Establishing a Practical Collaborative Care Protocol

Although the 2009 pop-rock hit “Two Is Better Than One” by Boys Like Girls and Taylor Swift isn’t about the collaborative care of cataract and refractive surgery patients, the song’s title easily applies to this relationship. What’s more, the success of this relationship is contingent on the OD and MD fulfilling their full roles. For us, this means preparing patients for these procedures and communicating with their surgeons regarding preoperative data and the patient’s visual desires. In recognizing the importance of our role in postoperative success, we created a collaborative care protocol, discussed here.

OUR TECHNICIANS COMMUNICATE SUSPICIONS

Working in a tertiary referral center for surgical care, technician training is of the utmost importance. To start, techs are detectives when it comes to listening for patient phrases such as, “I’m having trouble driving at night,” as these phrases tend to signal the need for a discussion with our ophthalmic colleagues about cataract surgery. Regarding refractive surgery, techs know that phrases such as, “I’d like to lessen my dependence on glasses,” or “I’m struggling to wear my contact lenses for a full day” are a clue the patient may want surgery. 

Finally, we have trained our technicians to perform the standardized tests for cataract and refractive surgery candidacy. These include refraction, biometry, corneal topography/tomography, and tonometry. Training our technicians to listen for these phrases and perform these standardized tests reduces chair time by eliminating unnecessary back and forth, which can disrupt clinic workflow.

WE OPTIMIZE THE OCULAR SURFACE

We recognize how crucial the health of the ocular surface is for improving the accuracy of biometry measurements and, ultimately, a patient’s long-term visual and ocular comfort outcomes. As a result, we are sure to look for and treat dry eye disease prior to either surgery (see “Prepping the Ocular Surface for Cataract and Refractive Surgery”). Additionally, we have found that doing so has the potential to preclude the need for spectacle wear in the patient who chooses a premium IOL. 

WE LOOK FOR SURGICAL RED FLAGS

In the case of precataract surgery patients, we keep an eye out for glaucoma, as patients who have this condition may benefit from a minimally invasive glaucoma surgery during the procedure. Of note: Subtle binocular vision anomalies may require prism after cataract surgery to maintain binocularity, so we include this in the surgical referral form(discussed later) to the surgeon. We look for pseudoexfoliation due to poor dilation and/or weak zonules. We look for certain systemic medications, such as selective alpha-adrenergic antagonists, or causes of floppy iris syndrome/poor dilation. We look for Fuchs corneal dystrophy on the transplant side. We also look for epithelial basement membrane dystrophy, Salzmann nodular degeneration, etc. This is because these diagnoses may require unexpected corneal procedures, such as a superficial keratectomy or phototherapeutic keratectomy. Additionally, these diagnoses can complicate surgery, prolong recovery, and decrease patient satisfaction with either procedure. 

Further, we are mindful of ongoing refractive instability and habitual eye rubbing, as these characteristics may indicate underlying issues, such as forme fruste keratoconus, or a risk of undesired postrefractive surgery vision changes.

WE SET PATIENT EXPECTATIONS

In discussing cataract surgery itself, we explain to the patient the potential complications, such as IOP changes, corneal edema, dysphotopsias, macular swelling, and recurrent uveitis and the characteristics of their IOL options. As an example, we educate the patient that while multifocal IOLs are designed to decrease the need for wearing glasses, patients have also reported halos around lights (see “Educating Patients on IOL Options”). In talking about refractive surgeries, such as LASIK and photorefractive keratectomy, we educate the patient on the risks (eg, infection, etc.), that no refractive surgery guarantees “perfect” vision or halts the aging of the eye, and that they can expect temporary postoperative symptoms, such as burning and foreign-body sensation (see “Identifying Ideal Candidates for Refractive Surgery”). By setting these expectations before the surgical referral, we often find that patients are not surprised or, therefore, dissatisfied with either procedure, should they experience any of the above.

WE USE A SURGICAL REFERRAL FORM

We further streamline the referral process by using a surgical referral form that concisely provides the critical details the surgeon needs to move forward with either surgical consultation (Figure). We find that establishing this closed-loop communication between the referring OD and the surgeon’s office provides that seamless transition these patients desire. Additionally, we have discovered that this form has facilitated the creation of a foundation for seamless communication, especially when urgent postoperative complications, such as an IOP spike, arise (see “Cataract Surgery: Identifying Postoperative Adverse Events”).  

• Pro Tip. We suggest establishing open, regular feedback with the surgeons you communicate with to discuss potential ways of strengthening the relationship.

WE CLARIFY NEXT STEPS

Finally, when the cataract or refractive surgery patient is scheduled to return to our care, we personally follow up with the surgeon to ensure we are on the same page regarding the recovery timeline, postop medication taper schedules, enhancement/referral thresholds for patients wanting more from their postop vision, as well as postop ocular dryness management. 

• Pro Tip. As the OD, it is important to receive a “release of care” document that transitions the postop billing and coding to you.

THE ULTIMATE GOAL

The ultimate goal of this collaborative care protocol is to ensure we play our part in the process, so patients feel supported through their surgery journey. Our approach has increased clinic workflow efficiency, patient confidence, and, ultimately, practice growth, showing two is, indeed, better than one when it comes to cataract and refractive surgery.