It may be time to rethink your MO if cataract surgery is part of your practice and the optometrists within your practice are not directly involved in patient care before and after surgery. My experience as an optometrist in various practices — which includes private optometry facilities, a small ophthalmology practice and now a larger fully-integrated ophthalmology group — has taught me more than anything else that optometrists are underutilized in medical eye care. People are living longer and need more advanced medical care, with eye care being no exception. An aging population brings with it an increased demand for cataract surgery, among other ocular procedures, and it would be hard to argue against coordination of surgical care between ophthalmologists and optometrists throughout diagnosis and treatment to keep up with such growing demand.1,2
A LOOK AT THE NUMBERS
Collaboration between optometrists and cataract surgeons eases the burden that arises from the growing patient population needing surgery.3 The number of optometrists who graduated in 2020 (1725) was more than triple the number of medical students who matched into ophthalmology residency (495) in the same year.4,5 That means your availability to perform surgeries is significantly limited if you are also performing the initial consultation and all postoperative care.
In our practice, the surgeons’ time is freed up to perform a higher number of surgeries by the contribution of our optometrists (see page 40). In 2014, our surgeons performed less than 3,000 surgeries. By 2021, the number of surgeries increased to more than 5,200.
The key difference was an increase in the number of optometrists. Because optometrists are highly qualified in patient care and can identify concomitant systemic disorders, which manifest within the eye or raise suspicion from patient history, we are ideal for preoperative and postsurgical care.6
CONSIDER A CLOSER RELATIONSHIP
While working in a private optometry practice, my role in cataract surgery co-management was limited to one or two postoperative examinations. In many of these cases, the patient did not return to me until the full postoperative care had reached its conclusion. I continued to follow the patient after the process of cataract surgery had finished its course but did not directly participate in the surgical care. This model excludes the referring provider from the consultation process and the immediate care following surgery.
By contrast, the access I have to the advanced diagnostic equipment used in our fully integrated ophthalmology group allows me to advise patients on what surgery options best serve their needs and gives me an active role in the surgical process. During cataract surgery consultations, for example, I find tremendous value in the corneal hysteresis information obtained from our group’s ocular response analyzer (ORA-G3, Reichert) when assessing risks and benefits associated with the inclusion of minimally invasive glaucoma surgery (MIGS) devices. Therefore, I now have the ability to work to a fuller potential as a doctor compared to my previous roles, and this goes a long way toward earning the complete confidence of our cataract surgeons.
The judgment of optometrists throughout the entire surgical process is trusted in practices that coordinate care internally like ours. The broad surgical options available to patients are standardized between all surgeons and shared in quarterly meetings with all providers. We typically have a consensus for the surgical plan but do consult each other on the infrequent occasion when there is a question or disagreement. Mutual respect fosters an open line of communication which in turn reinforces trust between colleagues.
Each day a cataract surgeon is in the operating room eliminates a day of preoperative and postoperative care, but optometrists in an integrated practice get around such restrictions. OD integration means the shortest wait time possible for each patient to achieve maximal visual outcome from surgery, engendering patient satisfaction and creating the most lean and efficient surgical process. I believe this is the best way of optimizing care for our patients.
AN OPHTHALMOLOGIST’S CONVERSION STORY
BY MICHAEL PERNULA, MD
When I was first exposed to the comanagement of preoperative and postoperative care of cataract surgery cases with optometrists, I was admittedly skeptical. Fresh out of ophthalmology residency, I was concerned about many of the implications of sharing responsibility with other providers. How would this model affect the relationship between the surgeon and the patient? What level of trust could I have in someone else treating a patient in the same manner as I would? Fast forward to now, and as a high-volume cataract surgeon who works in multiple locations, I am convinced that I couldn’t provide the level of care that I do without our team and, most critically, our optometrists.
Characteristics of a successful model
A few key points have become clear in the successful comanagement model in our practice. First, proper hiring and training of motivated and caring optometrists is paramount. Second, sustaining open lines of communication between providers — and between providers and patients — is necessary to provide the appropriate level of patient care. For example, deeper discussion into the options for an upcoming surgery, especially considering the plethora of options with premium cataract cases, oftentimes requires an additional phone call or visit.
Finally, maintaining some degree of flexibility in scheduling is necessary and beneficial. There are times when complications require a visit back to the surgeon. Other times, a patient may prefer to meet the surgeon prior to undergoing the procedure. Having an open policy of accommodating surgery patients into my clinic, even last minute, has been important in delivering quality patient care.
The future of comanagement
After extensive experience in co-managing cataract surgery cases with optometrists, I am convinced that their role in patient care has been positive to both the surgeons and the patients in our practice. As such, since starting my practice, I have increased the role that optometrists play in both pre- and postoperative cataract surgery care. The optometrists at our practice have earned my trust in providing excellent patient care, maintaining communication and referring back to the surgeon when applicable. I expect that this model will be increasingly employed with the growing surgical load that cataract surgeons in the United States will face in the future. OM
TRAINING REQUIREMENTS
Optometrists have the extensive clinical education, training and experience to provide highly effective primary eye care. To offer services in medical and surgical settings, an additional year of residency training after optometry school is recommended, and it is required for those seeking a career in academia or research. Approximately 26% of optometry school graduates take advantage of residencies, but the number is rising.7 Residency provides optometrists with further experience, knowledge and the clinical skills necessary to intervene in more complicated cases and reduces the need to refer care to other providers, so they are ideally suited for coordinated care throughout the cataract surgery process.
THE OD’S ROLE
Optometrists in our practice guide patients during the preoperative evaluation toward the best option for their individual needs. Technological advancements continually offer greater patient satisfaction and desired visual outcomes, so it is important to assess the patient’s lifestyle, visual demand and personality while recommending lenses and other surgical options.
To that end, patients are given a lifestyle questionnaire on the day of surgery consultation regarding their hobbies and daily activities. The optometrist then has a thorough conversation with the patient. The questionnaire does not take long to fill out, but the length of discussion with the patient will vary depending on each patient’s personality. It is not uncommon for a patient who is considering premium IOLs to require extended time in the exam room, and this is where an optometrist’s value in the surgical process is the greatest.
A thorough knowledge of all IOLs and surgical methods utilized by cataract surgeons within the practice gives an effective proxy voice to optometrist colleagues who can discern the ideal option for patients once associated costs and potential postoperative visual limitations have been addressed. For instance, a cutting-edge IOL like the Light Adjustable Lens (RxSight) is a great option for many cataract patients but has the potential to add many postoperative visits in order to achieve patient expectations. In states where it is permitted by scope of practice, optometrists can perform the postoperative refractions and lens adjustments through the light delivery device — procedures that consume significant time that the surgeon likely cannot afford.
If you want your ophthalmology practice to grow with the pace of technological advancement, the best option is to use the skills and talents of your optometrist colleagues.
GLAUCOMA, TOO
Advancements in cataract surgery also include treatments for glaucoma. Simultaneous cataract and glaucoma surgery decrease ocular surface disease by limiting the need for topical therapy, which improves visual outcomes. Reduced need for topical glaucoma therapy after implantation of a MIGS device performed concurrently with cataract surgery is a welcome bonus for both the surgeon and the patient. As a result, the cataract surgery evaluations I perform often include recommendations for the type of MIGS device depending on the angle anatomy and preferences of the surgeon in order to properly tailor the surgery and ongoing treatment plan for each patient.
BENEFITS
So, what are the benefits to your practice when a team of optometrists handle the patient care outside of cataract surgery? The best benefit is substantial growth of your practice. Our organization may have started small, but we have been able to open multiple new locations and offer new subspecialty services, and our group can now support the contributions of additional surgeons.
Setting aside the benefits I previously mentioned that contribute to practice growth, postoperative findings assessed by our optometrists provide ample data to track the outcomes of each surgery because the availability of optometrists is many times that of the surgeon. Collaborative care internally maximizes efficiency in your process and consistency with the data you collect on your outcomes. Tracking the results after cataract surgery helps the practice improve by identifying and eliminating steps that do not result in good outcomes and reinforcing the steps that do, so you can be sure which advanced technologies are optimal for each patient’s needs while reducing the risk of offering less effective surgical options.
CONCLUSION
The high prevalence of vision impairment by cataracts in an aging population ensures a high demand for surgery to restore vision and improve quality of life. Giving treatment to the maximum number of patients requires effective collaborative care between cataract surgeons and optometrists.3,7 It is not efficient for every patient to be evaluated by the cataract surgeon prior to surgery and followed afterward. We know which patients are complicated or have personalities that may require a visit with the surgeon beforehand, but that is the exception rather than the rule in our practice.
You may be worried that your patients will not be pleased with seeing different providers between the surgery and the treatment management. However, in my experience, patients are more concerned with access to convenient care and utilizing their insurance benefits than they are with seeing the surgeon for all visits before and after surgery.
In our practice, residency-trained optometrists work hand in hand with ophthalmologists. Together, we diagnose and treat a much broader array of ocular pathologies than we would have had the time to accommodate without such collaboration. The roles for our optometrists are evaluated and defined by our lead optometrist in collaboration with our lead surgeon, so they are subject to change but have largely remained the same.
Integrated care between ophthalmologists and optometrists is beneficial for all providers involved and increases the growth of your practice, but the greatest benefit is to the patient because of the optimal experience it affords. OM
REFERENCES
- Mangione CM, Phillips RS, Lawrence MG, Seddon JM, Orav EJ, Goldman L. Improved visual function and attenuation of declines in health-related quality of life after cataract extraction. Arch Ophthalmol. 1994;112:1419-1425.
- National Eye Institute. More Americans facing blindness than ever before. https://www.nei.nih.gov/about/news-and-events/news/more-americans-facing-blindness-ever . Accessed August 4, 2022.
- Kalloniatis M, Ly C. The role of optometry in collaborative eye care. Clin Exp Optom. 2016;99(3):201-203.
- ASCO Student Data Report 2020-2021. Published online Mar. 29, 2022. https://optometriceducation.org/wp-content/uploads/2022/03/ASCO-Student-Data-Report-2020-21-updated-3-29-22.pdf . Accessed August 21, 2022.
- 2021 Ophthalmology Residency match summary report. Published online 2021. https://059987482848-shared-prod.s3.amazonaws.com/Specialties/OPHTH-R/2021+Ophthalmology+Residency+Match+Summary+Report.pdf . Accessed August 21, 2022.
- Murrill CA, Stanfield DL, VanBrocklin MD, et al. Care of the adult patient with cataract. Published online 1995. Accessed August 4, 2022. https://www.aoa.org/AOA/Documents/Practice%20Management/Clinical%20Guidelines/Consensus-based%20guidelines/Care%20of%20the%20Adult%20Patient%20with%20Catract.pdf
- Residency programs. https://www.aoa.org/education/studying-optometry/residency-programs?sso=y . Accessed August 4, 2022.
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