One additional step might be valuable in negotiating partnership agreements: Make sure to include spouses in any negotiated agreements, including signatures.


Step 8: Get Your Spouse to Sign On

7 Steps to a Winning Partnership Agreement (November 2008) was very well presented and informative.

I have one additional step (to make it 8) that might be found valuable in negotiating partnership agreements: Make sure to include spouses in any negotiated agreements, including signatures.

Spouses can become very influential in future partnership decisions with financial demands on a partner that can influence important business decisions, as well as partnership relationships. It can lead to a partnership desolation.

Howard Levenson, O.D.

San Rafael, Calif.


Points on Pre-Op Comanagement

Preoperative Comanagement of Cataract Surgery Patients (November 2008), part 6 of your Back to the Basics series, was an extensive discourse on the topic, but I found several points with which to take issue.

The coverage of risk factors citing studies of Chesapeake Bay watermen and Blue Mountain eyes may be helpful in Massachusetts and Australia, but they dont matter a great deal when examining folks in the Southeast. The only real question is: Does this patient in my chair have a visually significant cataract? If it is unusual in presentation due to age or clinical appearance, an expanded history and examination is warranted.

Corneal topography can indeed uncover otherwise undetected corneal disease. Nice, but again, not required information from the referring doc. Astigmatism can

easily be picked up with keratometry readings as included with IOL calculation or by manual keratometer. Should any of these measurements be inconsistent or of significant amount, it is the responsibility of the surgeons practice to add topography to the mix.

Neuro-ophthalmic status is checked on every patient. However, having a cataract does not require color vision and threshold visual field testing unless the vision loss is not consistent with the degree of cataract observed. Confrontation field testing is adequate in the absence of observed pathology. 

It is good to grade the lens opacity. Photodocumentation of the lens is not requireda simple note in the chart will do. Neither is photodocumentation of pupil size required. Again, a simple note in the chart and heads up to the surgeon on patients with small pupils (less than 5mm) post-dilation is all that is needed. Also, patients with small pupils are at greater risk for surgical complications and surgery may take longer. Making the surgeons office aware of this helps them more appropriately schedule your patients.

Baseline gonioscopy is required in examination of all glaucoma patients and those with narrow angles. If phacomorphic narrowing of the anterior chamber is observed, then gonioscopy is indicated. However, the mere presence of a cataract does not require that gonioscopy be performed.

Cataract surgery is not always controversial in the presence of retinal disease. The basic principle remains: Is the cataract causing or contributing to the vision loss and will surgery make it better? That said, a complete retinal exam by the referring O.D., surgeons office or retinal specialist is warranted to detect and treat coexistent retinal pathology and to set post-op vision expectations.

Ultrasonography is likewise not required of the referring O.D. for the purpose of IOL calculation. Indeed, most surgeons would prefer these measurements and calculations be performed in their office.

Modern day cataract surgery using topical-only anesthesia in an ambulatory surgery, by far the most cost effective and safest surgical delivery system, has also changed the requirements for pre-op history and physical. Communication between the referring O.D. and surgeon, the hallmark of comanagement, will allow the patients to have only the pre-op tests they need performed rather than a mindless list of standard tests set by a hospital surgical department. Moreover, many of the pre-op testing is time-specific. It expires after a certain window of time. If the surgery date is set for after the expiration on the history and physical form, the tests must be redone. This is a needless waste of health-care dollars. So, either let the surgeons office request those tests they need or become familiar with what the surgeon needs and order appropriately.

The delivery of excellent cataract comanagement requires good communication between the referring doctor and the surgeons office. This allows each to provide their own special services without needless duplication of testing and ordering superfluous testing. It results in excellent patient outcomes and the most prudent use of health-care dollars.

Howell M. Findley, O.D.

Lexington, Ky.

Vol. No: 146:02Issue: 2/15/2009