Cataract comanagement requires trust, commitment between optometrists, cataract surgeons

Issue: May 1996

ByBob Kronemyer

NEW YORK—If optometrists and ophthalmologists are to effectively comanage cataract patients, they need a combination of mutual trust, communication and commitment.

It is also helpful if the optometrist has had the opportunity to observe cataract surgery at least once so he or she can better counsel patients about what to expect.

"I think the OD can advise the patient better if he or she is personally familiar with the technique the surgeon will be using," said Richard S. Witlin, MD, medical director of Omni Eye Services of New York and New Jersey.

Anthony A. Cavallerano, OD, dean of clinical affairs and director of the New England Eye Institute in Boston, added: "Very often, the OD is the first person to discuss the surgery with the patient."

The two practitioners presented a course on cataract comanagement at the annual International Vision Expo here.

Witlin strongly urges ODs to affiliate themselves with surgeons who perform phacoemulsification on a regular basis. "Small-incision cataract surgery is state of the art," he said. Therefore, "Optometrists should look for someone who has experience and is skilled at phacoemulsification."

Phacoemulsification also minimizes potential complications, he noted, and accelerates visual recovery. "It makes everybody's job easier," he said.

And even though the patient realizes that the OD is not the surgeon, it is likely that a comfort level exists because of a doctor-patient relationship of several years. Therefore, the patient often expects to be personally guided through the odyssey by the optometrist.

Role of the OD

During the immediate postoperative period, the optometrist manages inflammation and IOP, then chronic inflammation, retinal complications and chronic IOP elevation in the intermediate to late stage.

"The optometrist needs to consider complications of the surgery vs. complications of the intraocular lens," said Cavallerano. "Understanding risk factors and understanding what might happen after surgery is the first line in comanagement."

Optometrists should be encouraged to participate in postoperative care, said Cavallerano, "because it is not that difficult. They should not be intimidated by the fact that their patient has had intraocular surgery. Essentially, they are simply managing inflammation. If they're comfortable managing inflammation under other circumstances, then they should be very comfortable with this."

Commitment and communication

It is important that ODs seek out MDs who sincerely believe in the concept of cataract comanagement, "not somebody who is simply looking to get some referrals from some optometrists," said Witlin. "The surgeon has to believe that what he or she is doing is right for the patient. To send a patient back to the referring OD, you have to believe that the OD is truly capable of doing this."

Communication between the two disciplines is equally important; "otherwise, there is a greater risk of patient complications," said Cavallerano.

Timely and accurate communication between the OD and the MD can be greatly facilitated by a structured communications system.

"Both parties need to know what's going on," said Witlin. "When a patient is seen for a postoperative visit at our office, we generate a duplicate form. One part is filed with the chart, the other part is mailed to the referring optometrist. So when a patient comes back to the OD's office, the OD knows how that patient is doing, including what medicines have been prescribed."

By duplicating records, "The OD has a frame of reference, so he or she knows whether the patient's postoperative course is proceeding normally and the eye is getting better," said Witlin. "It is crucial to be able to do that."

Financial rewards

At this time, the only insurance carrier that permits the fee for cataract surgery to be divided for comanaged care is Medicare. "The surgeon bills out the operation with a modifier that indicates someone else will be doing the postoperative care as well," explained Witlin. "The OD files for the part of the postoperative care he or she has done."

In many cases, Medicare earmarks 80% of the total fee for surgery, with an OD receiving most of the remaining 20%. Said Witlin, "If an OD is going to be really comanaging, he or she should be compensated for it."

Therefore, ODs should seek out MDs who are willing to share such a divided fee.

Bright future

Witlin, who comanages cataract patients with approximately 500 optometrists in the New Jersey area, says such comanaged cases have dramatically increased over the past several years. "When we started doing comanagement 10 years ago, you could probably count the number of comanaging ODs on one hand," Witlin said.

"They have gradually learned how to do it," he continued. "But that means that the surgeon must feel comfortable doing this and allowing the patient to go back to the referring optometrist, not waiting until the eye is all healed."

The growth in managed care is also fueling the link between ODs and MDs. "If ODs don't participate, they're going to be phased out of managed care panels," predicted Cavallerano.

Added Witlin, "I believe it is something that works extremely well to everybody's benefit. The patient is able to receive most of his or her care by the doctor with whom a long-term relationship has developed." Likewise, "the surgeon is able to do what he or she does best, which is surgery, and monitor the patient in the immediate postoperative period."

Moreover, patients are not as inconvenienced because they don't have to travel as often to an out-of-town MD.

Witlin concluded, "Of the thousands of cases I have comanaged, I cannot think of a single case that has backfired."

CATARACT COMANAGEMENT

Postoperative examination

Surgical history
Visual acuity
Refraction
Keratometry
Gross external exam
Slit lamp exam

Possible complications

Iritis
Hemorrhage/hyphema
Elevated IOP
Corneal edema
Superficial punctuate keratitis
Wound gape or leak
Uveal prolapse
Exposed, broken or extruded sutures
Postoperative astigmatism
IOL dislocation
Endophthalmitis
Retinal detachment
Macular edema