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Keeping up with technology, new procedures crucial for comanagement
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The proliferation of discount laser centers and the emergence of new technologies have changed the face of refractive surgery comanagement. As a result, optometrists are now faced with the challenge of keeping up with the ever changing standard of care.
“We don’t want ODs to miss the boat on refractive surgery,” said Salvatore M. DeCanio Jr., OD, a practitioner in West Palm Beach, Fla., and a member of the Optometric Council for Refractive Surgery (OCRS). “Some people are negatively motivated, and they have to feel that they are losing patients before they get on board. By then, it is often too late.”
Advances in pre-op testing technology
One way in which optometrists can maintain a thriving comanagement practice is by keeping up with the latest equipment for preoperative screening.
The use of technology such as pupillometers, pachymeters and corneal topographers has become increasingly important to refractive surgery comanagement. More and more optometrists have begun to invest in this technology, according to practitioners.
“The numbers are growing,” said David J. Conway, OD, a practitioner located in Boston. “I would say that 30% to 40% of comanaging doctors are using topography, 10% are using pachymetry and 5% are using pupillometers.”
Dr. Conway said he recommends that comanaging optometrists invest in all of these devices.
“I think that anyone who is actively comanaging should have all of these,” Dr. Conway said. “These devices are very helpful in evaluation and follow-up and in reassuring the patient that the comanaging doctor is the one that he or she wants.”
Paul M. Karpecki, OD, a practitioner based in Overland Park, Kan., and also a member of the OCRS, said that while he would not assume that this equipment is necessary for all optometrists, it can be invaluable to those with a strong interest in refractive surgery comanagement.
“For those who are interested in practicing at the highest level of refractive surgery comanagement, it would certainly behoove them to have a pachymeter, and, without question, they have to measure pupils reliably under scotopic or dim light illumination. It just makes sense.”
Dr. DeCanio said despite the growing numbers of comanaging optometrists to invest in this equipment, there are still many who have not acquired it.
“That is disappointing at best, because these devices would definitely prove valuable to them,” he said. “This technology enables them to participate more in the preoperative process, rather than asking someone at their local surgery center to help them with it. There is no one better able to determine the treatment plan or outcome than the OD, who knows the patient better than anybody.”
Postop visits: shorter span dates
Another change in refractive surgery comanagement has been a cutback in the span dates of postoperative visits. While patients were once seen for visits up to 1 year postoperatively, many practitioners have cut back on their follow-up schedules to some extent.
“We like to see them at 1 day, 1 week, 1 month, 3 months and 6 months (especially if hyperopic), as a routine,” Dr. DeCanio said. “We see them more frequently if necessary and certainly if we have a patient who looks like he or she is a re-treatment possibility. I also recommend annual examinations for general eye health care reasons, and they are responsible for that cost.”
Dr. DeCanio acknowledged that this decrease in span dates is due at least in part to the emergence of discount laser centers with significantly fewer follow-up visits.
“For these lower cost centers to compete on a price level, they have to cut out something,” he said. “Generally, what is cut is the extended follow-up care, like the 1-month or the 3-month visit. I’ve heard at some centers, they even cut the 1-week visit. You have to be more cavalier on the postoperative care side if indeed you are trying to play cost games.”
Dr. Karpecki said he adheres to a follow-up schedule of 1 day, 1 week, 1 month and 3 months. While 1-week postoperative visits are becoming less of a standard, Dr. Karpecki believes they still are important.
“It is still a time when patients need a lot of hand-holding,” he said. “So unless you have a really good ability to gauge patients’ success at 1 day, the 1-week visit is certainly still warranted.”
Dr. Karpecki pointed out that the 3-month visit is critical because it marks the earliest a practitioner should ever consider doing an enhancement on a patient. “Looking back at our clinic, we reviewed some charts, and we found that at 1 month, more than 20% of the patients looked like they needed an enhancement,” he said. “By the time they got to 3 months, that number dropped to less than 6.%.”
Dr. Karpecki added that he will include a 6-month visit if needed for an enhancement. “I use the 6-month if I have to wait on enhancements as part of the follow-up,” he said. “We are now seeing a few more hyperopes, although not a whole lot, and they certainly need 6 months before their enhancements.”
Dr. Conway said he continues to offer follow-up visits of 1 day, 1 week, 1 month, then 3, 6 and 12 months. “This isn’t to say that others aren’t relaxing their standards on the latter visits, or dropping them entirely,” he said. “But we have kept them to be sure the patient doesn’t have some regression or late complications.”
Dr. Conway said the cutbacks on post-surgery visits can be attributed to many factors. “I think part of it is just a recognition that complications, thankfully, are very rare,” he said. “It is also about recognizing the financial realities and the financial pressures on providers at all levels. The comanaging doctor is in no way distanced from that.”
Comanagement for LASEK
For comanaging practitioners, different postoperative regimens apply to LASEK patients. “There is more hand-holding,” Dr. Karpecki said. “The ‘wow’ factor is not readily there at 1 day. The day after, there is a fair amount of discomfort.”
As a result, practitioners should monitor the bandage contact lens, which is generally removed on day 4. “You need a little bit more reassurance,” he said. “So, instead of the 1-day, 1-week, 1-month, I do a 1-day, 3-day, 4-day if necessary, then a 1-month.”
Dr. DeCanio compared LASEK to PRK, which he considers to be its closest equivalent. “LASEK is essentially PRK with an epithelial flap instead of a scrape,” he said. “So the postoperative care in a sense is a bit shorter, but the pain threshold is still there, as with PRK.”
LASEK requires more lengthy postoperative care than LASIK, Dr. Conway said. “The recovery period for LASEK is, of necessity, slower than with LASIK,” Dr. Conway said. “During the early stages, more follow-up is required.”
Dr. DeCanio said the pain factor for LASEK can make it somewhat less attractive than LASIK. “It’s the pain there in the first week of the procedure that makes it different from LASIK and makes it less sellable,” he said. “But it is still an excellent procedure for patients with higher prescriptions or lower corneal thicknesses than are indicated for LASIK.”
For Your Information:
- Salvatore M. DeCanio Jr., OD, practices at City Laser and Optique in West Palm Beach, Fla. He can be reached at 701 South Rosemary Avenue Suite 103, West Palm Beach, FL 33401; (561) 659-2299; fax: (561) 659-1123.
- David J. Conway, OD, is manager of refractive surgery for Harvard Vanguard Medical Associates in Boston. He can be reached at 2161 Massachusetts Ave., Cambridge, MA 02140; (617) 576-2020; fax: (617) 576-1958.
- Paul M. Karpecki, OD, is a practitioner based in Kansas and a Primary Care Optometry News Editorial Board member. He can be reached at 1115 West 109th St., Overland Park, KS 66210; (913) 906-9329; fax: (913) 906-0729.