Cataract Co-Management Manual Cataract Surgery Coordinators K’marie: 808-593-9196 [email protected] Angela: 808-380-7544 [email protected] Billing question? Contact Administrator, Pamela Utu, [email protected] 808-777-4413 E-mails: Dr. Tyrie Jenkins at [email protected] Dr. Jeffrey Peterson at [email protected] Dr. Jacqueline T. Ueda at [email protected] Tyrie Jenkins, MD ● Jeffrey Peterson, MD, PhD ● Jacqueline T. Ueda, OD 615 Pi`ikoi Street Suite 205, Honolulu, HI 96814 Phone: (808) 591-9911 Toll Free: (855) 522-2020 Fax: (808) 591-9909 After Hours:(808)524-2575 Updated January 2018 TABLE OF CONTENTS Topics Page Introduction 3 Pre-Operative Evaluation 3 Scheduling 4 Neighbor Island Co-management 5 Intraocular Lens (IOL) Options for Cataract Patients 6-8 ORA Technology 9 Laser-Assisted Cataract Surgery (LenSx) 9 Cataract Surgery for Patients with Glaucoma 10 Surgical Technique 11 Post-Operative Care and Complications 12-17 Conclusion 17 Billing Co-managed Care, Tips & References 18-20 Premium Lens Fees, Financing Options 21 Co-Management Forms Cataract Referral Record 22 Consent for Co-management after Eye Surgery 23 Pre-Operative Checklist 24 Post-Operative Report Form 25 2 INTRODUCTION The co-management model of primary care eye doctors working with secondary and tertiary care ophthalmologists has been successful in Hawaii. This joint arrangement provides patients with the alternative of having post-operative care provided by their own eye care professional with whom they have a longstanding relationship, and may be more accessible, especially on the neighbor islands. Ongoing and clear communication between doctors is essential for ethical and safe co-management for cataract and refractive surgery patients. This manual is intended to serve as a guide for co- management of cataract patients. It includes a brief description of the pre-operative evaluation, our current surgical technique and post-operative findings. Fortunately, most cataract surgeries result in safe, rapid visual rehabilitation. However, there is the possibility of vision threatening complications. The ability to recognize abnormal from normal post- operative findings is paramount to ensure a successful post-operative result. PRE-OPERATIVE EXAM Cataracts are a leading cause of reduction of vision, particularly in the aging population. A careful dilated eye exam is needed to determine the nature of the cataract and to ensure that the cataract is the only cause of visual loss. Macular disease is common in this older population and its presence may reduce the visual benefit from cataract surgery. Questions to consider before proceeding with surgery: Is the patient having problems doing the things he or she needs or likes to do? What is the predicted outcome? What is the condition of the other eye? What is their medical status? Do the benefits outweigh the risks? The chief criterion for proceeding with surgery is interference with lifestyle. 3 This subjective guideline may mean different recommendations for different patients. For example, a patient with nuclear sclerotic cataracts and 20/80 distance best vision who experiences no visual difficulties in their daily activities and does not drive may not be a candidate for surgery at this time. An accountant with 20/25 distance vision and posterior subcapsular cataracts may be very affected, as he or she could be experiencing difficulty with their predominantly near tasks and demonstrate a significant reduction in vision with glare testing. In every case a decision should be made based on the individual patient’s needs and desires. SCHEDULING When you call to schedule a patient for cataract surgery, please let us know if you are interested in co- management. There are two forms that must be completed to appropriately bill for co-management: Cataract Referral Record and Patient Consent for Co-management. It is important for the patient to understand that you will participate in their post-operative care and to have them sign the patient consent form for co-management. Not all local insurance companies recognize co-management, but we will gladly check on the patient’s insurance. We will always try to schedule a cataract evaluation as soon as we can when you call but if you need the patient to be seen sooner, just let the receptionist know their time frame, and we will do our best to accommodate their schedule. Please inform your patients that they will need surgical clearance from their primary care doctor within 30 days of their surgery. On the day of the cataract evaluation, surgery will be scheduled (if not done so already). If the patient has received clearance from their primary care doctor, an earlier surgery date may be arranged. After surgery, our team will see the patient on the one-day post-operative visit. We will fax the result of the exam to you so that you will have it on subsequent patient visits. Please fax post-operative forms back to us and always give us a call if you have any questions. 4 NEIGHBOR ISLAND CO-MANAGEMENT Dr. Jenkins and Dr. Peterson work with neighbor island doctors for refractive and cataract surgery co- management. If a patient chooses to have cataract surgery on Oahu, we will be glad to help with the arrangements. Neighbor island patients may have their cataract evaluation the day before surgery and undergo surgery the next day, followed by their one-day post-operative visit on the third day. This schedule requires a two-night stay on Oahu. We require that the patient arrange for a surgical clearance from their primary care physician before arrival on Oahu. For scheduling neighbor island patients, please call our office and speak with our Cataract Surgery Coordinator, K’Marie at 808-593-9196. 5 INTRAOCULAR LENS (IOL) OPTIONS FOR CATARACT PATIENTS When a cataract is removed, it is replaced with an artificial intraocular lens (IOL). There are a variety of IOLs that can be used in cataract surgery. Each has their own set of advantages and disadvantages. The FDA approval process for IOLs is among the most rigorous in the world. Fixed Focus Monofocal IOLs are used in the majority of cataract procedures. These lenses have a fixed focal point, and may be set for distance or near vision. This requires detailed discussion with the patient on what their refractive goal will be. These lenses have the advantage of excellent quality distance or near vision under a variety of lighting conditions. For patients willing to use reading glasses for near tasks, these IOLs are an excellent choice. Millions of lenses of this variety have been used for decades with an excellent safety record. Recent refinements in the optical quality of these lenses have allowed an even higher quality of vision than previously achieved. Using innovative wavefront lens technology, aspheric IOLs can improve contrast so one can see well even in low-light situations such as night driving. Some IOLs are available with special materials used to block potentially harmful blue light. Fixed focus monofocal IOLs are usually covered by most insurance companies, along with the expense of the surgery. 6 Toric Monofocal IOLs are a great refractive surgical option for patients with high corneal cylinder. Although limbal relaxing incision (LRI) procedures can be effective for mild to moderate corneal astigmatism correction (-0.75 to -1.25 diopters of cylinder), there is no better surgical choice for those with higher corneal cylinder (> -1.25 diopters) than a toric monofocal IOL like Alcon’s AcrySof Toric. The toric IOL has been approved to correct over 4 diopters of astigmatism. The criterion for selection of these patients is that their refractive astigmatism is corneal based, not lenticular (i.e. refracted cylinder is similar to keratometry or topography cylinder). As this is considered a refractive option, insurance policies will not cover both the toric IOL and LRI, so there will be an out of pocket expense for your patients. Cylinder Power and Recommended Correction Model Range Corneal Range IOL Plane Plane* SN6AT3 1.50 1.03 +.75 - +1.50 SN6AT4 2.25 1.50 +1.50 - +2.00 SN6AT5 3.00 2.06 +2.00 - +2.50 SN6AT6 3.75 2.57 +2.50 - +3.00 SN6AT7 4.50 3.08 +3.00 - +4.00 SN6AT8 5.25 3.60 +4.00 - +4.50 SN6AT9 6.00 4.11 +4.50 on AcrySof Toric 7 Multifocal IOLs enable patients to achieve good distance and near vision without glasses. Excellent results have been achieved by FDA approved lenses of this type. The ReSTOR, Tecnis Multifocal and the Symfony are among the most popular multifocal IOLs. These IOLs use a patented diffractive optical design to divide light into two focal zones so that near and distance objects can both be seen without glasses. Multifocal IOLs have a slightly greater tendency to cause halos at night than other IOLs, so those who drive a great deal at night may wish to consider a different IOL. Patients should also be aware of the possibility that a mild pair of reading glasses may be required for fine print or long term reading. Both the ReSTOR and the Symfony IOL are also available to correct astigmatism, greatly expanding the patients who are candidates for these lenses. ReSTOR IOL Tecnis Multifocal IOL Symfony IOL Toric IOLs and Multifocal IOLs are high technology lenses that require additional measurements and preoperative counseling. The cost of these services as well as the cost of the IOL is NOT covered by insurance (though the cost of the cataract surgery is typically covered). 8 ORA (Optiwave Refractive Analysis) SYSTEM OPTIPLUS uses a wavefront analyzer in the operating room that can assist the surgeon in determining the ideal power and position of the implanted IOL. Surgical Suites is the only facility in Hawaii that has this system.