KALEIDA HEALTH

Name ______Date ______

DELINEATION OF PRIVILEGES – OPHTHALMOLOGY

All members of the Department of Ophthalmology at Kaleida Health must have the following Credentials: 1. Successful completion of an ACGME, AOA, Royal College of physicians and surgeons of Canada, or an ACGME equivalent Ophthalmology Residency Program. 2. Must be AMBS Board Certified in Ophthalmology or, if not board certified, must obtain certification within two (2) years from appointment. Maintenance of Board Certification is mandatory for those who have achieved this status. 3. Demonstrate or document requisite training for credentials and requested privileges as indicated below.

PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive.

LEVEL I (CORE) PRIVILEGES Level 1 (core) privileges are Muscle Transposition those able to be performed after successful completion of an accredited residency Repair of iridodialysis program in that core specialty. The removal or restriction of these privileges would Cataract extraction require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually. Intraocular lens implantation and removal Repair of wound for flat anterior chamber Admission and Discharge privileges at Kaleida Health facilities to Anterior (including pars plana) include hospital inpatients, ambulatory service center patients and Muscle operation for squint other categories of patient admissions. Astigmatic Keratotomy History and Physical for diagnosis and treatment plan CONJUNCTIVA: : Suture of conjunctiva for laceration Blepharotomy; drainage of abscess Biopsy Xanthelasma, plastic excision and repair Excision of Lesion Excision of nevus or papilloma Conjunctivoplasty: Lid margin lesion, benign or malignant; block Free graft with conjunctiva excision & plastic repair with graft Free graft with buccal mucous membrane for redundant skin or herniation of Flap operation for ulcer, perforation of operative wound orbital fat through orbital septum Repair of symblepharon Canthoplasty LACRIMAL: Plastic restoration of eyebrow by graft Drainage, lacrimal gland abscess, I & D Blepharorraphy, , canthoplasty Drainage, lacrimal sac abscess Lid lacerations, reconstruction and plastic repair Excision, lacrimal gland Ptosis, plastic correction: Excision, lacrimal sac Levator resection/Illif or similar method Catheterization, nasolacrimal duct Entropion or ectropion, plastic repair, muscle or tarsal resection or Plastic repair of severed or lacerated canaliculus imbrication with graft (cicatricial) Temporal artery biopsy Closure, punctum Botulinism Injections Dilation and/or irrigation of punctum or canaliculus Fascia Lata Sling for Ptosis Probing, nasolacrimal duct ORBIT: GLAUCOMA: Orbitotomy; for exploration, abscess, foreign body, tumor or Intraocular surgery for glaucoma, peripheral and pseudo-tumor; fracture of orbit with repair; decompression filtering including glaucoma drainage devices and antimetabolites Exenteration or evisceration of orbit Implantation of Glaucoma Drainage Devices Orbital injection of alcohol for pain Antimetabolites () GLOBE: LASER SURGERY: Enucleation or evisceration with or without implantation Iridotomy Secondary implantation; plastic restoration of orbital volume Lysis of suture Repair of perforated globe Lysis of adhesions Paracentesis, treatment or diagnosis, aspiration Pterygium, excision Retinal Photocoagulation Curettage and cautery of Removal of intraocular foreign body with or without magnet Excision, lesion of iris, malignant or non-malignant Excision, lesion of ciliary body, cyclectomy

Ophthalmology 2-2020

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Level II (Core) The following privileges require successful completion of an AUPO Accredited Fellowship Penetrating Keratoplasty Deep Anterior Lamellar Keratoplasty Endothelial Keratoplasty (DSEK) The above Core privileges are those able to be performed after Requested Granted Not Granted Granted with successful completion of an accredited training program in that core following specialty. The removal or restriction of these privileges would requirements: require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually.

Level II Core (Fellowship Trained Privileges)

Level II (Core) The following privileges require successful completion of an AUPO Accredited Cornea/Refractive Fellowship or completion of post-graduate Refractive surgery Training Refractive Surgery The above Core privileges are those able to be performed after Requested Granted Not Granted Granted with successful completion of an accredited training program in that core following specialty. The removal or restriction of these privileges would requirements: require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually.

Level II Core (Fellowship Trained Privileges)

Level II (Core) The following privileges require successful completion of an AUPO Accredited Retinal – Vitreous Fellowship Repair Of Retinal Detachment Posterior Vitrectomy Laser Endophotocoagulation The above Core privileges are those able to be performed after Requested Granted Not Granted Granted with successful completion of an accredited training program in that core following specialty. The removal or restriction of these privileges would requirements: require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually.

Level II Core (Fellowship Trained Privileges)

Pediatric Level II (Core) The following privileges require successful completion of an AUPO Accredited Pediatric or Cornea Fellowship Penetrating Keratoplasty Deep Anterior Lamellar Keratoplasty (DALK) Endothelial Keratoplasty (DSEK) The above Core privileges are those able to be performed after Requested Granted Not Granted Granted with successful completion of an accredited training program in that core following specialty. The removal or restriction of these privileges would requirements: require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually.

Level II Core (Fellowship Trained Privileges)

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Pediatric Level II (Core) The following privileges require successful completion of an AUPO Accredited Pediatric or Glaucoma Fellowship Antimetabolites (Glaucoma Surgery) Implantation of Glaucoma Drainage Devices The above Core privileges are those able to be performed after Requested Granted Not Granted Granted with successful completion of an accredited training program in that core following specialty. The removal or restriction of these privileges would requirements: require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually.

Level II Core (Fellowship Trained Privileges)

Pediatric Level II (Core) The following privileges require successful completion of an AUPO Accredited Pediatric or Oculo-Plastic Fellowship Botulinism injections Fascia Lata Sling for Ptosis The above Core privileges are those able to be performed after Requested Granted Not Granted Granted with successful completion of an accredited training program in that core following specialty. The removal or restriction of these privileges would requirements: require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually.

Level II Core (Fellowship Trained Privileges)

Pediatric Level II (Core) The following privileges require successful completion of an AUPO Accredited Pediatric /Strabismus Fellowship Muscle Transposition Glaucoma Under Age 2 Cataract Under Age 1 The above Core privileges are those able to be performed after Requested Granted Not Granted Granted with successful completion of an accredited training program in that core following specialty. The removal or restriction of these privileges would requirements: require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually.

Level II Core (Fellowship Trained Privileges)

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MODERATE/CONSCIOUS SEDATION 1. Providers seeking privileges in moderate/conscious sedation must complete either the ASA sedation course or Medsimulation course receiving a score of 85% or above and repeat the course every four (4) years, or two (2) years for those with a two (2) year expiration date.

2. Providers must also maintain airway management skills through current completed training and certification in ACLS, ATLS, PALS OR NRP.

(For details on course availability and maintenance please review the Moderate/Conscious Sedation document located on our credentialing web page.) With following Requested Granted Not Granted* requirements** (provide Details)

KEY *NOT GRANTED DUE TO: **WITH FOLLOWING REQUIREMENTS Provide Details Below Provide Details Below 1) Lack of Documentation 1) With Consultation 2) Lack of Required Training/Experience 2) With Assistance 3) Lack of Current Competence (Databank Reportable) 3) With Proctoring 4) Other (Please Define) (i.e., Exclusive Contract) 4) Other (Please Define below)

DETAILS:______

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National Practitioner Databank Disclaimer Statement: Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (43 U.S.C. 11101 et seq.)

/ __ Signature of Applicant Date

(1) I recommend approval of the procedures requested by the applicant. a) ____ as requested b)____ as amended,

(2) That I, the Chief of Service, have consulted with the Chief of the Division of Pediatric Surgical Services concerning any requests of this applicant for Level II/III privileges on patients below the age of 18.

______/______Signature of Chief of Service Date

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APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS

Ophtholomology 4-2020