommendation by Procedures Credentialing Request QM Committee

Yes No Yes No

ANTERIOR CHAMBER

Tap/irrigation

Reformation

Removal of foreign body

Paracentesis

CILIARY BODY

Cyclodiathermy

Cyclocryopexy

Excision of prolapse

Cyclodialysis

Repair of dialysis

Argon laser

CONJUNCTIVA

Repair of major laceration

Conjunctivoplasty - without graft

Conjunctivoplasty - with sliding graft

Conjunctivoplasty - with mucous membrane graft

Flap to repair/restore anterior chamber

Gundersen lap

Excision of conjunctival tumor

CORNEA

Repair of laceration

Removal of (superficial) foreign body

Radial keratotomy

Keratectomy

Keratoplasty - lamellar and penetrating

Excision pterygium

Repair of wound leak

Resuturing for

Keratomeilusis

Epikeratophakia

Page 1 of 3 MS2H DELINEATION OF CLINICAL PRIVILEGES - Ophthalmology - (continued)

Recommendation by Procedures Credentialing Request QM Committee

Yes No Yes No

EXTRAOCULAR MUSCLES

Strabismus procedure

Biopsy

Repair of laceration

Repair of wound, extraocular muscle, tendon or

Tenon's capsule

IRIS

Iridotomy

Iridectomy

Excision of lesion

Repair of prolapse

Repair of dialysis

Laser photocoagulation

Iridoplasty

LACHRIMAL SYSTEM

Irrigation and drainage

Dilation/probe/irrigation - under general anesthesia

Intubation w/silicone tube

Punctal & canalicular exploration with or without plastic repair

LENS

Discission

Capsulotomy

Extraction - extracapsular

Extraction - intracapsular

Extraction with IOL implant

Removal/reposition of IOL

Exchange of IOL (Replacement)

Yag laser

LIDS

Repair major laceration

Repair marginal laceration

Canthoplasty

Tarsorrhaphy

Blepharoplasty

Excision of lesion with reconstruction/plastic repair

Excision of lesion with skin graft

Punctal repair

Entropion repair

Ectropion repair

Ptosis repair

Dermatochalasis repair

Page 2 of 3 MS2H DELINEATION OF CLINICAL PRIVILEGES - Ophtha lmology - (continued)

Recommendation by Procedures Credentialing Request QM Committee

Yes No Yes No

LIDS (continued)

Brow lift

Severing

Permanent lashliner

Chalazion excision

ORBIT

Revision/plastic repair or socket

RETINAL

Transcleral diathermy

Transcleral cryopexy

Laser photocoagulation for retinal tear

Laser photocoagulation for diabetic retinopathy

Laser photocoagulation for branch retinal vein occlusion

Laser photocoagulation for macular degeneration

Focal retinal photocoagulation

Pan retinal photocoagulation

SCLERA

Repair of laceration

Sclerotomy

Sclerotomy - partial or full thickness - for variety of glaucoma procedures including

MISCELLANEOUS

Goniotomy

Goniopuncture

Enucleation

Evisceration

Examination under anesthesia

Vitreous tap

Vitrectomy (anterior or posterior chamber)

Trabeculectomy

Endoscopic laser ciliary photocoagulation

Conscious sedation

Phakic intra-ocular lens implant lens extraction and implant for refraction and near vision

Use of 810 nm diode laser

Glaucoma surgery

For Administrative Purposes Only

Clinical privileges recommendations approved by Governing Body. Governing Body Chairperson Date

Page 3 of 3 MS2H