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CLEVELAND AMBULATORY SURGERY CENTER DELINEATION of CLINICAL PRIVILEGES Ophthalmology

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CLEVELAND AMBULATORY SURGERY CENTER DELINEATION of CLINICAL PRIVILEGES Ophthalmology 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 .
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