Practical Pearls

A Handy Guide to the Best Take-Home Tips in the January 2010 Issue of Ophthalmology MANAGEMENT

To recover a dropped lens nucleus or fragment, use a second instrument to stabilize it from below, lower the flow rate and bottle height just enough to maintain the anterior chamber, and change to a 15-degree phaco needle or flatter for maximum occlusion and followability, then draw the piece into the chamber………Find it!

Practices seeking to reduce their overhead ratio frequently achieve that by reducing staff, but data show that practices with the most support staff also have the highest collection ratio………Find it!

Rheumatoid arthritis patients may be candidates for refractive surgery, despite their compromised autoimmume status, if their meds are stable and no extra-articular disease is present………Find it!

Among pathogenic bacteria isolated in neonates, Neisseria gonorrhea and Chlamydia trachomatis are the most feared. Both are responsible for ophthalmia neonatorum; however, the former may invade intact corneal epithelium and cause rapid perforation with systemic sequelae………Find it!

When adding a second OR to your ASC, you can reduce the upfront investment in additional equipment by sharing some resources, such as an ECP unit, between rooms and scheduling patients so as to avoid overlap………Find it!

For unilateral uveitis, consider a 1 cc peribulbar or sub-Tenon's triamcinolone acetonide injection (40 mg/ml). If the macula is not flattened sufficiently, a second periocular injection or an intravitreal injection is a potential next step………Find it!

PRK's greater safety profile vs. LASIK makes it a better choice for patients suspected to have subclinical keratoconus………Find it!

With zonular compromise during cataract surgery, consider stabilizing the capsular bag with capsule retractors. Assuming an intact capsulorhexis, choose either the Mackool capsule retractors or traditional iris retractors………Find it!

HSV patients can be considered for LASIK if they are on antiviral therapy and there has been no HSV recurrence in the last six months………Find it!

Most “related care” (i.e. connected with the initial surgery) provided in a global period is not separately billable. Use modifier 78 to inform the payer of the circumstances and place of service that justifies separate reimbursement………Find it!

5-fluorouracil and mitomycin C are equally effective and safe adjuncts to primary trabeculectomy in low-risk patients. If there's a high risk of failure, or the patient has inflammatory, neovascular or congenital glaucoma, mitomycin C is probably more effective………Find it!

One preventive measure that may help avoid at least some capsule ruptures is the rounded-end Dewey Radius Phaco Tip………Find it!

The increased Medicare reimbursement for retinal ASC procedures and relatively quicker procedure time when using the latest techniques makes it really quite feasible to add these surgeries to an ASC schedule………Find it!

For greater cataract surgery efficiency, avoid scheduling toric lens implantations back to back, given the added preop step of marking the cornea and use of instruments that need resterilization prior to their next use………Find it!

Most aqueous shunts are placed on the superior scleral hemifields, a more predictable and safer area for implantation. The supero-temporal quadrant provides the best balance between safety and efficacy. The superonasal quadrant is the second choice………Find it!

Financial benchmarking allows practices to identify business opportunities, contain costs, drive revenue, manage staff and communicate more effectively with their boards………Find it!

A medical practice needs to ensure the confidentiality of patient information not only within its domain, but also with third parties who have access to the same information (outside vendors, laboratories, consultants, etc.)………Find it!

“Quality-adjusted life years” takes into account the utility of a medical intervention on patient quality of life and its duration of effect………Find it!

A dispensary should generate 20% of your profit, and this percentage will need to grow with decreasing medical reimbursements………Find it!

Cyclosporine (3-5mg/kg daily in divided doses) has been shown to be as effective as and to function synergistically with prednisone in the treatment of uveitis………Find it!

Recutting a flap in a LASIK enhancement case can separate the lamella between the two flaps, causing irregular astigmatism. Experts advocate surface ablation instead………Find it!

Repeat injections of Healon 5, and reducing aspiration flow and vacuum, may help to complete an IFIS case without further iris prolapse ………Find it!

Contact lens wear can disrupt the synergistic relationship between Staphylococcus species and diphtheroids, and may suppress normal immune mechanisms which serve to clear foreign pathogens………Find it!

In glaucoma patients at low to moderate risk of functional vision loss, it is acceptable to repeat SLT if needed, particularly if the patient had a good response with the first treatment………Find it!

The ocular flora can provide a protective effect by secreting antibiotics and other mediators to maintain homeostasis, or may simply outcompete pathogenic bacteria for available nutrients………Find it!

Practices may “panic” if their financials don't conform to a nationwide benchmark, or may make a business decision based solely on that national average. Yet practices often don't know why their practice falls outside of the benchmark, or if it's really a bad thing………Find it!

In acute uveitis, when drops are deemed insufficient, subconjunctival beta- or dexamethasone and lidocaine is relatively low risk, and may provide the patient some relief (albeit short term) and respite from a frequent drop regimen ………Find it!

When performing cataract surgery on a patient at risk for MRSA, substitute Polytrim in lieu of a 4th generation quinolone for pre- and postop antibiotic treatment………Find it!