Mapping the OD’s Role in Follow-Up Care

It has long been said—and I agree—that optometry must start adopting more of a medical model. Many optometrists already practice this way, the goal is for more to embrace it. The need for optometry to take on a greater role in medical eye care is driven by an aging population, a rising prevalence of ocular disease, and stagnation in the number of practicing ophthalmologists.^1-3 This requires the delivery of eye care, from a public health perspective, to shift and rely on a clinical care team to helpfully treat and manage patients to ensure their vision and ocular health are maximized.

SUCCESS IN COLLABORATIVE CARE

There are many successful comanagement centers across the country, but I believe the most successful ones partner with optometrists and use them to their fullest capacity. In other words, these centers ensure that each provider practices to the top of their licensure and does only what the doctor can do—meaning that beyond the provider, there must be a strong clinical support staff to help care for the patient.

A successful practice arrangement is built on relationships. There must be a strong and open relationship between the ophthalmologist and optometrist that generates seamless communication and sharing of clinical questions or complications between the two providers. Feedback, both positive and negative, is important for learning and growth and ultimately leads to better patient outcomes.

If we use a person as an analogy to represent a patient care team, the optometrist would be the eyes and ears, while the surgeon would be the hands. I will explain how this management arrangement works in clinical practice, specifically with regard to cataract surgery, but the same concept is applied in our practice to cornea, glaucoma, retina, and oculoplastic procedures.

An Example Scenario

Let’s say a local optometrist refers a long-time patient whose visual requirements they are well acquainted with to our center. The referral note indicates that the patient has been happy wearing multifocal contact lenses for the past 10 years, but has begun having difficulty reading fine print due to an advancing cataract. This information is valuable to the providers at the surgical comanagement center to ensure the patient’s refractive outcome is successful. Note: We do not have an optical, nor do we write glasses or contact lens prescriptions.

The patient is scheduled for a cataract evaluation with one of the nine consultative optometrists at our clinic who support five anterior segment surgeons, three retina surgeons, and one oculoplastic surgeon. The consultative optometrist performs a complete cataract evaluation with all preoperative measurements, including optical biometry and corneal topography, as well as a full comprehensive examination to ensure all insurance requirements are met for the surgery and that the patient will benefit from cataract surgery (ie, has no underlying ocular conditions that could potentially limit their visual outcome). If there are any ocular diseases, the consultative optometrist identifies and treats the condition in conjunction with the referring optometrist. Additionally, the consultative optometrist, being the eyes from our analogy, makes notes of any findings that could affect the cataract surgery itself (eg, pseudoexfoliation syndrome causing loose zonules, small pupils secondary to tamsulosin [Flomax], which increases the risk of intraoperative floppy iris syndrome, or posterior polar cataracts, resulting in an open posterior capsule). These findings alert the surgeon of potential risks and determine whether the surgery should be performed under topical or a local block anesthesia to allow the surgeon to have better control of the eye during the procedure.

Next, the consultative optometrist discusses the entire cataract surgery with the patient, including what to expect during the surgery, the risks and benefits associated with the procedure, any alternatives if available, and expected outcomes. If a decision is made to move forward, then the conversation turns to the patient’s desired refractive outcome. The consultative optometrist will listen to the patient’s goals (also being the ears in the analogy) and, with the information provided by the referring optometrist, determine which type of intraocular implant would be best for this patient.

In this case, because the patient was a successful multifocal contact lens wearer, we would recommend a multifocal IOL to achieve the patient’s goal of spectacle independence. Current IOL technologies are great, but there are drawbacks to everything, and the pros and cons should be discussed (and documented) with each patient during the preoperative examination in order to manage expectations. After all the patient’s questions are answered, the patient speaks with our schedulers to pick a day and time for their surgery and to discuss surgical costs.

On the day of surgery, the patient meets the surgeon at the surgery center, where the desired procedure is confirmed and any last-minute questions are addressed. The surgeon then performs the surgery (being the hands from our analogy), and if all goes routinely with no intraoperative complications and the patient has chosen to be comanaged, they are sent back to the referring optometrist for the 1-day postoperative visit. The patient returns to the comanagement center only if a complication arises or if they need surgery on the second eye.

If the patient is not comanaged by the referring OD, one of our consultative optometrists sees the patient for the 1-day postoperative visit to ensure there are no complications and that the IOP is appropriate. If any issues, such as elevated IOP, increased corneal edema, or corneal abrasions arise, then care of the patient is handled by the consultative optometrists in the clinic, unless the patient needs to return to the OR for an additional procedure.

AN IDEAL SCENARIO

A setting in which optometrists manage the clinic and ophthalmologists spend most of their time in the OR allows each provider to practice at the top of their licensure. It can also increase the efficacy and efficiency of eye care delivery and maximize the financial reimbursement for everyone involved.

Several comanagement centers across the United States use the type of practice model described in this article, and I hope it will be adopted by more optometrists and ophthalmologists to meet the rising demand for eye care. To achieve this, both providers need to work together in a more cohesive way regarding education. The information taught to optometrists and ophthalmologists is not different, but we can do a better job sharing it between professions to ensure that everyone is trained to the highest level, which ultimately benefits and increases patient outcomes. Furthermore, compensation structures for ODs and MDs need to reflect the equivalent level of work in clinic and not create a tiered provider system. The model would be a win-win for all involved and promote synergistic partnerships between the optometrist and ophthalmologist.