In this episode of Interventional Mindset, Dr. Jonathan Solomon and Dr. Preeya Gupta collectively discuss the vital components of getting started with office-based cataract surgery. As owners of surgical suites, these surgeons share their tips and tricks that have allowed them to provide the best care.
Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.
Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.
Transitioning to office-based ophthalmic surgery
Each year, approximately 3.7 million of today’s cataract surgeries may occur in ambulatory surgery centers (ASC) or a traditional hospital setting.1 In the early years, an ASC allowed surgeons to break away from the hospital.
They were able to perform cataract procedures in an environment where they had some level of control over their selection of intraocular lenses (IOLs) and surgical staff, coupled with the idea of customized patient care.
As healthcare has continued to evolve, the tailored surgical experience has changed, too. The prospect of bringing surgery in-house has piqued some surgeons' interest in office-based ophthalmic surgery to create a personalized experience during the patient’s cataract journey.
Let’s take a further look at how Drs. Gupta and Solomon have taken an interventional mindset in how they approach certain facets of the office-based cataract surgery experience.
Sedation protocols for office-based cataract surgery
The core principle of sedation for cataract surgery is to allow the patient the ability to remain conscious but also to be relaxed with minimal to no pain throughout the procedure. With this thought in mind, administration of 1 to 2mg of Xanax (Alprazolam) orally is a common standard in the operating room (OR).
After initiating 1mg of Xanax, an additional dose is administered after 20 to 30 minutes if the patient does not seem sedated enough and is still exhibiting some anxiety or nervousness.
Xanax can be a fast-acting drug with an even, slow-rise onset, states Dr. Solomon, though this can differ based on the patient’s gastrointestinal (GI) status. Unlike in an ASC setting, where patients fast prior to operations, office-based operations do not require patients to take nothing by mouth (NPO) ahead of surgery.
Further, Drs. Gupta and Solomon have not observed significant memory loss in patients when administered Xanax prior to surgery. Constant verbal and physical communication peri- and post-operatively the procedure by the surgeon and surgical staff can also assist in preserving memory.
Preventing oversedation during office-based cataract surgery
Patients are given local anesthetic eye drops to numb the eye marked for surgery around the same time as sedation. If patients are given their sedatives too early, they may become oversedated by the time of operation. In his professional medical opinion, Dr. Solomon believes patients can often experience oversedation, which could lead to a loss in patient cooperation during surgery.
Although these medications tend to be given in small doses, it is recommended to be mindful of the selected sedative, namely fentanyl, to manage the addiction risk profile. Dr. Gupta maintains in her surgical experience that during these relatively short cases, patients can tolerate sedation rather well.
Patient selection for office-based ophthalmic surgery
Not all patients may be an appropriate fit for office-based ophthalmic surgery. When evaluating each case, surgeons can “feel out” whether a patient is well-suited for a particular setting to ensure a favorable surgical experience. Invariably, some patients may fare better in an ASC where they could be administered intravenous (IV) sedation and possibly have greater access to staff.
Some patients have a tendency to squeeze their eyes during surgery, especially if they have not reached an optimal level of sedation, which can increase the difficulty of the procedure. Though Dr. Gupta has adjusted her technique to work around this challenge, she is thoughtful in her approach by exercising appropriate surveillance of pain management for her patients.
Tip: Dr. Gupta’s pre-operative protocol includes light palpation around the eyes to check for heightened sensitivity (squeezing and flinching), which could be a barometer for how the patient may respond during surgery.
Utilizing biometry to identify risk factors for cataract surgery
Analyzing certain biometry factors can guide the surgeon in the patient selection process for cataract surgery. Characteristics of a patient’s anatomy, such as short axial length, ocular surface instability, or suspicion of corneal ectasia, may be a risk factor for cataract surgery.
If the case is erring on the side of mounting complexity, it may be prudent to take a conservative approach by electing to operate in an ASC primarily for access to skilled surgical staff and overall resources.
This is not to say that office-based ophthalmic surgeries are less safe than ASC operations. In fact, research has demonstrated that they are considered equivocal for efficacy and safety, with the former oftentimes even more efficient.1
Preparing your surgical suite for office-based ophthalmic procedures
To potentially improve post-operative outcomes for office-based ophthalmic surgery, staff preparedness, and appropriately maintained equipment can be considered a high priority during the integration of this model.
Selecting staff for office-based ophthalmic procedures
Identifying members of your staff who might be candidates for the surgical team is a crucial first step to running a seamless office-based surgical operation. Just one experienced and attentive staff member can make a difference in assisting the surgeon during an operation.
On her team, Dr. Gupta has a technician and a staff member who only spend time in the OR to assist her during operations. A dedicated OR staff isn’t always necessary, though, especially for practices that only operate once a week. Exposing staff members to the nuts and bolts of cataract surgery can empower them to gain both confidence and a greater appreciation of the procedure.
Further, it may provide staff with a better understanding of the journey patients undergo, which could improve the quality of care delivered across the practice. This can also encourage staff to explore something new, creating a meaningful learning environment at the practice.
Buying necessary equipment for office-based ophthalmic surgery
It may be expensive to purchase advanced equipment, but this investment can set up surgeons for success as they operate in a setting with tools that allow them to feel the most comfortable and confident in their surgical skill set.
There are various ways offices can offset some of the cost when acquiring new equipment, such as renting or taking advantage of tax depreciation mechanisms. It is recommended to consult with surgical equipment manufacturers and your trusted accountant to understand payment terms and tax regulations, respectively.
Conclusion
When looking at the big picture of possibly integrating office-based ophthalmic surgery in your practice, it comes down to several key points:
- Patient selection
- Proper sedation protocols
- Use of optimized and appropriate surgical equipment
- Investing in staff training
While the adoption of this office-based surgical model might initially create some operational growing pains, the dividends can be reaped long term.
As surgeons and their staff gain confidence in delivering a personalized cataract surgery experience, this can become a stepping stone to expand service offerings to patients, such as microinvasive glaucoma surgeries (MIGS) and ocular aesthetics, all in the comfort of your own office.
The key to having an interventional mindset is always to look to push yourself forward and keep an open mind to disruptive models such as office-based ophthalmic surgery—in the name of patient care.
