Defining Comanagement Roles

BY JAMES V. AQUAVELLA, M.D.
MAR. 1996

PRK is much more than the delivery of laser energy. It also involves determining appropriate candidates for the procedure, informing patients of their options for surgery, and coordinating postoperative care.

It's essential that M.D.s and O.D.s in comanagement relationships share the same philosophy and approach to refractive surgery, particularly regarding patient selection. They must agree on what levels of myopia and astigmatism should be treated, as well as the relative merits of RK, PRK, contact lenses or spectacles for each patient.

PREOPERATIVE EVALUATION

The optometrist is best suited to help patients determine their goals and expectations. For instance, they can help determine if a patient should be emmetropic after treatment, or if a slight undercorrection or even monovision is preferable.

A comprehensive preoperative optometric evaluation should include:

• assessing the stability of the myopia;
• determining the results of the cycloplegic examination; and
• withholding contact lenses prior to surgery.

Referring optometrists must provide patients with reasonable expectations and also be prepared to answer questions about the discomfort associated with the procedure, the routine postoperative course and the financial responsibilities.

POSTOPERATIVE CARE AND FOLLOW-UP

The M.D. and the O.D. must be comfortable with their roles during the postoperative period when they evaluate the integrity of the epithelium, the stromal healing process, the degree of haze, the refraction and the titration of medications.

For example, once the integrity of the epithelium has been re-established after excimer laser surgery, it will still take several weeks to re-establish a completely normal epithelial pattern. During this early period, some refractive hyperopia is normal, however, excessive hyperopic shift in the early postsurgical period may indicate the need to reduce the frequency of steroid administration. Conversely, if there is minimal hyoperopia or even residual myopia, this may be enhanced by increasing the frequency of postoperative topical steroids. Haze will also respond to topical steroids.

Considering these variables, the M.D. and the O.D. who are monitoring postoperative status must communicate effectively and agree on the overall philosophy of postoperative management.

DISCUSSING FEES

Comanaging partners must also agree on how professional fees will be allocated. Patients should realize that, of the total fee, a percentage accrues to the O.D. for preoperative and postoperative evaluation, a percentage accrues to the M.D. for the surgery and some postoperative care, and a third portion accrues to the laser center for the technical/facility component. All parties should agree upon the time frame during which the patient is not charged additional fees. If the patient needs re-treatment, be sure to discuss any additional fees early in the process.

Key to developing a successful refractive surgery team is clearly defining the responsibilities for each aspect of the preoperative, operative and postoperative management.

Welcome to the new world of O.D./M.D. cooperation. CLS

Dr. Aquavella is chairman of the Genessee Valley Eye Institute and director of the corneal research lab at the University of Rochester.