November 14, 2016
4 min read
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An effective comanagement team improves patient outcomes

Surgeons and optometrists can be most productive when working together in the patient's best interest.

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I am fortunate to have a network of referring optometrists and primary care ophthalmologists who comanage surgical patients. The benefits of working with colleagues who have a longer-term relationship with the patient are clear.

Their input on the patient’s ocular and systemic health history, lifestyle, expectations and tolerance for pain are invaluable. For example, if a particular patient has always been picky about his glasses and bothered by new glasses, that information is important in determining realistic expectations.

The patient’s past success with monovision, a history of central serous maculopathy or prior use of Flomax (tamsulosin, Boehringer Ingelheim) are all insights that optometrists have been able to share that would not necessarily have been noted by the patient during our history taking. This kind of information helps the surgeon anticipate what complications might arise during cataract or corneal refractive surgery and take steps to achieve the best possible outcome for that patient.

In return, I am a big believer in professional courtesy. I take phone calls from referring doctors immediately (unless I am in surgery) and fit in their emergency referrals the same day, no matter how busy my schedule. I trust that if my comanagement partners are sending someone to me on an emergency basis they have a good reason. I also refer many patients to my partners in the community for contact lenses, spectacles, low vision care or other services.

Sandy Feldman

I strongly believe that comanagement benefits those who make the referrals, too. Patients who want to have LASIK or lens surgery will seek out a surgeon themselves. And when they do, they rarely list their primary eye care provider on the intake form. They have had regular eye exams for years, but if their optometrist never discussed LASIK with them, patients tend to view that doctor as not relevant to the surgical decision. The optometrist misses the opportunity to participate in the surgical care and share in what is a happy, life-changing moment for the patient. In addition, the patient misses the opportunity for their surgeon to be educated about their ocular and vision care history by the person who knows it best.

Avoiding pitfalls

What to look for in a comanaging surgeon

 

 

I have seen my own or others’ comanagement relationships go awry in a few areas, when courtesy and professional respect could have saved the day.

It is a basic courtesy that both partners in a comanagement relationship should send each other surgical records and exam findings. However, even in the most organized office, records or faxes do go missing. Do not assume that missing information is being withheld or mismanaged. Give the other provider the benefit of the doubt and calmly (and privately) follow up on missing information outside the patient’s earshot.

It is important to recognize that there are outliers. Patients heal differently, resulting in over- or under-responses. An unexpected outcome does not necessarily mean the surgeon performed bad surgery or the referring optometrist provided bad information. It is always worth investigating how comanagement partners can reach the patient’s goals together.

Smart people can disagree. Questions about a comanagement partner’s decision making should be directed to the other provider for clarification, using the literature, and not conveyed to the patient in a way that might undermine his or her confidence.

When a referral for surgery (or any other care) is made, patients should be informed about who they are being referred to and why. In fact, the major professional organizations in ophthalmology emphasize the need for transparency and patient involvement in any decision to comanage.

Elevating the premium package

Primary eye care providers have always referred patients for cataract surgery, but new technology means there are more factors to consider now, both in choosing a surgeon and in counseling patients.

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New femtosecond laser technology, for example, allows surgeons to better plan surgery because the lens density, shape and size can be observed by three-dimensional imaging before entering the eye. In addition, because the laser performs some of the steps of cataract surgery, it provides other advantages, including more precise capsulorrhexis shape and centration based on the scanned capsule. This enables better lens positioning — which is more important than ever with newer, premium channel lenses. The laser also enables correction of astigmatism and reduced energy going into the eye, creating less trauma and more rapid recovery.

IOL technology has seen many new innovations, so it is critical for comanaging providers to stay abreast of the latest developments. Previous experiences with presbyopia-correcting IOLs are not representative of what we have today in this ever-evolving field. A year or so ago, low-add multifocal IOLs were introduced. With add powers of 2.50 D to 3.25 D, these provided better intermediate vision and have reduced the incidence of night-time glare and halo.

Most recently, the Tecnis Symfony IOL (Abbott Medical Optics) was introduced. It is the first extended-range-of-vision IOL and relies on different optical principles to provide a continuous range of high quality vision. In clinical trials, patients achieved approximately 20/20 binocular uncorrected distance and intermediate acuity and near vision between 20/25 and 20/32. The rates of glare, halo and starbursts for this lens are low, similar to rates with standard monofocal IOLs.

As we have observed for some time, aspheric IOLs themselves improved contrast and drivers’ abilities to identify signs and obstacles in the dark compared to previous, spherical monofocal lenses.

The maintenance of good contrast sensitivity is reassuring because it means that even if the patient experiences other issues in the future that reduce contrast, the IOL will not be compounding that loss. In fact, this means that we might even consider a Symfony lens for people who would not previously have been candidates, such as post-LASIK patients or those with drusen. The sphere and toric versions of this lens were approved at the same time, so it also opens up new opportunities for those with significant astigmatism to enjoy the freedoms of a presbyopia-correcting IOL.

Today we have more choices that provide better results for our patients. However, that means it is more important than ever that referring doctors seek out surgeons with the latest technology who have the ability to provide a full range of surgical correction, including correction of astigmatism and enhancement of the refractive results when needed after cataract surgery, as patients will expect better. Additionally, educating the patient in advance about new options can go a long way toward building confidence and demystifying the decision making process for the patient.

Ultimately, we all provide the best care when we work together in a patient-centered way, focusing on achieving the best surgical choices and outcomes for each patient.

Disclosure: Feldman reports she is a consultant for Abbott Medical Optics.