Download co management guidelines

MEMORANDUM
TO:
Co-Managing Optometrists
FROM:
R. Douglas Cullom, M.D.
DATE:
January 1, 2006
RE:
Co-management of Surgical Care
Cullom Eye and Laser Center is committed to complying with specific statutes
and regulations governing the practice of medicine and optometry. With this in
mind we have revised our co management process to ensure the decision to co
management is a result of a determination of what is best for the patient and not
economic considerations. If co management is done on a routine basis for
predominantly financial reasons, it represents unethical behavior. Above all
patients’ interest must never be compromised as a result of co management.
Included in the packet are guidelines for compliant co management, pre and post
evaluation guidelines, patient consult forms, transfer of care and
acknowledgement of division of care related to fees forms, helpful hints for filing
Medicare global fees and a quick guide on calculating the split.
Thank you for the opportunity to co manage cataract and refractive patients. I
appreciate your assistance with these compliance guidelines. As always, please
do not hesitate to give me a call if you have any questions.
___Doug
Cullom________
R. Douglas Cullom, M.D.
CO MANAGEMENT GUIDELINES
Co-management is defined as the sharing of postoperative responsibilities
between the operating surgeon and another provider. If co management of
surgical patients is being considered, justifiable circumstances* should exist.
Co management requires a written transfer agreement** between the surgeon
and the receiving doctor. The receiving doctor cannot bill*** for any part of the
service included in the global period until (s) he has provided at least one
service.
Specific modifiers must be used on claims (54,55)
*Justifiable circumstances:
Situations that arise where surgeon concludes the delegation of postoperative
care is in the patients best interest. The patient must voluntarily consent to this in
writing. Justifiable circumstances include: surgeon taking leave of absence,
patient is unable to travel, large distance between patients home and surgeon’s
office, patient voluntarily wishes to be followed by another provider. Comanagement is not to be done as a matter of routine policy on all patients.
**Transfer agreement:
A transfer agreement between the surgeon and the receiving doctor
(optometrist) contains the surgeon’s discharge instructions and effective transfer
date. A unique transfer agreement should be constructed for each patient.
For overlapping postoperative co-management of 2nd eye, if the surgeon has
transferred care for the first operated eye prior to the second surgical procedure
then two transfer letters must exist. The patient must be reassured that he/she
has access to the surgeon, if necessary at no additional cost.
***Billing:
Modifier 54 is used to designate the surgical event; modifier 55 is used with the
claims for postoperative care. 66984-55 = surgical event 66984-55 = postoperative care by surgeon 66984-55 postoperative care by the receiving
doctor/co-manager.
Co-management is working together and relies upon effective communication in
both directions. There needs to be coordination between the surgeon and the
receiving office to make sure all pre-operative requirements are met and all post
op days are accounted for.
Pre & postoperative examination guidelines for reports.
Herewith please find samples for preoperative evaluation.
Please forward preoperative examination along with transfer agreement prior to
patients visit with surgeon.
Please note preoperative evaluation for specific guidelines.
Please forward postoperative report upon completion by fax.
Fax number (757) 345-3102
Cataract and Refractive Lensectomy Guidelines
Cataract Preoperative Evaluation
Patient’s who are determined to have a visually significant cataract that is
affecting the patient’s ability to do daily activities can be referred to Dr. Cullom for
a pre-operative consultation. During that visit, in addition to the examination, Dr.
Cullom will go over the risks and benefits of cataract surgery and have an
operative consent signed. The patient is usually set up for another visit to have
biometrics performed-keratometry, A scan and IOLmaster. This will assist in
choosing the proper intraocular lens. Logistical aspects of the surgery as well as
medications are discussed.
Counseling includes a discussion of the expectations concerning best
corrected visual acuity(BCVA) including preoperative conditions that may
prevent perfect results, such as age related macular degeneration. Counseling
regarding uncorrected visual acuity (UCVA) may address goals of surgery i.e.
plano for distance or being left moderately nearsighted to allow for near work to
be performed without correction. Realistic expectations are discussed. Patients
with high amounts of astigmatism may not be able to rid themselves entirely of
glasses. Possible upgrade to a multifocal implant may be considered if the
patient desires.
Indications:
The primary indication for cataract surgery is decreased vision or glare from
cataract formation causing a decreased ability to perform daily activities. Other
indications may be traumatic injury to the lens, phacomorphic glaucoma and
phacolytic glaucoma,
Refractive Lensectomy Pre-operative Evaluation
Although patients who undergo refractive lensectomy undergo essentially
the same procedure as cataract patients they require much more counseling-especially regarding expectations. They also need a careful pre-operative
examination to be certain that they are good candidates for refractive lensectomy
(RL).
Refractive lensectomy may also involve a discussion of multifocal lenses and
issues associated with this choice. Present options include the Alcon ReSor lens
and the AMO Rezoom lens. The ReStor lens provides good near, fair
intermediate vision, and good distance vision. The Rezoom lens give good near
and intermediate distance vision, but has a slightly higher incidence of night
vision flare and halos. Both lenses result in a small compromise for distance
vision, but may allow patients to be less reliant on glasses. Patients presently
doing monovision should be treated as such with standard intraocular lenses.
Patients that are more particular about good distance vision such as engineers,
pilots, truck drivers or just those who desire the best distance vision possible
should stick with standard intraocular lenses set for distance.
Indications:
The desire to eliminate or decrease the dependence on glasses or contacts for
distance and/or near vision is the main indication for RL. The best RL patients
are those over 40 years particularly those in their 50’s or older who may have
early nuclear sclerosis or other cataractous changes of the lens, however do not
have much loss of actual visual acuity. Because of this, they do not qualify for
cataract surgery by their insurance carrier or Medicare. Hyperopes, especially
over +2.00 dioptors may be especially good candidates. This range is less
predictable with conventional lasik. High myopes who do not qualify for LASIK
may be good candidates, but do have an increased risk of post-op retinal
detachment. Patients who are presently in mono-vision contact lenses may also
make excellent candidates. Astigmatism can be controlled by changing the
location of the incision or utilizing a toric intraocular implant, but high amounts
make less predictable results. Remaining astigmatism can be treated after
healing by LASIK or PRK if the patient desires.
Cataract Surgery and Refractive Lensectomy
Risks and Alternatives
RISKS (this section is written in layman’s terms)
Surgery is performed under topical anesthesia with intravenous sedation
resulting in minimal patient discomfort. Mild discomfort for the first 24 hours is
typical, but severe pain would be extremely unusual. Since this RL is essentially
the same as cataract surgery, the same risks apply. These risks include, but are
not limited to:
1. Infection, which if serious can lead to complete loss of vision
2. Swelling in the central area of the retina, cystoid macular edema, which
usually improves with time.
3. Clouding of the outer layer of the eye, corneal edema, which typically
resolves, but in rare cases requires correction with corneal transplantation.
4. Detachment of the retina (particularly in highly near-sighted eyes). Retinal
detachment can usually be repaired.
5. Increased astigmatism
6. Inaccuracy of the intra-ocular lens power
7. Decentration of the intra-ocular lens, which may provide unwanted images
and increased glare
8. Development of increased pressure in the eye (glaucoma).
9. The need for a second operation to remove retained lens fragments in very
rare cases.
Although all of these complications can occur, their incidence following cataract
surgery is very low.
DISADVANTAGES OF SURGERY
1. One definite disadvantage that may be more obvious with clear lensectomy,
(especially in a patient less than 50 years of age), is the loss of the near
focusing power of the eye (accommodation). Thus, it must be clearly
understood that even with a successful surgery and an accurate intraocular
lens calculation targeted to correct the eye’s distance vision, close vision will
usually remain blurred, requiring a separate pair of glasses for close and
intermediate vision. It may be possible to deliberately correct one of the eyes
for close vision instead of distance, which would allow the patient to read
without glasses, even though this eye would then be nearsighted and require
a corrective lens for distance vision. This combination of a distance eye and
a reading eye is called monovision. It has been employed quite successfully
in many contact lens patients.
This option will be discussed and
demonstrated by the operating surgeon. A discussion of the multifocal
intraocular lenses Rezoom or ReStor may also be addressed. These lenses
require extensive discussion of near, intermediate issues as well as possible
induced night vision problems.
2. Even with the latest formulas used to evaluate lens implantation power it is
possible to be off on predicted refractive outcome. This is more common in
high refractive errors. In the event of a minor error in the calculation, the
vision can usually be corrected by a glass prescription, which should be
considerably weaker than the patient’s original prescription. A large error in
the lens calculation could be corrected by a stronger pair of glasses, contact
lenses, or the exchange of the implant or the insertion of a second implant in
another operation, or possibly laser surgery.
3. Since only one eye will undergo surgery at a time, the patient will experience
a period of imbalance between the two eyes (anisometropia). This usually
cannot be corrected with spectacle glasses because of the marked difference
in the prescriptions, so the patient will either temporarily have to wear a
contact lens in the non-operated eye or will function with only one clear eye
for distance vision. Surgery, in the second eye can usually be accomplished
within 1 to 4 weeks, once the first eye is stabilized.
NON-SURGICAL ALTERNATIVES
Non-surgical alternatives to clear lens extraction are to continue to wear
spectacle lenses or contact lenses. Although there are essentially no risks to
wearing glasses, the quality of vision with strong farsighted or nearsighted
glasses is not normal because of an enlarged image and a slight decrease in
peripheral vision caused by the thickness of the lenses. Although contact lenses
provide higher quality and more normal vision, they have a slight risk of
complications, especially if they are worn overnight. The risks of contact lenses
include: infection, which if involving the central cornea can rarely cause loss of
vision; allergies (giant papillary conjunctivitis, GPC) which can make wearing the
lenses difficult; mild irritation; and discomfort. Alternatives to cataract surgery
includes changing daily activity habits, such as stopping night driving and using
better lighting when reading.
Post-operative Management
Of Cataract Surgery and Refractive Lensectomy
Postoperative Visit Schedule*
Day 1-Surgeon
1 Week
4-6 weeks
3 months (optional)
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*This is a minimal recommendation. Increase frequency of visit with any
unusual findings or significant change in vision. Always refer patient back
to surgeon immediately if there are any concerns about recovery.
Frequently cataract surgery on the second eye is indicated one or two weeks
after the first procedure. In this case the one week visit may be performed by
the surgeon the day after the second eye operation.
Medications:
Zymar antibiotic- one drop operated eye four times a day for one week
Acular non-steroidal- one drop operated eye four times a day for one week
Pred Forte steroid - One drop operated eye four times a day for one week then
One drop operated eye three times a day for one week then
One drop operated eye two times a day for one week then
One drop operated eye one time a day for one week.
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Medication flow sheet outlining above is provided to patient
Note Zymar and Acular are begun the day prior to surgery and must be
filled at the pharmacy by a script provided by Dr. Cullom. Pred forte is
supplied by Dr. Cullom
Zymar is a broad spectrum flouraquinalone topical antibiotic
Pred forte steroid helps control post-operative inflammation
Acular, a non-steroidal anti-inflammatory, has been shown to decrease the
incidence of cystoid macular edema as well as anterior segment
inflammation.
Patients with pre-operative glaucoma should continue their glaucoma
medications
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Post-operative Guidelines:

If there are any concerns about your patient whether from a post-operative
examination or a worrisome call to your office by the patient please call
our office immediately to arrange an examination by the surgeon. If Dr.
Cullom is not available, there is always an ophthalmologist on call who will
see your patient. Calling 757.875.7875 or 345-3001 at any time will get
you in touch with our office or the ophthalmologist on call.

All visits:
-check uncorrected visual acuity (UCVA)-operated eye at distance
- check UCVA-operated eye at near if goal is near vision
-careful slit lamp exam
-Intraocular pressure

Dilated funduscopic exam should be done if vision is below that expected or
with new or significant symptoms of flashes, floaters, or shadows in vision.

Manifest refraction and new glasses prescription is usually done 3-4
weeks post-operatively, but occasionally sooner if required
Common complaints occurring at any visit:
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Foreign body sensation at incision. Explain to the patient that this can last
for several months in some cases, though usually is present only for a
couple of days. If bothersome I will begin patient on erythromycin ointment
at bedtime for a week and increase artificial tears.
Unusual visual sensations, photopsias, often noted on day one as arcuate
peripheral light. Reassurance that these almost always go away
completely. If these are described a pulsation of peripheral flickers and
associated with new onset floaters, a careful dilated peripheral retinal
exam is indicated.
Post-op day 1 (done by the surgeon)
UCVA
Slit lamp exam
IOP
UCVA –Occasionally lower than expected if there is some residual corneal
edema. A manifest refraction may be done especially in refractive lensectomy
patients if UCVA is not what is expected.
Slit lamp exam-Evaluate cornea for edema. Carefully check anterior chamber
for inflammation and depth. Note that wound is secure. (Usually this is a self
sealing suture-less wound.
IOP-May be elevated from retained viscoelastic. Although this material protects
the corneal endothelium during surgery, it frequently results in increased IOP for
24-48 hours. If pressure is significantly elevated i.e. above 30 mmHg the
surgeon may elect to put gentle pressure on the limbus posterior to the
paracentesis incision to allow aqueous to drain from the anterior chamber. This is
done after instillation of topical antibiotic. This procedure should be done only by
the surgeon and never beyond post-op day one. Increased pressure can also be
treated with standard glaucoma medications as indicated.
1 Week Post-op Visit
UCVA
Consider Manifest Refraction with BCVA (optional)
Slit Lamp Exam
IOP
Counseling
UCVA, BCVA and Manifest Refraction-. Presbyopic patients may require
temporary or permanent reading glasses particularly if the pre-op goal was plano.
Refraction is optional on this visit.
Slit lamp examination- Cornea should be clear. An occasional patient may have
a foreign body sensation at the wound which can be helped with nightly
erythromycin ointment. Anterior chamber reaction should be gone. An increase
in cell and flare may indicate early endophthalmitis especially if accompanied by
increased vitreous cells, decreased vision or pain. Patients with any significant
anterior chamber inflammation should be referred immediately to the surgeon.
Posterior chamber intraocular lens should be in good position.
IOP -should be normal. Occasionally a “steroid responder” may have an
increased IOP from the steroid use and a quick taper of the Pred Forte may be
considered or topical glaucoma medications may be considered.
Counseling- Presbyopic patients, even when properly counseled before surgery
may have difficulty adjusting to new reading glasses. Monovision patients may
struggle with an adjustment period as well. Temporary glasses for distance or
near may be required until second eye is done. Refractive lensectomy patients
may be more demanding and concerned about uncorrected visual acuity. They
may have post-operative astigmatism that requires PRK or LASIK. This can be
discussed with the surgeon. Small amounts of residual astigmatism are usually
not treated with laser correction.
1 Month Post-operative visit
UCVA
MR with BCVA
Slit lamp exam
IOP
Dilated funduscopic exam
UCVA, BCVA, Manifest refraction-spectacle correction if required are given at
this visit
Slit lamp exam: Cornea and anterior chamber should be clear.
IOP-should be in control
Dilated funduscopic exam-should be performed. Diabetics need to watched
closely for worsening of nonprolifitive diabetic retinopathy which commonly
occurs during the first post-operative month
Counseling:
Most patients are doing very well at this visit. Now that the excitement of their
new vision is less acute, many patients may have minor problems that need
discussion. Problems such as minor eye dryness or the need for new or different
reading glasses are generally easily corrected.
3 Month Post-operative Visit (if required)
UCVA
BCVA with manifest refraction
Slit Lamp Exam
Applanation Tonometry
LASIK, LASEK and PRK Guidelines
LASIK, LASEK & PRK Pre-operative Evaluation
All LASIK and surface laser correction at the Cullom Eye and Laser
Center is performed with the latest and most up to date technology available.
Flap formation is done with the Intralase laser which allows for a more consistent
and thinner flap. This decreases the incidence of post LASIK dry eye. It also
greatly reduces the chance of flap complications. There are also less induced
high order aberrations than a bladed keratome, and several large studies have
shown that lasik with laser flaps give better visual outcomes than bladed
keratomes. Customized wavefront guided treatments have been shown by the
FDA to give slightly better quality of vision in dim illumination as well as a higher
chance of better than 20/20 visual outcomes. All patients who qualify for
customized laser correction will automatically be treated by that method at the
Cullom Eye and Laser Center. Patients who are out of the custom diopter range
or have other contraindications may be treated by non custom LASIK.
Proper patient selection is of utmost importance in obtaining excellent results
with LASIK and PRK. Proper selection requires a thorough history addressing
patient motivation and expectation, a complete medical and surgical history and
a complete dilated eye examination, topography and pachymetry. For the
convenience of the co-managing doctor, pachymetry, topography wave-front
analysis* and additional pre-operative evaluation can be scheduled with Dr.
Cullom or his staff at Hampton Roads Eye Associates in Newport News or the
Laser Center in Williamsburg.
(At this time Wave-front analysis portion of evaluation is only being performed at the Williamsburg location)
Candidacy
Myopia to
-11 Diopters
Hyperopia to
+6 Diopters
Astigmatism to
-6 Diopters
Astigmatism combined with hyperopia or myopia is treatable with the VISX laser.
Age 18 yrs or older
Stable refraction-less than 3/4 Diopter change over a year
Contraindication to LASIK or PRK:
Active collagen vascular, autoimmune or immunodeficiency diseases (Systemic
Lupus Erythemetosis, Rhuematoid Arthritis, Sjögren's disease etc.)
Medication use-amiodarone, isotretinoin (Accutane)
Ocular Herpes zoster or simplex
Pregnancy
Keratoconus
Caution:
Diabetes (must be well controlled)
Severe atopic disease
Severe amblyopia
History
Motivation
The reason a patient desires Laser Vision Correction will give the
examining doctor an understanding of patient expectations and desires. Patient
motivations may be occupational, recreational, or purely lifestyle related. It is
important to document the patient's occupation and hobbies to determine how
they use their vision. Spectacle wearing low myopes i.e. -2.00 dioptors in the
early presbyobic age should be given extra attention since they may be
accustomed to taking their glasses off for reading. A frank discussion of the
tradeoffs of correcting all their myopia as well as the option of monovision should
be discussed. Although LASIK is generally safe for patients with very active
lifestyles, those expecting frequent blows around the eyes like boxers and karate
participants may consider PRK as an alternative. Patients having unrealistic
expectations should be screened out during this phase of the exam.
Past Medical history:
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Active collagen vascular diseases including Rheumatoid Arthritis, Systemic
Lupus Erythemetosis, Sjogren's disease-may increase risk of scarring and
corneal melts
Diabetes mellitus that is in poor control may result in poor refractions.
Refractive surgery should be avoided in those with significant retinopathy.
Pregnancy-hormonal changes during pregnancy can alter refractions
therefore LASIK is postponed until several months after pregnancy.
Family history of significant medical or ocular diseases
Past Ocular History
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Contact Lens HistoryType of lens:
Soft daily wear, Soft extended wear, Rigid Gas Permeable, PMMA.
Hours/day
Note: Before final refraction and topography, patients should be out of their
contact lenses for: *
Soft lenses- 10-14 days minimum
RGP lenses-3 weeks minimum or until refraction is stable
*Logistically, this can be difficult to achieve. For the co-managing doctor and the
patient's convenience we frequently do the final refraction and topography the
day prior (preferably) or the day of the surgery. This limits the patient's time out
of contact lenses.
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Ocular surgeries, corneal injuries, dry eyes
History of herpes simplex or zoster keratitis-LVC contraindicated
Glaucoma -patients with well-controlled glaucoma may be considered for
LVC. Proper baseline studies are important since IOP measurements
measure lower after LVC.
Retinal diseases/injuries
Strabismus surgery
Medications
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Drug allergies-including history of steroid response glaucoma
Accutane and Amiodorone -increase risk of corneal scarring
Prednisone -may alter refraction, increase risk cataract formation
Mydriasis inducing medications-many OTC medications as well as "herbal" –
appetite suppressants can enlarge the pupils. Patients with large pupils on
initial evaluation should return after stopping these medications to re-check
pupil size.
Ocular Examination

Visual Acuity-uncorrected visual acuity (UCVA) and best corrected visual
acuity (BCVA)
If the patient is not correctable to 20/20, evaluate the cause of reduced
vision. These include irregular corneal curvature (corneal warpage or
keratoconus), corneal or lenticular opacity, and retinal or optic nerve
pathology. In the absence of these findings and after other indicated
studies are obtained amblyopia may be diagnosed.
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Refraction-manifest and cycloplegic.
Perform the cycloplegic refraction with 1 % cyclogyl in younger patients and
1% mydriacyl in older patients. It is important to "push plus" as many
patients are discovered to be over "minus" in their present correction.
Treatment of these patients can lead to over corrections. Care must be taken
to find all the cylinder correction. Use Keratometry and retinoscopy to help
uncover subtle astigmatism. Contact lenses must be out as noted above prior
to a final refraction.
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Pupil size-should be checked in dim illumination. Patients with large pupils,
particularly high myopes, are at increased risk for night vision problems such
as halos, starburst and decreased night contrast sensitivity. This is felt to be
less of a problem with custom treatments.
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Motility exam-Significant phorias and tropias should be documented. Patients
who have prism in their glasses to control diplopia should not be treated.
Though they may see 20/20 with each eye, there may be diplopia without the
prism correction.
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Manual keratometry: will help in finding subtle astigmatism. Distortion of the
mires is a warning sign of irregular astigmatism and possibly keratoconus.
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Tonometry - obtain as a baseline on all patients. IOP by appplanation
tonometry usually runs lower after laser vision correction.
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Anterior slit lamp examination:
Lids/lashes: Blepharitis should be identified and controlled prior to
LASIK/PRK. Lid abnormalities may predispose to exposure and poor healing.
Cornea: It is very important to identify anterior basement membrane disease
(ABMD)--which can be seen as subtle microcysts or "fingerprints" below the
epithelium on retroillumination. These patients do better with PRK instead of
LASIK. PRK may smooth away this redundant basement membrane and it
avoids the sloughing that occurs when undergoing LASIK. Search for
evidence of dry eye syndrome such as decreased tear film break up time and
corneal punctate staining. Other corneal disease such as Fuch's dystrophy
should be identified. Old corneal scars should be documented.
Anterior chamber: should be without evidence of inflammation.
Lens: document lens opacities-even if minor. Lensectomy and intraocular
lens placement may be a better refractive surgery choice for those with
significant cataract formation.
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Dilated Funduscopic Exam-The macula should be examined for evidence of
myopic or age related degeneration. A careful peripheral retinal exam is done
to rule out lattice degeneration, retinal holes or breaks. The pressure of the
suction ring during LASIK may slightly increase the risk of retinal detachment
in patients with these conditions.
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Schirmer's test with anesthesia- perform on any patient with evidence of dry
eye syndrome. Consider this on women over 40 and patients over 50 yrs.
Place punctal plugs and or consider twice daily restasis therapy PRIOR to
LASIK on any patients with significant dry eye signs or symptoms and those
with Schirmer's less than 5 mm.
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Pachymetry*-is critical in determining adequate tissue for LASIK (including
possible enhancement) on high amounts of myopia. Although intralase flaps
allow for thinner and more accurate flaps, occasionally a thin cornea will
preclude treatment of even moderate amounts of myopia. Patients with
borderline corneal thickness may be better candidates for surface treatments
such as PRK.
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Corneal topography*-is used to look for evidence of irregular astigmatism,
keratoconus, form fruste keratoconus, and contact lens related corneal
warpage. Keratoconus and significant irregular astigmatism is a
contraindication for LASIK/PRK. Follow patients with contact lens related
corneal warpage until corneal topographies are stable. Use corneal
topography to uncover subtle regular astigmatism and guide the refraction.
Lasik, Lasek & PRK Post-operative Management
Postoperative Visit Schedule*
LASIK
Day 1
1 Week
1 Month
3 Months
6 Months
1 Year
PRK
Day 1
Day 2-5 (as needed until epithelialized)
1 Week
1 Month
3 Month
6 Month
1 Year
* This is a minimal recommendation. Increase frequency of visit with any unusual
findings or significant change in vision. When in doubt always refer patient back
to surgeon for second opinion.
Medications:
See medication sheets on the following pages for medication protocols for LASIK
and PRK/LASEK. These are handed to patients at the time of surgery. I
encourage preservative free artificial tears at least four times a day for the first
month. Take care that PRK patients do not suddenly stop there pred forte taper.
Usual pred forte tapering regimen for PRK is 4 times a day for one week, the 3
times a day for one week, then twice a day for one week, then daily for one
week.
(We supply all drops to the patient the day of surgery)
Post-operative Guidelines:

All visits:
-check uncorrected visual acuity (UCVA)-OU
-careful slit lamp exam
 All visits after 1 week:
-consider Manifest Refraction and best corrected visual acuity (BCVA)-OU
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Many rare but serious complications (infectious keratitis, diffuse lamellar
keratitis, and epithelial ingrowth) can present the first week, therefore never
allow patients to postpone this visit.
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Check tonometry at 3 months and sooner if on topical steroids.
 Prior to enhancement patient must undergo cycloplegic refraction.
Enhancements are considered when the refraction is stable-typically not until
three months.
Post-op day 1 (normally done by the surgeon)
UCVA
Slit lamp exam
Counseling
UCVA -day one is highly variable. Though typically 20/20 to 20/30, it may be up
to 20/50 in high myopes. Day one UCVA is not predictable of final UCVA.
Patients are typically over-corrected initially in anticipation of slight regression –
especially hyperopes. Patients under-corrected at day one and one week may
also improve considerably as the epithelium smoothes, dryness improves and
the flap settles.
Slit lamp exam-Day one the most important evaluation is of the flap placement.
The edge of the flap is mostly epithelialized by the next day. Some edema may
be present which will disappear by the next visit.
StriaeEvaluate carefully for shifted or dislodged flaps (usually from rubbing the
eye the first 2-4 hrs after the procedure). Fine peripheral microstriae are
common in higher myopes, as the flap needs to settle in an area to which
significant tissue has been removed. These may be observed. Return to
the surgeon, any patients with significant central microstriae, especially
accompanied by poor BCVA, for re-floating of the flap. Macrostriae involve
deeper layers of the cornea and must be seen by the surgeon. Any
patients with questionable striae should be returned to the surgeon since
the treatment is much easier and effective right after surgery.
Interface Debris
-minor interface debris-such as meibomian secretions, small fibers are of
minimal significance and do not affect visual acuity. The surgeon should
remove any fibers protruding from the border of the flap. These can act as
wicks and introduce infection under the flap.
Epithelial defects
-are now extremely rare with the introduction of the intralase laser flap.
They may rarely occur in patients with peri-operative trauma such as
rubbing the eye (look also for a dislodged flap) in hyperopes, patients with
anterior basement membrane syndrome (ABMD), dry eyes and older age.
Epithelial defects are treated with a bandage contact lens (BCL) after
surgery. Follow these patients daily with BCL in place until healed.
Careful removal of the BCL using artificial tears and avoiding the flap is
essential. Watch patients with significant epithelial defects closely for
interface inflammation such as DLK. They may also take slightly longer to
achieve good UCVA.
Diffuse lamellar keratitis (DLK, Sands of the Sahara)-presents 1-5 days
after LASIK. Inflammation is confined to the interface with no flap or
stromal extension in early phases (as opposed to infection). A “pseudoDLK” appearance with minor fine haze at the peripheral flap is sometimes
seen with the intralase flaps. This is opposed to the true granular
appearing cells of DLK. Any doubts treat as DLK.
Grade 1: white granular cells in the periphery of the interface
Grade 2: White granular cells in the interface center involving the
visual axis with or with out peripheral involvement
Grade 3: Dense aggregates of clumped cells appear centrally with
relative clearing peripherally.
Grade 4: Scarring and stromal melting
Etiology is unclear, but epidemic cases are related to endotoxin exposure
or oils from keratome blades. Grade 1 and 2 are treated with intensive
topical steroids-initially every one hour- with topical antibiotic coverage.
Grades 3 and 4 require lifting the flap for interface irrigation and scrapping
and possible oral steroids. One should always be aware that infectious
keratitis, though rare, may initially mimic DLK. Suspect infection with any
inflammation extending into the stroma and flap especially when
associated with pain. Suspected cases of DLK or infectious keratitis are
referred immediately to the surgeon for evaluation and treatment. Patients
with large epithelial defects or looseness are followed closely during the
first week for DLK.
Counseling- Remind patients during the early postoperative period to expect:
1. fluctuations in vision
2. intermittent dryness
3. night vision problems
These symptoms are more common with higher corrections and generally
resolve over the next several weeks. I mention that although their Snellen Acuity
may be excellent on day one; expect a big improvement in the quality of vision.
Research on Navy Seals undergoing Laser Vision Correction demonstrated
subtle contrast sensitivity loss in dim illumination took up to 12 weeks to fully
recover. Acute visual changes or sudden onset of ocular pain warrants an
immediate return visit for evaluation.
1 Week Post-op Visit
UCVA
Manifest Refraction with BCVA
Slit Lamp Exam
Counseling
UCVA-generally 20/15 to 20/30 for intralase LASIK, 20/30-20/100 for PRK.
Higher myopes who require more overcorrection may be > 20/30. Surface
dryness with superficial punctuate keratitis can limit UCVA slightly at this visit.
MR and BCVA -the manifest refraction at this visit may help predict the need for
enhancement. The refractive error is not yet stable however, particularly in higher
myopes and hyperopes. An occasional patient may require temporary distance
glasses for situations such as night driving. Presbyopic patients may require
temporary or permanent reading glasses.
Slit lamp examination- at one-week careful examination to look for evidence of
significant striae, epithelial ingrowth, interface inflammation -such as DLK, or
infection.
Epithelial ingrowth –extremely rare with intralase flaps. More common
after enhancements. May be noted in the first 1-2 weeks, but may take up
to 4 weeks to present Appearance varies from small pearls of epithelium
at the flap edge to a peninsula extending from a flap edge with a whorl
pattern. Severe cases can lead to stromal melt. Small non-progressive
areas at the edge require no treatment. Progressive cases are treated by
the surgeon by lifting the flap and debridement of stromal and flap surface.
Anyone with a suspicion of epithelial ingrowth should be referred to the
surgeon for evaluation.
Diffuse lamellar keratitis –See above on day one discussion. This must be
treated immediately and aggressively. Please call Dr. Cullom and have
patient follow up immediately.
Counseling: Though most patients are extremely happy at the one-week visit,
some patients require encouragement at this visit. Patients may need to have reassurance that night vision problems, crispness of vision, and minor eye dryness
generally improve substantially over the next several weeks. Presbyopic
patients, even when properly counseled before surgery may have difficulty
adjusting to new reading glasses. Monovision patients may struggle with an
adjustment period as well. Temporary glasses for distance or near may rarely be
required, especially for patients doing monovision who have problems with night
driving. PRK patients still have a way to go before obtaining their full improved
vision.
1 Month Post-operative visit
UCVA
MR with BCVA
Slit lamp exam
UCVA and BCVA are generally close to target at the one-month visit, though
hyperopes and very high myopes, (especially younger patients) and PRK
patients may continue to improve over the next several months.
Manifest Refraction: at this visit will give patients a sense of whether
enhancement will be required.
Slit lamp exam: Flap should be clear, gutter well healed, and there should be no
interface inflammation, significant striae, or epithelial ingrowth. As mentioned
above, DLK presents within five days of treatment, but may occur later after
minor flap trauma. Epithelial ingrowth rarely presents this late.
Dry Eyes:
Every visit should include careful attention to complaints and slit lamp
evidence of corneal dryness. Examine the cornea carefully for evidence
of dry eye- decreased breakup time, superficial punctate keratopathy
(SPK), and decreased BCVA. Flap formation cuts the superficial corneal
nerves and although intralase laser flaps are much thinner at the periphery
temporary corneal desensitization occurs. This can last six months or
longer in some cases. This results in less blinking and worsening of dry
eye symptoms, particularly during concentrated efforts such as computer
use or driving. There is also less neural feedback to the lacrimal gland
and therefore less reflex tear formation.
Patients with significant dry eye signs or symptoms should be started on
restasis eye drops twice daily, ideally 2 weeks prior to surgery and
continuing this for several months afterwards. I will also place punctal
plugs at the first sign of a dry eye problem. Additionally, preservative-free
artificial tears such as Bion tears, Theratears or Refresh tears should be
used from four times a day to every one-hour. Use an ointment such as
Refresh-PM or Genteal gel at night may be need to help relieve severe
symptoms particularly in patients who sleep with their eyes slightly open
and have worse dryness in the morning. Counsel patients to avoid air
vents directed at their eyes while sleeping. Wearing protective sunglasses
and/or clear glasses when biking or other outdoor activities helps as well.
Counseling:
Most patients are doing very well at this visit. Now that the excitement of their
new vision is less acute, many patients may have minor problems that need
discussion. Problems such as minor eye dryness or the need for new or different
reading glasses are generally easily corrected.
Enhancements:
Customized treatments as well as the use of intralase for all flap
formation has greatly reduced our enhancement rate. However, patients
still occasionally come in slightly under or overcorrected. If there is
significant undercorrection along with dissatisfaction in vision, it may be
time to discuss the need for an enhancement. Patients may be 20/40 and
very happy with their vision or 20/25 and having a difficult time with their
vision. I generally try not to enhance patients before 3 months to allow for
stability. Patients with low initial corrections may stabilize sooner and
therefore can be treated sooner. The key is to show stability of refraction
over several visits. Remember that sometimes patients with slightly
myopic outcomes are happy as this may allow for more range of vision up
close. Care must be taken not talk a happy patient into a procedure that
may trade one problem for another. For example, a 45 year old patient
that is -0.50 D and 20/25 at distance states that he is satisfied with his
vision. If that patient receives an enhancement he may suddenly need
readers and be much less satisfied with his outcome.
3 Month Post-operative Visit
UCVA
BCVA with manifest refraction
Cycloplegic refraction- (if enhancement considered)
Slit Lamp Exam
Applanation Tonometry
UCVA BCVA MR CR: Uncorrected vision is usually (but not always) stable at this
point. A cycloplegic refraction will help guide the need for enhancement.
Occasionally a patient appearing to have residual myopia is shown by
cycloplegic refraction to be emmetropic or minimally myopic.
Slit Lamp Exam: The cornea should be well healed without striae, inflammation,
and evidence of epithelial ingrowth or dryness
Applanation Tonometry: should be considered at this visit
Counseling: Problems with night vision, dryness or uncorrected visual acuity are
uncommon at this point, but each should be addressed. Enhancements are
generally first considered around this period. The flap may be lifted well after the
first year of surgery for most patients, therefore enhancements by lifting the flap
may be delayed if the patient desires. One limit to enhancement is adequate
corneal tissue, therefore patients with borderline corneal thickness, must be
counseled appropriately.
6 and 12 Month Visit
Generally a repeat of the 3 month visit. Applanation tonometry is optional at this
point, but should be done yearly. Perform a dilated funduscopic exam with any
complaints of floaters, flashes or decreased vision.
CONFIRMATION OF POSTOPERATIVE C0-MANAGEMENT SELECTION BY PATIENT.
CATARACT SURGERY
PATIENT NAME ___________________________________
(PRINT)
My surgeon, R Douglas Cullom, has given me and I have read, the instructions
regarding proper eye care following cataract surgery.
It is my desire to have my own optometrist, Dr _____________, perform my
postoperative follow-up care after my cataract surgery as soon as it is medically
appropriate. I have discussed this post-operative selection with my
ophthalmologist R. Douglas Cullom M.D.
R. Douglas Cullom M.D. has informed me that an optometrist may lawfully
provide post-operative care under applicable state law. I understand that my
optometrist will contact Dr. Cullom immediately if I experience any complications
related to my eye surgery. I understand that I may also contact R. Douglas
Cullom M.D. at any time after the surgery.
I acknowledge that my optometrist will bill my insurance for my postoperative
care and will receive payment from my insurance company for service rendered.
I have been advised by the surgeon and my optometrist of the financial details of
this arrangement including charges and length of global period.
PATIENT SIGNATURE ____________________________
DATE: ________________
WITNESS _______________________________________
DATE:_________________
OPTOMETRIST CONFIRMATION
I have agreed to provide follow up care for______________________. I will see
the patient after surgery when R Douglas Cullom M.D. notifies me the he is
releasing the patient to my care. I agree to notify Dr Cullom immediately should
complications arise and to provide written progress reports during my portion of
the postoperative period.
_____________________________________________
Optometrist Signature
DATE:___________________
CONFIRMATION OF POSTOPERATIVE C0-MANAGEMENT SELECTION BY PATIENT.
REFRACTIVE SURGERY
PATIENT NAME ___________________________________
(PRINT)
My surgeon, R Douglas Cullom, has given me and I have read, the instructions
regarding proper eye care following refractive surgery.
It is my desire to have my own optometrist, Dr _____________, perform my
preoperative and postoperative follow-up care relating to my refractive surgery as
soon as it is medically appropriate. I have discussed this post-operative
selection with my ophthalmologist R. Douglas Cullom M.D.
R. Douglas Cullom M.D. has informed me that an optometrist may lawfully
provide post-operative care under applicable state law. I understand that my
optometrist will contact Dr. Cullom immediately if I experience any complications
related to my eye surgery. I understand that I may also contact R. Douglas
Cullom M.D. at any time after the surgery.
I acknowledge that my surgeon will reimburse my optometrist for pre and
postoperative care. I have been advised by the surgeon and my optometrist of
the financial details of this arrangement s including charges; postoperative care
schedule and enhancement fees.
PATIENT SIGNATURE ____________________________
DATE: ________________
WITNESS _______________________________________
DATE:_________________
OPTOMETRIST CONFIRMATION
I have agreed to provide follow up care for______________________. I will see
the patient after surgery when R Douglas Cullom M.D. notifies me the he is
releasing the patient to my care. I agree to notify Dr Cullom immediately should
complications arise and to provide written progress reports during my portion of
the postoperative period.
_____________________________________________
Optometrist Signature
DATE:___________________
CONFIRMATION OF POSTOPERATIVE C0-MANAGEMENT SELECTION BY PATIENT.
REFRACTIVE LENSECTOMY
PATIENT NAME ___________________________________
(PRINT)
My surgeon, R Douglas Cullom, has given me and I have read, the instructions
regarding proper eye care following refractive lensectomy surgery.
It is my desire to have my own optometrist, Dr _____________, perform my
preoperative and postoperative follow-up care relating to my refractive
lensectomy surgery as soon as it is medically appropriate. I have discussed this
post-operative selection with my ophthalmologist R. Douglas Cullom M.D.
R. Douglas Cullom M.D. has informed me that an optometrist may lawfully
provide post-operative care under applicable state law. I understand that my
optometrist will contact Dr. Cullom immediately if I experience any complications
related to my eye surgery. I understand that I may also contact R. Douglas
Cullom M.D. at any time after the surgery.
I acknowledge that my surgeon will reimburse my optometrist for pre and
postoperative care. I have been advised by the surgeon and my optometrist of
the financial details of this arrangement s including charges; postoperative care
schedule and enhancement fees.
PATIENT SIGNATURE ____________________________
DATE: ________________
WITNESS _______________________________________
DATE:_________________
OPTOMETRIST CONFIRMATION
I have agreed to provide follow up care for ______________________. I will see
the patient after surgery when R Douglas Cullom M.D. notifies me the he is
releasing the patient to my care. I agree to notify Dr Cullom immediately should
complications arise and to provide written progress reports during my portion of
the postoperative period.
_____________________________________________
Optometrist Signature
DATE:___________________
HELPFUL HINTS FOR FILING MEDICARE GLOBAL FEES
1. The date of surgery is the date of service.
2. The global procedure is 66984-55. If the second eye is done in the global
period of the first eye, then include a modifier 79. Also in block 24D
specify which eye.
3. The diagnosis code is 366.16, it is more specific than 366.9. Be sure to
list which eye.
4. File separate claims for each eye.
5. There are 90 days in the global period. In block 19 of the CMS-1500 form
write the day your doctor assumed care of the patient. This will be the
second day after surgery. After the assumed care date, you put the
relinquished care date also in block 19, which would be 90 days after
surgery.
6. Do not bill Medicare until you actually see the patient.
7. Your units in 24G should be 89-you can bill for this amount of days per
Medicare, as long as the M.D. has turned the patient over to the O.D.
8. The place of service has to be 11 and the type of service has to be 2.
9. Block 17 a & b should be Dr Cullom, his UPIN is G70256
HOW TO CALCULATE THE 54-55 SPLIT
1. Multiply the total charge by 20%
2. Divide that number by 90 to arrive at the daily rate.
3. Multiply that by the number of days your doctor was responsible for
post op care
Fee for service patients.
20% of collections.