BLOG: The five S’s of office-based surgery
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Finishing a cataract surgery informed consent discussion, we are asked most commonly by patients, “When can I get it done?” Wouldn’t it be nice if we could look at our watch and say, “Both of your eyes are dilated — let’s adjust the chair.”
Transitioning to office-based surgery won’t be quite that simple, unfortunately, and I anticipate five barriers I’ll call the “five S’s” that we must overcome.
The first S is a $. Alternative fee models for facility, anesthesia and surgeons are being designed at CMS with industry input to motivate even ASC owners to move much surgery into the office. Details are still forthcoming, but CMS stands to save billions by motivating this trend. Count on it happening.
Sterility is a small hurdle. Experience with hundreds of thousands of office-based cases has already shown that modern small-incision surgery with intracameral antibiotic treatment does not require a full operating room to maintain the same low infection rates seen in ASCs. Bilateral surgery is a natural follow-on.
Space is already a problem for many offices. Phaco machines — or their replacement — will need to shrink, along with their consumables. The Zeiss miCOR extractor, in which your Bluetooth-connected iPhone acts as the console, and streamlined microscopes such as the Beyeonics One (Beyeonics) look promising here. We need to shrink IOL and viscoelastic boxes, too — a move in the works as manufacturers go virtual with the bulky “directions for use” paper insert that’s currently in every box.
Sedation is a challenge. In our ASC, I’ve tried oral sedation with the impressive MKO Melt from Imprimis, but despite our best efforts with timing and dosing, we’ve found about half of patients still need IV “sedation titration.” Other high-volume practices tell me of similar experiences. In sicker patients, too, many of us would feel uncomfortable operating without IV access. Still, we need solutions that eliminate IVs in the vast majority of patients for office-based surgery to realize its full potential.
Speed of flow will depend on both eliminating IVs and establishing efficient traffic patterns — a mind-bender in offices already crowded with 50 to 60 patients per doctor per day.
Despite the five S’s, I’m excited at the prospect of a more patient-friendly future for cataract surgery in the office. Fortunately, some of the best minds in our industry are paving the way. I’m grateful for their leadership.
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