CLEVELAND AMBULATORY SURGERY 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 trabeculoplasty
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 astigmatism
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 capsulotomy
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 tarsorrhaphy
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 trabeculectomy
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