THE NVISION ANSWER BOOK

Transcription

1 THE NVISION ANSWER BOOK LASIK CATARACTS

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3 TABLE OF CONTENTS LASIK: CO-MANAGEMENT WITH NVISION 1 Role of the Optometrist 2 LASIK: Process Overview 3 Process Details 4 Pre-Surgical Evaluation 5 & 6 Post-Procedure 7 Medication Protocol Recommended ranges for laser vision correction with wavefront ablation 8 LASIK Contraindications Patient Selection 9 Risks and Complications 10 Expanded Laser Procedures and Implants 11 CATARACTS: CO-MANAGEMENT WITH NVISION 12 Co-Management of Cataracts and IOL Implant Patients 13 Process for Implant Surgery Co-Management 14 Post-Operative Cataracts and Intraocular Surgery Medication Protocol for Intraocular Surgery 15

4 LASIK Join NVISION and see why LASIK patients have greater satisfaction with more technology, more experience, more options and superior results. NVISION partners benefit from patient fulfillment, improved continuity of care and increased income. NVISION is committed to helping you incorporate LASIK and Cataract co-management and accomplishes this because: NVISION will guide you through the co-management process to ensure success for your patients and your practice. NVISION provides continuing education for local optometrists and has delivered quality education programs for over 10 years. NVISION will train and educate your staff. Our Area Managers (AMs) can add value to your staff through training programs. Come see why eye doctors are choosing NVISION for their LASIK services. 1

5 ROLE OF THE OPTOMETRIST We believe the optometrist is the primary eye care provider and has the best knowledge and understanding of the patient s visual needs in terms of motivations for surgery. Whether your patients have refractive or cataract surgery, they should be screened and educated to understand that continued primary eye care is necessary even after vision correction procedures. The optometrist has an obligation to the patient to be knowledgeable about the type of treatment the patient will receive upon referral to the eye surgeon. The role of the optometrist is to: Select the appropriate candidate for the vision correction procedure. Provide basic information, educate and counsel patients. Demonstrate monovision pre-operatively with the use of contact lenses, when applicable. Perform a manifest and cycloplegic refraction prior to the procedure. Monitor patients at specific intervals and to report findings. Reassure, comfort, and support patients whose expectations exceed the natural healing process. Continue to monitor the health of the patient s eye during the aging process, aside from any refractive procedural considerations. Assist presbyopic patients with near vision needs. Report all pre- and post-op exams, and any problems to the surgeon. 2

6 LASIK: LASER VISION CORRECTION PROCESS OVERVIEW OPTOMETRIST PRE-SURGERY Initial evaluation Assess if patient is interested in laser vision correction Pre-procedure examination Send patient to NVISION for consultation POST-SURGERY 1 day post-operative (post-op) 1 week post-op 1 month post-op 3 month post-op 6 month post-op 1 year visit is not a post-op (annual eye exam - responsibility of patient) Refer back to NVISION for enhancement, if needed (NVISION recommends waiting 4-6 months to ensure that there is refractive stability prior to any enhancements). NVISION COMPLIMENTARY CONSULTATION Tech/Patient Counselor (PC) performs: Ocular/Medical History Pupil Size Eye Dominance Autorefractor Orbscan Wavescan BCVA/UCVA Note: If the patient is over 40 years old, measure near vision as well. NVISION MD/OD DETERMINES CANDIDACY Performs ocular exam, discusses test results, presbyopia/monovision when appropriate, complications, side effects, expectations, concerns, assessment and recommendation of specific procedure PC Scheduling paperwork Fee discussion/financing POST-SURGERY Unusual healing or possible complications, return to NVISION for evaluation with surgeon When a patient comes to NVISION for an initial evaluation and does not currently have an eye doctor, we will refer the patient to a co-managing doctor in his or her own area. The patient will be introduced to the doctor and will have all pre-testing performed. Occasionally, we may complete the pre-testing at our facilities if the patient is highly motivated and time constraints do not allow them to be seen by the co-managing doctor. In this case, the patient will be seen by the co-managing doctor for all post-procedure visits. 3

7 PROCESS DETAILS INITIAL EVALUATION (Can be annual exam, checkup, CL exam, etc.) Determine if the patient is a good candidate for laser vision correction, refractive lens exchange, cataract surgery, corneal inlay for presbyopia, or any other surgical procedure we are performing or co-managing. Stability: The patient must be at least 18 years of age, and 2 refractions (one year apart) must be stable, with a.5 diopter, or less, in change. Schedule the patient for a consultation at NVISION. CONTACT LENS PROTOCOL FOR CONSULTATION Soft contact lenses should be removed 3 days prior Hard or gas permeable lenses should be removed at least 1 week, or even longer, prior to initial testing. If any distortion is noted, it will be necessary to leave the lenses out for a longer period of time until the refraction and topography maps show stabilization (this function is performed at NVISION). PATIENT CONSULT AT NVISION Our goal in the consultation process is to make the patient feel as comfortable at our facility as they do at yours. Your patient should expect to spend about 1 hour with a patient counselor and our clinical director (OD). The patient will meet with the surgeon, upon request, when a consultation appointment is made. Patient s chart will have the consultation form from the Optometrist with all their information that was previously faxed, ed, mailed, or called in. The patient s candidacy is explained based on their expectations, refractive error, pachymetry and corneal topography measurements that will be performed at NVISION. The refractive procedure that is best suited for the patient s refractive error is explained. The patient is informed of what to expect pre-operatively, the day of surgery, and post-operatively. We will explain how the co-management process works (i.e., the role of the referring doctor as well as our role). If presbyopia or monovision are applicable to the patient, the patient will be given his/her options. NVISION MONOVISION PROTOCOL Presbyopia is discussed with all presbyopes and pre-presbyopes. The need for reading glasses after the age of 40 and monovision, as an option, is also reviewed with the patient. Listed below is how NVISION s clinical directors, optometrists, and surgeons discuss presbyopia with the applicable aged patients. Define Monovision: One eye is focused at distance and one eye is focused at near. Review Advantages of Monovision: A way to reduce dependence on reading glasses and the ability to maintain some close up vision as the patient ages. Review Disadvantages of Monovision: depth perception, as well as distance vision, is slightly compromised, especially driving at night. Test Eye Dominance: determine the dominant eye, explain to patient that the dominant eye will be for distance and the non-dominant eye will be the near vision eye. Perform a Loose Lens Test: Demonstrate monovision with available loose lenses. Test their distance and near vision. If the patient is interested, then proceed to MV contact lens trial. This can be done by their optometrist or at our office. Return to clinic after 1 week for follow up. Note: Some optometrists like to be more involved with determining if their patient is a candidate for monovision, since they ve been their patient s primary eyecare provider for many years. If that is the case, the NVISION doctor will consult with the referring optometrist prior to proceeding with surgery. Surgeon experience and qualifications are discussed. The patient is given the opportunity to watch a LASIK procedure and meet with the surgeon. Cost and method of payment is discussed. The patient is then scheduled for surgery. If a patient does not schedule surgery, the refractive surgery counselor will confirm the reasons and make a follow-up call in the near future. The optometrist will be contacted regarding the consultation visit and date of surgery. 4

8 PRE-SURGICAL EVALUATION MEDICAL HISTORY Allergies - including drug allergies Medication - systemic and ocular Systemic disease - a list of all medical illnesses Pregnancy is a contraindication OCULAR HISTORY It is essential to record a complete ocular history, including any history of amblyopia, ocular injury, ocular surgery, retinal detachment, or herpetic keratitis in the patient s chart. DETERMINING STABILITY AFTER CONTACT LENSES ARE REMOVED Have the patient discontinue his/her contact lens wear for the appropriate period of time before testing, as well as before their procedure. Please keep in mind that we have all patients discontinue contact lens wear prior to surgery and re-check all tests on the surgery day. Soft lenses: 7 days Toric lenses: days dependent on topography* RGP lenses: 4 weeks or longer until refraction is stable* Typically 4 weeks + 1 week per decade *NVISION will perform topography and determine stability of refraction after discontinuing contact lens use. EXAM ELEMENTS: Discuss the benefits of co-managing with the patient. Perform refractions, visual acuity measurements, fundus exam, measure I.O.P. and keratometry. Make any recommendations regarding retinal issues. Bilateral fogged refractions should be utilized to minimize the myopic sphere and maximize the hyperopic sphere as much as possible to achieve the best-corrected vision. For the cycloplegic refraction, use MydriacylTM 1% (Tropicamide). If the patient is either a latent hyperope, a pre-presbyope, or you suspect they have accommodative spasm, use 1% CyclopentolateTM for a minimum of 3 days prior to the surgery; otherwise, the eye will still be dilated and the surgery will need to be postponed. Even if patient is only having surgery on one eye, it is important to perform a cycloplegic exam on both eyes. The cylinder should be maximized. As much cylinder as the patient will accept without reducing best-corrected visual acuity should be measured and documented. Minimum myopic sphere, maximum hyperopic sphere, and maximum cylinder increases the likelihood of achieving emmetropia. Patients who cannot be refracted to 20/20 or better need closer evaluation. If the cornea, lens, macula, and optic nerve appear normal, a rigid contact lens over-refraction can be performed to rule out irregular astigmatism. If this yields better results, keratoconus or contact lens induced corneal warpage may be the cause. This is best determined using corneal topography at NVISION. OCULAR DOMINANCE Ocular dominance must be determined, especially when monovision is selected by the patient. CORRECTED VISUAL ACUITY It is important to document the best-corrected visual acuity prior to the surgical procedure in order to assess any loss of best-corrected visual acuity post-operatively. Many myopic patients, especially those who are severely myopic, may not be able to read 20/20 pre-operatively and should not expect to achieve this level of visual acuity post-lasik or other refractive procedures. In addition, if the patient is amblyopic, appropriate expectations will need to be discussed. REFRACTION Complete a thorough manifest and cycloplegic refraction to provide a basis to calculate surgical parameters. Refractions for refractive surgery differ from refractions for glasses or contact lenses. EYE ALIGNMENT If patient has previous history of strabismus or large phoria, document with cover test and educate the patient that the condition will not improve with refractive surgery, also that it is possible that it may worsen with time. Prism in glasses might be necessary for significant eye misalignment. CORNEAL TOPOGRAPHY Corneal topography is performed to measure the curvature and elevation as well as corneal thickness distribution and any irregularities on the surface of the cornea. It is used, among other measurements and findings, to determine if a patient is a candidate for refractive surgery. Topography will be performed at the NVISION center. cont d 5

9 PRE-SURGICAL EVALUATION SLIT LAMP EXAMINATION CORNEA: Note any previous scars/opacities, especially those suspect to being herpetic in origin. Herpes virus may be reactivated by the excimer laser and it should be treated prior to proceeding with surgery. Scars could interfere with the femtosecond flap creation. Look for signs of Keratoconus such as Fleischers ring, striae, apical thinning and scarring, corneal guttata, epithelial disease, and epithelial staining patterns. ANTERIOR CHAMBER IRIS: Pigment dispersion and iris transillumination detect characteristics of pigmentary dispersion syndrome, which could contribute to future elevations of IOP. LENS: Any progressive lenticular opacity may cause a change in refraction, thus any refractive procedure is a contraindication. Patients with higher degrees of correction may be candidates for the ICL or IOL implants, if so indicated. RETINAL EVALUATION A dilated fundus examination is required to thoroughly evaluate any evidence of retinal pathology, such as macular disease or peripheral retinal pathology (i.e., more lattice degeneration, white without pressure, hole, tear, or detachment, which is common in myopes). The patient must understand that the risk of retinal detachment does not decrease simply because the dependence on glasses decreases. Annual examinations are still required and must be emphasized. If appropriate, refer to a retinal specialist for any diagnosis or treatment prior to refractive surgery. COMMUNICATING WITH NVISION Complete and fax the pre-op form to your local NVISION center. Contact your local NVISION center to confirm the patient has a reservation for their procedure. Each patient having surgery will be seen by the surgeon prior to his or her procedure. 6

10 POST-PROCEDURE Follow-up evaluations should be performed at 1 day, 1 week, 1 month, 3 months, 6 months and 1 year following refractive surgery. (The 1-year evaluation is considered an annual eye exam, for which the patient is financially responsible.) POST-OP EXAMINATION Patient will be seen by NVISION the day of surgery and will be released back to their eye doctor after a successful procedure. Contact your local NVISION center to learn more about the NVISION surgeon(s) with whom you are co-managing. ROUTINE LASIK POST-OP: Review drops and restrictions Monocular and Binocular VA, distance and near SLE Flap check for striae, debris, inflammation, SPK, or dislodged flap UCVA Within 1-2 lines of BCVA Pinholes if 20/30 or worse Glare and Halos expected the first 3 months after surgery 1 DAY Routine LASIK Post-Op: Return to Center for unexplained UCVA worse than 20/30 and if complications exist. Possible Symptoms: Some fluctuation in VA not uncommon, halos and glare. Dryness may be experienced. 1 WEEK Routine LASIK Post-Op: IOP. Manage any lid disease/dry Eye Syndrome (DES). Consider Restasis for dry eye if routine drops not sufficient. Return to NVISION for unexplained UCVA worse than 20/30 or loss of BCVA. Possible Symptoms: Some fluctuation In VA not uncommon, halos and glare. Dryness may be experienced. 1 MONTH Routine LASIK Post-Op: Artificial Tears/Restasis as necessary. Manage Dry Eye/ lid disease. Manifest refraction with BCVA. If patient is on steroid treatment for any reason including PRK, check IOP. Possible Symptoms: Occasional (rare) foreign body sensation with possible dryness, may still have halos and glare. 3 MONTH Routine LASIK Post-Op: Artificial Tears/Restasis as necessary. Manage Dry Eye/lid disease. Manifest refraction with BCVA. Possible Symptoms: Occasional (rare) foreign body sensation with possible dryness. 6 MONTH Routine LASIK Post-Op: Artificial Tears/Restasis as necessary. Manage Dry Eye/lid disease. Manifest refraction with BCVA. Possible Symptoms: Occasional (rare) foreign body sensation with possible dryness. 1 YEAR Routine LASIK Post-Op: Comprehensive examination with fundus evaluation. All post-op visits must be faxed or ed back to NVISION for review. Co-management of patients is decided on a case-by-case basis and occurs when medically appropriate. For details about possible post-op findings, please refer to the Post-Op Guide (Located in the NVISION Answer Box). Also, contact your local NVISION center and surgeon to learn more about post-op care. Questions and additional education about IOL post-op care are always welcomed. It may be necessary to see the patient more often than these suggested intervals. If so, all visits that are related to the procedure should be included in your co-management fee. Your co-management fee does not include the cost of spectacles or contact lenses. If you wish to provide glasses to the patient, you may do so. After completing each post-op evaluation, please fax your findings to the NVISION Eye Center where the surgery took place. Make sure to print your name and sign the document. Our clinical directors will review the examination and contact you by either phone or fax, if requested. We request that you fax all post-op examination results to us, in order to monitor doctor and patient satisfaction as well as to perform data analysis. If you have questions on any of the post-op visits, please call our office. If a patient needs immediate attention, you may call our office 24 hours a day and have an NVISION doctor paged. 7

11 MEDICATION PROTOCOL FOR LASER VISION CORRECTION SURGERY LASIK PRE-OP Antibiotic: Zymaxid/Besivance/ Vigamox/Ocuflox 4 times a day starting 1 day prior to surgery Steroid: Lotemax Gel/Pred Forte/Prednislone 4 times a day starting 1 days prior to surgery OR Compounded Antibiotic/Steroid: 4 times a day starting 1 day prior to surgery POST-OP Antibiotic: 4 times a day for 1 week following surgery Steroid: 4 times a day for 1 week following surgery OR Compounded Antibiotic/Steroid: 4 times a day starting 1 day prior to surgery Lubrication: Preservative-free Optive/Systane/Blink/Oasis 1 drop every 1-2 hours for the first month, then as needed Protocols may vary from center to center. NVISION sells generic or compounded prescriptions in all centers for patient s convenience. Contact your NVISION location for PRK post-op medication schedule. RECOMMENDED RANGES FOR VISION CORRECTION WITH CUSTOM WAVEFRONT ABLATION DIOPTER RANGE PROCEDURE MYOPIC CORRECTION to D Myopic LASIK Can be combined with Astigmatic Correction ASTIGMATIC CORRECTION to D Astigmatic LASIK HYPEROPIC CORRECTION to D Hyperopic LASIK Can be combined with Astigmatic Correction ICL to Myopic Phakic IOL Can be combined with LASIK or PRK for additional treatment LASIK: Laser-assisted in situ keratomileusis (LASIK) is the most comfortable vision correction, and patients experience better vision almost immediately. LASIK has a large range of correction for myopia, hyperopia, and astigmatism. Most vision needs can be addressed with this procedure. PRK/LASEK: Photorefractive Keratectomy and Laser Epithelial Keratomileosis are available for patients who are not candidates for LASIK. These can be performed with custom Wavefront ablation or Wavefront optimized ablations. Hyperopic LASIK: Currently, this procedure is effective in correcting up to +6.00D of hyperopia, with similar levels of astigmatism. Patients having this procedure should understand that it will take longer for a farsighted patient to see clearly at distance. 8

12 LASIK CONTRAINDICATIONS OCULAR CONTRAINDICATION Absolute Active infections Active herpetic keratitis/herpes zoster Forme fruste keratoconus (SEE PROTOCOL BELOW) Keratoconus Clinically significant cataract Relative (The surgeon will determine if appropriate to proceed with surgery on a case-by-case basis.) History of herpes simplex keratitis Active collagen vascular disease severe dry eye (SEE PROTOCOL BELOW) Active or residual/recurrent ocular disease Unstable/progressive myopia Irregular astigmatism Depressed corneal scars Fuchs dystrophy Exposure keratopathy PROTOCOL FOR DIAGNOSING FORME FRUSTE KERATOCONUS (Performed at NVISION) 1. Corneal topography (Orbscan/ Pentacam) 2. Pachymetry 3. Wavefront aberrometry PROTOCOL FOR DRY EYE EVALUATION The following tests are (performed at NVISION) based on lid and tear film evaluation as needed: 1. Tear film evaluation with and without Fluorescein 2. Tear Breakup Time (TBUT) 3. Corneal/conjunctival evaluation with Lissamine Green/Rose Bengal 4. Lid evaluation for Blepharitis and/or MGD 5. Schrimer s test 6. Lipiview - Lipid layer thickness (only at select NVISION locations) SYSTEMIC CONTRAINDICATION Absolute Pregnancy Relative (The surgeon will determine if appropriate to proceed with surgery on a case-by-case basis.) Autoimmune diseases (rheumatoid arthritis or lupus) Immuno-suppressed patients Illnesses that affect healing Lactation PATIENT SELECTION INTRODUCTION Because optometrists have patients they have followed for years, they can provide better insight to a patient s personality traits and qualifications as a candidate for refractive and cataract surgery. Patients are most likely to be satisfied with results of refractive surgery if they have specific objectives in mind. A specific objective creates an end point, which marks the success of the procedure for the patient. It is important that the patient have realistic expectations. MOTIVATION Reasons for considering refractive procedure: Occupational Recreational Cosmetic Emergency situations (fear of being disabled without glasses during an earthquake) Being able to function without being completely dependent on glasses or contact lenses SELECTION Questions that will assist you in selecting the best candidates for a refractive procedure: Does the patient have realistic, well-defined goals and expectations? Is the patient willing to accept some risk that their objective might not be achieved? Is this patient able to understand the concept of risk/benefit ratio? Does the patient understand presbyopia? Monovision? Understands the need for readers? 9

13 RISKS AND COMPLICATIONS 20/20 VISION: Although over 98% of our patients will have bilateral uncorrected 20/20 visual acuity 1, success of a refractive procedure often depends on the patient s expectations. Based on the results of other refractive patients with similar vision, the surgeon may give a patient a general idea of the expected outcome. UNDER/OVER CORRECTION: If a patient is a myope and there is an under-correction or an overcorrection and the patient has residual refractive error and/or astigmatism, an enhancement surgery can be performed as early as 3 months after their initial surgery. In patients who have marked to severe myopia (>8D) or hyperopia (>4D), an enhancement is preferably delayed closer to 6 months. If the patient is a hyperope, and there is an overcorrection or under-correction, we typically wait a total of 6 months prior to proceeding with an enhancement. PRESBYOPIA: If a patient has reading glasses before a refractive procedure, he or she will still need them after the procedure, unless the patient elects monovision. Monovision will delay the need for reading glasses. However, if a person is going to read fine print or read for long periods of time, reading glasses may still be required. If a patient is approaching years of age and has noticed a decrease in reading vision, he or she will most likely be dependent upon reading glasses immediately following a refractive procedure. Unless a patient is accustomed to an add of more than 1.50 prior to surgery, we prefer not to recommend more than 1.50 add. Enhancements are always possible to fine tune this outcome when needed in the future. LOSS OF VISION: In over twenty years of performing refractive procedures, no patient of NVISION Eye Centers has lost their sight as a result of refractive surgery. However, an acquired infection following surgery could result in possible vision loss. This is why patients must use their antibiotics as directed and be seen by their eye doctor the day following the procedure, as well as for all follow up visits. FLUCTUATION OF VISION: Following a refractive procedure, a patient s vision will fluctuate. The length of time a patient s vision will fluctuate depends on: Which procedure was performed (myopia, hyperopia, or astigmatism) How quickly the patient heals How much correction was performed. (High degrees of correction take longer to achieve the best results.) LASIK patients usually experience good, clear vision soon after surgery. Some LASIK patients experience blurred vision post-operatively, but notice gradual clearing with each passing day. GLARE AND HALOS: Following any refractive procedure, patients may experience glare or halos around lights at night. Many contact lens wearers are familiar with these nighttime images, even before having a refractive procedure. In most cases, this side effect will diminish with time, sometimes taking from 3 weeks to 3 months to completely disappear. Long-term glare or halos are more likely in patients with a higher degree of refractive error. The glare can be minimized by wearing a mild prescription for nighttime driving, if needed. With the development of Custom Wavefront ablation and Wavefront Optimized ablation, we can minimize the risk of halos and glare at night and achieve better contrast sensitivity along with the best visual results. CORNEAL DRYNESS/LACK OF TEAR FILM: Patients may experience dry eyes for the first several weeks. During this temporary period of dryness, liberal use of lubricating drops is recommended. Collagen plugs may be placed prophylactically prior to surgery, on the day of surgery or post-operatively. If collagen plugs are found to be effective, the optometrist may prefer permanent silicone plugs. Also, Restasis, Freshkote, fish oil and blepharitis treatments have been found to be excellent adjunct treatment modalities and can be used pre-operatively in patients prone to dryness. LOSS OF BEST CORRECTED VISION: If a patient needs glasses or contacts following a refractive procedure, vision with correction (glasses or contacts) may not be as sharp as it was before the procedure. The chance of losing best-corrected vision becomes greater as the degree of myopia, hyperopia, and astigmatism increases. Frequently, additional procedures can be performed to eliminate or substantially improve the symptoms. CONTACT LENSES AFTER SURGERY: A soft contact lens may be fitted 1 month or sooner after surgery, and a gas permeable lens as early as 3 months after surgery. CORNEAL HAZE: Corneal haze is a side effect of the PRK treatment. It is an exaggerated healing response. Corneal haze is very unusual in LASIK, but may occur. We now routinely use mitomycin during the PRK/LASEK surgery. This has been shown to minimize haze in these patients. 1 Based on findings from Datalink reports for Supporting data can be provided by NVISION on request. 10

14 EXPANDED LASER PROCEDURES AND IMPLANTS ZIEMER/INTRALASE Ziemer and Intralase are available for essentially all LASIK candidates to create thinner flaps in LASIK patients who have normal topography. These lasers are considered femtosecond lasers that will create a flap without the use of a blade (microkeratome). IMPLANTABLE COLLAMER LENS (ICL) ICL is a foldable intraocular lens implanted between the iris and the patient s own lens. The procedure has proven to be quite effective in correcting extreme degrees of nearsightedness up to D. ICL can also be combined with LASIK for higher levels of myopia than D and patients with low pachymetry readings (insufficient corneal thickness for LASIK). Both eyes are done at least 1 week apart. ICL is not approved for hyperopia at this time. INTACS INTAC segments are available for keratoconus and pellucid marginal degeneration patients to improve uncorrected and best corrected vision. It also improves contact lens tolerance and wearing time. CROSS-LINKING Since both eyes have the same genetic makeup, both eyes should be cross-linked. The best way to diagnose early keratoconus is by using your manual keratometer. If the mires do not coincide with each other, it is likely that the patient has irregular astigmatism which may be secondary to keratoconus. All patients with a new diagnosis of keratoconus should have Collagen Cross-Linking. Collagen Cross-Linking in patients around the age of frequently results in improved corneal regularity and reduced astigmatism and myopia of 1-1.5D. CORNEAL INLAY Corneal inlays are used in the functionally non-dominant eye to reduce or limit the need for reading glasses. CLEAR LENS EXTRACTION An excellent alternative treatment to correct high levels of myopia or hyperopia when LASIK or ICL are not acceptable options. This is especially good for patients older than 40 years old. With this procedure, we can use a monofocal, multifocal or accommodative IOL to restore the patient s distance and/or near vision at the same time. MONOFOCAL IMPLANTS a. Monofocal IOLs can be chosen to correct for distance or near vision. b. Toric IOLs can be chosen to correct distance or near visual acuity plus astigmatism. PRESBYOPIA CORRECTING IMPLANTS (called Lifestyle Lenses at NVISION) a. ReSTOR Aspheric: The newly designed Alcon Acrysof ReSTOR IOL has a basic design that allows for clear distance vision. The center of the IOL also allows for near and intermediate vision. Results from a clinical study showed that patients can see better for distance, near and intermediate vision with ReSTOR IOL implanted in both eyes compared to it being implanted in just one eye. b. Tecnis Multifocal: similar design to the ReSTOR IOL except the concentric rings on the lens extend out to the edge of the IOL. This makes the lens less pupil-size dependent. c. Crystalens Accommodating is a monofocal lens which corrects for distance and midrange. This is the only true accommodating implant available today. 11

15 CATARACTS Join NVISION and see why cataract patients have greater satisfaction with more technology options, exceptional surgical experience, and superior vision results. NVISION partners benefit from patient fulfillment, improved continuity of care, billing services and increased income. NVISION is committed to helping you incorporate cataract co-management in the same fashion we helped you incorporate LASIK co-management. This is accomplished through: If co-managing cataracts is new to you, NVISION will guide you through the process to ensure success for your patients and your practice. NVISION provides continuing education for local optometrists and has delivered quality education programs for over 10 years. NVISION will train and educate your staff. Our Area Managers (AMs) can add value to your staff through staff training luncheons. Come see why eye doctors are choosing NVISION for their Cataract services. 12

16 CO-MANAGEMENT OF CATARACTS AND IOL IMPLANT PATIENTS OUR GOAL FOR EYE CARE PROVIDERS At NVISION Eye Centers, our goal is to work with Eye Care Providers (ECP) to provide their patients the best experience and visual outcome for their intraocular procedure. Collaboration with a patient s ECP has been NVISION s commitment for over 10 years. NVISION offers a range of vision care technologies and services that allow each patient the vision that best fits his/her lifestyle; a truly customized approach to cataract surgery. NVISION wants to partner with you to offer your patients the best refractive cataract surgery outcome possible, regardless of the patient s lens selection. This section outlines the co-management process with NVISION Eye Centers. It will detail the pre-and post-op care guidelines after cataract extraction and intraocular (IOL) implant surgery. It is our policy to provide the highest quality of care for our mutual patients, consistent with our patient s needs and goals. INTRODUCTION TO IOL CO-MANAGEMENT NVISION Eye Centers will co-manage post-surgical care under the following conditions. These guidelines comply with applicable state and federal statutes and regulations regarding co-management of patient care and referral arrangements. 1. The patient will determine their preference of a post-op care provider, so long as it s medically advisable. The desire to return to the co-managing ECP must be determined by the patient prior to surgery. 2. A Co-Management Consent Form is required for all patients choosing care with a provider other than the NVISION team of doctors. This consent is taken prior to surgery. 3. Cataract Co-Management is not a routine policy for all patients. It must be discussed with each patient, if applicable. 4. ECP doctors will be Doctors of Optometry, ODs, and Doctors of Ophthalmology, MDs, licensed to practice. 5. The selection of an operating surgeon for a referral patient will be based on providing the best potential outcome for the patient. 6. The transfer of post-op care will always be clinically appropriate and depend on the particular facts and circumstances of the surgical event. 7. Following surgery, transfer of care from the surgeon to an ECP will occur when clinically appropriate, at a mutually agreed upon time or circumstance. Such time will be clearly documented in the Transfer of Care Form and included in the patient s medical record, and copied to the ECP. 8. The surgeon and the ECP will communicate during the pre- and post-op period to ensure the best possible outcome for the patient. 9. In case the patient wishes to be co-managed, compensation for care will be commensurate with the services provided as legally permitted by the third party payer. a. Cases involving care for Medicare beneficiaries will reflect the proper use of modifiers and other Medicare billing instructions for IOL procedures. 10. Compensation for post-op care patients with Astigmatism Management and/or Presbyopic Correcting IOL procedures, with or without Medicare, will not require the use of modifiers, as this will be co-managed as elective refractive surgery procedure with NVISION. 11. The ECP will send the proper follow-up documentation to the NVISION surgeon following each visit with the patient during the co-management period. Step-bystep instructions and co-management forms are provided in the following pages of this document. 12. NVISION retains the right to change post-cataract formularies based on new technologies or medicines. NVISION will communicate those changes to the ECPs when implemented. 13

17 STEP-BY-STEP PROCESS FOR IMPLANT SURGERY CO-MANAGEMENT THE PATIENT IS IN YOUR OFFICE 1. Patient is seen by his/her ECP and charged the usual and customary fee for the performed services. 2. The doctor identifies the patient s need for possible cataract/iol implant surgery and completes the Consultation Request Form (CRF). a. A phone call can be made to NVISION while the patient s exam is occurring. The CRF would still be sent to NVISION after the visit is complete. 3. The referring ECP educates the patient about the availability of different IOL technologies to achieve the patient s desired visual outcome and provides the patient with an NVISION Cataract brochure to read before the consultation. FAX THE CONSULT REQUEST FORM TO NVISION 1. Check the I desire to co-manage this patient box on the Consult Request Form before faxing it in. 2. The Patient Care Coordinator at the specific NVISION location contacts the patient and schedules an appointment for a consultation. 3. The referring ECP will be notified of the date of the consultation appointment, or the reason the patient declined to book the appointment. THE PATIENT MEETS THE NVISION SURGEON 1. The patient is examined by an NVISION surgeon who determines the medical suitability for IOL implant surgery and a treatment recommendation, and lens type is discussed and determined. This visit is a comprehensive new patient visit in which the patient is typically dilated. 2. The patient is scheduled for surgery and any necessary pre-op testing. The surgeon and surgical staff will provide educational materials and consents on the procedure, give the patient instructions, and review fees. 3. The co-management process is discussed with the patient. The patient will be given the option of having the post-op care provided by the ECP. The following documents are completed and signed by the patient: a. Surgery Schedule/Fees b. Informed Consent documents c. Co-Management Consent Form d. Other forms as necessary NVISION KEEPS YOU INFORMED 1. The surgeon will communicate the results of the consultation to the ECP. 2. The Surgery Coordinator faxes the completed Consult Results Fax to the co-managing ECP advising of the date of surgery, patient findings and pre-operative protocols. A post-op Calendar is faxed. PATIENT HAS SURGERY AT AN OUTPATIENT SURGICAL CENTER OR HOSPITAL 1. The Surgery Results Fax is sent to the ECP office which signifies actual surgery performed, type of lens implanted, if astigmatism management was performed, and patient insurance type. It will also signify the next scheduled visit for the patient. The ECP will receive this fax the day AFTER the procedure, in most cases. 2. After surgery, at the 1-day post-op examination, the surgeon will communicate the post-op results by fax to the co-managing ECP. 3. The patient will be transferred to the ECP once their condition is deemed to be stable by the surgeon. This will typically occur at 1-day to 1-week post-op, depending on the patient. PATIENT IS TRANSFERRED BACK TO YOUR OFFICE 1. The Transfer of Care Form, Post-op Exam Form, and the Post-op Patient Instructions will also be sent to the ECP. 2. The patient is seen in the ECP office based on the time frame designated by the surgeon. The co-managing ECP completes a Post-op Exam Form with the findings of the visit and faxes the letter to the surgeon at NVISION following each visit. 3. The co-managing ECP will submit the appropriate claim to third party payers or prepare patient billing for his/her portion of the post-op treatment, if applicable. a. This billing can occur after the patient s first visit with the ECP following IOL implant surgery. b. Billing for post-op care from Medicare requires the co-managing ECP to be a Medicare provider. The ECP may bill Medicare for pseudophakic spectacles following cataract surgery. c. For help with billing, see our Optometrist Guide to Billing after Cataracts. 4. The necessary information for billing the ECP s portion of the co-managed care is located on the Transfer of Care Form. a. Many third party private insurances do not recognize modifier codes for post-op co-managements. NVISION will see these patients within the 90-day period, and refer back to ECP for glasses. 14

18 POST-OPERATIVE CATARACTS AND INTRAOCULAR SURGERY POST-OP EXAMINATION Patient will be seen by NVISION until transfer of care communication is sent to the Affiliate. This can occur at any time during the 90-day global post-op period, once the patient is considered stable, but not sooner than 1 to 2 weeks post surgery. Contact your local NVISION center to learn about the NVISION surgeon(s) with whom you are co-managing your patients. ROUTINE IOL POST-OP: Monocular VA, distance and near Pinhole if VA < 20/30 IOP MR 1 wk, 1 mo Rx prn SLE: Check incision, cornea, AC, IOL position, PCO Suture removal at 2 wks post-op, if applicable Review medications and patient s visual recovery/expectations Fax exam to NVISION 1 DAY ROUTINE IOL POST-OP 1 WEEK ROUTINE IOL POST-OP: Manifest refraction; refer back to NVISION if suture is present. 1 MONTH ROUTINE IOL POST-OP: Manifest refraction; Toric IOL patients require dilation to compare the rotation of the lens with the axis of the corneal astigmatism; if any decrease in VA, dilate looking for PCO/CME. 3 MONTH ROUTINE IOL POST-OP: Manifest refraction, prescribe residual glasses (if applicable); if any decrease in VA, dilate looking for PCO/CME, refer back for refractive sx management. 6 MONTH (EXTENDED PERIOD FOR ASTIGMATISM AND LIFESTYLE LENSES): Routine IOL post-op; manifest refraction, if residual correction present, refer back for refractive sx management. All post-op visits must be faxed or ed back to NVISION for review. Co-management of patients is decided on a case-by-case basis and occurs when medically appropriate. For details about possible post-op findings, please refer to the post-op Guide (located in the NVISION Answer Box). MEDICATION PROTOCOL FOR INTRAOCULAR SURGERY Also, contact your local NVISION center and surgeon to learn more about post-op care. NOTE: Ranges given for drop frequency and start date due to variations in drop brands and surgeon preference. Please refer to the specific NVISION center you work with for more detailed instructions. PRE-OP Antibiotic: 2-4 times a day for 1-2 days prior to surgery Steroid: 2-4 times a day for 1-2 days prior to surgery NSAID: 1-3 times a day for 1-2 days prior to surgery POST-OP Antibiotic: 2-4 times a day for at least 2 weeks following surgery Steroid: 2-4 times a day for at least 2 weeks following surgery, tapering 2 times a day for the next 2 weeks NSAID: 1-3 times a day for 4 weeks following surgery Additional topical drops for the management of elevated intraocular pressure as needed. As mentioned earlier, the patient will be returned to the ECP practice after stability has been achieved. Contact your Area Manager for a copy of NVISION s Cataract Program Co-Management Policy. 15

19 QUICK GUIDE STEP-BY-STEP PROCESS FOR CATARACT CO-MANAGEMENT THE PATIENT IS IN YOUR OFFICE You diagnose a cataract You discuss possible options including ORA, LenSx, Lifestyle Lenses and Astigmatism Management FAX THE CONSULT REQUEST FORM TO YOUR NVISION CENTER THE PATIENT MEETS THE NVISION SURGEON The NVISION surgeon will determine the lens technology best suited for your patient Patient schedules for surgery and any necessary pre-op testing (performed at NVISION) NVISION will provide educational materials, consents on the procedure, give the patient instructions, and review fees NVISION KEEPS YOU INFORMED The center communicates the completed evaluation results to your office, including: Date of surgery Patient findings Pre-op protocols Post-op calendar (varies depending on lens type) PATIENT HAS SURGERY AT AN OUTPATIENT SURGICAL CENTER OR HOSPITAL The surgical results are sent to your office and include: Actual surgery performed Type of lens implanted If astigmatism management was performed Patient s insurance type The post-op patient medications PATIENT IS TRANSFERRED BACK TO YOUR OFFICE Once their post-op is deemed stable by the surgeon Typically occurs at 1 day to 1 week post-op YOU GET THE INFORMATION YOU NEED The Transfer of Care Form Post-op Exam Form THE PATIENT IS SEEN IN YOUR PRACTICE You complete a post-op exam form and fax to NVISION following each visit APPOINTMENT HOTLINE: (888)

20 QUICK GUIDE STEP-BY-STEP PROCESS FOR LASIK CO-MANAGEMENT THE PATIENT IS IN YOUR OFFICE You discuss the value of a free consult and the patient s options You may mention new bladeless LASIK with the Femto LDV TM FAX THE EVALUATION REQUEST FORM TO YOUR NVISION CENTER THE PATIENT MEETS THE NVISION SURGEON Patient is seen by the NVISION surgeon and/or clinical director Patient schedules for surgery and any necessary pre-op testing NVISION will provide educational materials, consent on the procedure, give the patient instructions, and review fees NVISION KEEPS YOU INFORMED The Surgery Coordinator faxes or s the completed Consult Results: Date of surgery Patient findings Pre-op protocols Post-op calendar PATIENT HAS PRE-OPERATIVE VISIT AT YOUR OFFICE Manifest and Cycloplegic Refraction are performed Visit information is sent to NVISION PATIENT HAS SURGERY AT AN NVISION SURGICAL CENTER The Surgery Results Fax is sent to the ECP and includes: Actual surgery performed PATIENT IS TRANSFERRED BACK TO YOUR OFFICE Typically occurs at 1 day post-op THE PATIENT IS SEEN IN YOUR PRACTICE Follow-up exams in your office at 1 day, 1 week, 1 month, 3 months, 6 months, 1 year (not including annual eye exams) You complete a Post-Op Exam Form and fax to NVISION following each visit The patient returns annually to maintain the VISION for LIFE Commitment Program APPOINTMENT HOTLINE: (888) LECC / NVISION Eye Centers. All rights reserved. Reproduction of any content herein requires the express written permission of NVISION Eye Centers.