January 16, 2016
4 min read
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Close comanagement relationship results in optimal patient outcomes

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Optometrists today have more career choices than ever before. As generations of patients and their demands have changed, so have the options to treat them.

While the majority of ODs still elect to establish private practices, comanaging patients in a surgical center can be fulfilling. Advanced technologies offer exciting options and freedom from glasses for patients, and a change from traditional eye care provider structures can result in a successful patient approach.

Today’s patient

Patients have traditionally chosen LASIK surgery to eliminate the need to wear glasses, and this has enabled the majority to see better at distance. Today’s patient is different. Some patients who have had LASIK previously now need glasses again, but this time for reading. Others that never had LASIK now need to wear reading glasses over their contact lenses or are suddenly moving into bifocals, and others simply need readers after a lifetime of excellent vision.

Sondra Black

The Baby Boomer population is highly active into their 70s, has disposable income and has a tremendous amount of information within their reach. They take care of themselves in a completely different way, they want to know their surgical options and, overwhelmingly, they want to be glasses-free.

Refractive ophthalmologists and optometrists can provide exquisite results for their patients when they work together to offer a thorough clinical assessment of the patient’s entire visual system and then decide whether a corneal-based procedure or a lens-based procedure would be the best option. This is not a change to our process, but rather a paradigm shift in how we approach these patients.

Jeffery J. Machat

Patient evaluation

The increasing surgical options for myopia, hyperopia, astigmatism and presbyopia render a comanaging relationship a more efficient way to run a practice. An optometrist is the best person to spend up to 45 minutes in an initial consultation, thoroughly refracting and examining a patient, getting to know their needs and counseling them about their options. A surgeon’s time is best spent doing surgery; that is where they excel.

For patients with presbyopia, the optometrist first assesses if the lens is clear and has low optical scatter, which would allow for optimal outcomes from a corneal-based procedure. If so, the next determination is if the patient is intolerant to any kind of monovision, dysphotopsia or blur.

In our practice, all staff and technicians have been taught to note what a patient is like during scheduling and testing. We have had great success with the Kamra corneal inlay (AcuFocus Inc., Irvine, Calif.) for our presbyopic patients, but an understanding of each patient’s personality is necessary to determine which are most compatible with the procedure. This is impossible to assess in a standard 15-minute interlude with a surgeon.

A growing body of evidence indicates the importance of optimizing the ocular surface prior to any form of refractive procedure. This is also the domain of the optometrist partner in our practice. We measure tear osmolarity with the TearLab unit and perform complete, dynamic testing with the AcuTarget HD instrument (AcuFocus Inc.). We are aggressive with using collagen punctal plugs, prescribing ophthalmic cyclosporine and managing meibomian gland dysfunction as needed prior to, during and after any procedure, as we know how this affects preoperative readings, postoperative comfort and final visual results.

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Staff optimization

Optimizing the surgeon-optometrist-staff relationship requires both careful selection and ongoing education. The first step is to identify a partner and staff with a patient care philosophy that mimics your own. Both of us are extremely detail oriented and are focused on the whole patient experience, from initial consultation to results. The way we approach patients and our commitment to going the extra step is the same, which is the foundation of a strong partnership. We make sure that all of our staff feel the same. They work hard to minimize waiting, maximize patient education and reduce anxiety in any way possible.

The second step is a commitment to training. At the beginning of the relationship, attending all consultations, surgeries and postoperative meetings together does wonders for teaching both doctors to think and work alike.

The optometrist is in the best position to determine which patients are most compatible with the Kamra corneal inlay procedure.

Image: Machat JJ

We have developed a common language and simple analogies to explain medical concepts to patients. We work on new techniques and new technologies together and attend all major ophthalmic meetings together so we share a common educational foundation and approach. Our enthusiasm then carries over to the staff. We even offered the Kamra procedure to our patient consultant, who excitedly accepted, further building her rapport with patients.

Successful practitioners have long realized that the quality of their staff has an equal or greater impact on their patients than their own optical prowess. This includes having a patient consultant who is age-appropriate — someone in their 40s or, ideally, their 50s to talk to the patients. Refractive surgeons also benefit greatly by having an optometric clinical director who not only really relates to the referral network, but also provides the upfront care, service and assessment of every patient.

The referral network

As a refractive surgery center, neither of us sees patients for routine care; thus, we rely on our referring optometric network. We regularly do lectures together for ODs and MDs, demonstrating our philosophy that we are all colleagues working together for the good of our patients. Dr. Black maintains an open line of communication with her colleagues, with most of them having her cell phone number, and Dr. Machat routinely provides his personal cell number in postoperative reports.

Referring optometrists have long-standing relationships with patients that allow them to know that a certain patient will never tolerate a multifocal lens or that they did try monovision and were intolerant. We ask a patient these things but then always check back with the referring optometrist to make sure they corroborate what the patient says.

Many referring ODs will mark on the top of a referral sheet that they believe the patient is a good candidate for LASIK, the Kamra inlay or refractive lens exchange. They rely on us to make the final call, but we rely on them for information on patient history and personality type.

The future

The Baby Boomer generation is demanding a level of outcome that is different from what we have experienced before. Therefore, every refractive practice will have to become a presbyopic practice. We have to approach the patients who arrive on our doorstep differently than in the past, and the most critical aspect of our success is centered upon our close MD-OD relationships.

Disclosures: Black is a consultant for AcuFocus. Machat is a member of the international medical advisory board of AcuFocus and a consultant for the company.