SECO University Blog

The honorees for the 2019 Best Practices program were announced in a special Facebook Live session from Vision Expo East on March 25th.

Now in its fourth year, CooperVision’s Best Practices program recognizes and celebrates practices in the U.S. that go above and beyond to find ways to differentiate themselves and deliver extraordinary care to their patients, even in the face of increasing competition.
“Best Practices is one of the many ways CooperVision partners with eye care professionals,” said Michele Andrews, OD, Senior Director of Professional and Academic Affairs, North America, CooperVision. “Year after year, we continue to be captivated by so many optometry practices. From what motivated the honorees to open their doors to the patient lives they have since impacted, from the challenges they have faced to the risks they have taken to overcome them—it is endlessly rewarding to hear their stories, and partner with these practices to share them more broadly. It is our hope that their varied experiences can help inspire other eye care professionals to perhaps try a new approach, implement meaningful changes, and find even greater success in their own practices. Congratulations to our 2019 Best Practices honorees.”

Honorees come from practices large and small, newer and well-established. This year’s honorees are:

• Azman Eye Care Specialists / Global Complex Eye Care – Timonium, Md.
• Briggs Vision Group – Dunwoody, Ga.
• Drs. Quinn, Foster & Associates – Athens, Ohio
• Lakeline Vision Source – Cedar Park, Texas
• Northeast Ohio Eye Surgeons – Kent, Stow, and Akron, Ohio
• Shoreline Optometry – Mountain View, Calif.
• Spring Hill Eyecare – Spring Hill, Tenn.
• Vancouver Vision Clinic – Vancouver, Wash.
• Vision Source of Farr West – Farr West, Utah
• West Shore Eye Care – Ludington, Mich.

The honorees will convene for the first time at the 2019 Best Practices Summit in Austin, Texas later this month. An overview of the Best Practices program was recently released on OD Wire TV. Future OD Wire TV episodes will provide an opportunity for this year’s honorees to share about their areas of interest and expertise… and what makes each of their practices a Best Practice. For ongoing updates about this year’s honorees and the group’s activities, bookmark the Best Practices category page on CooperVision’s ECP Viewpoints℠. Applications for the 2020 Best Practices program will open this fall.

Congratulations to the 2019 Best Practices honorees!

Richard E. Castillo, OD, DO

 

INTRODUCTION

Optometric physicians in states with an advanced scope of practice can choose from several modalities for incising, ablating, or tightening tissue when performing office surgery. Experience, the nature of the procedure, and the type of tissue under consideration, such as the thin skin of the eyelid or the thicker periocular skin, as well as cost, can all impact the choice of instrumentation selected.  With the possible exception of ophthalmic lasers, no other piece of modern technology has influenced the evolution and practice of procedural optometry as has office-based radiosurgery.
 

RADIOSURGERY EXPLAINED

Modern radiosurgery involves a radio-wave generator (Fig 1) that emits a 4-MHz radio wave that travels from a wire fitted handpiece (active electrode) through the patient to a ground plate (passive electrode) placed underneath or nearby the patient.  The bioelectrical impedance (resistance) of human tissues to the radio wave transmission causes a combination of selectable tissue desiccation, protein coagulation, and intracellular cytoplasmic liquid-to-gas conversion with resultant rapid volume expansion which causes the cell to explode (volatilize) at the point of contact with the active electrode. In effect, a combination of cutting, coagulation (hemostasis) and tissue desiccation (fulguration) modes are selectable.  A decided advantage for optometric surgeons lies in the fact that collateral tissue damage can be minimized or carefully controlled by proper technique and appropriate selection of waveforms.

The optometric surgeon creates a radiosurgical incision by using a smooth continuous motion at an ideal speed of ~ 7mm per second. Unlike a scalpel, a radiosurgical electrode wire cuts without any downward pressure. The configuration of the active electrode, its contact time with the tissue, the intensity of power, waveform mode, along with the frequency determine the quality of the incision.

 

THE ACTIVE ELECTRODE

The active electrode wire delivers energy into the tissue at the point of contact when the device is activated (Fig. 2).  It is used to cut, coagulate tissue, or both.  Many electrode configurations, including several uniquely designed for optometric procedures such as lid lesion removal, punctal occlusion, and follicular ablation (for the treatment of trichiasis) are available. The optimal electrode configuration depends on the intended procedure and the optometric surgeon’s experience and preference.

Ergonomically designed electrodes favor the optometric surgeon while performing specific procedures. For example, small loop electrodes are particularly useful for removing small papilloma’s, raised nevi, and other benign periocular lesions. RS tissue ablation, shave biopsies, and incisional or excisional biopsies can efficiently be performed.  Careful ablation techniques allow for the precise and deliberate volatilization of cutaneous lesions with little to no involvement of normal lid structures.

Trichiasis is correctable via RS follicular ablation and a 0.004″ insulated needle electrode inserted along the hair shaft directly into the lash follicle.  Direct destruction of the hair follicle with little to no trauma to the hair shaft provides for post-procedure patient comfort and significantly minimizes the incidence of regrowth.

THE PASSIVE ELECTRODE (ANTENNA PLATE)

The passive electrode (Figure 3)  is the antenna plate that receives the radio waves emitted from the active electrode and returns the energy to the device completing the circuit. Unlike an electrocautery unit, the passive electrode is not a grounding terminal and does not have to be in contact with the patient’s skin.  Placing the antenna plate close to the active electrode improves overall efficiency, decreases the power required to cut tissue or coagulate small bleeders, and reduces lateral heat spread minimizing the possibility of collateral tissue damage.

TISSUE CONTACT TIME

The contact time between the active electrode and the tissue is directly proportional to both the energy transferred to the tissue at the point of contact and the amount of lateral heat transferred to the collateral tissues. With all parameters appropriately set, the electrode should move smoothly through the tissue at a rate of about 7mm per second.

POWER INTENSITY

Proper power intensity can be adjusted dynamically throughout the procedure and varies with the hydration status of the tissue being incised or ablated. The optimal power setting allows for adequate heat generation within the target tissue to volatilize cells at the tip of the electrode. With proper power intensity, the electrode passes smoothly through the tissue with little to no sparking, charring or dragging through the tissue.

 

WAVEFORM SETTINGS

Modern radiosurgical devices generally accommodate four waveform settings or modes, in addition to an adjustable power setting or waveform amplitude.  In addition to the four unipolar waveform configurations, many also allow for the attachment of a bipolar coagulation forceps. The bipolar forceps are safer to use on patients with implantable medical devices such as implantable defibrillators and tens units, as the current only travels between the tips of the forceps and is not dissipated throughout the body.

The fully filtered, or continuous, waveform setting yields a smooth cutting action and generates the least amount of lateral heat. Utilizing the continuous waveform setting and a fine-wire electrode produces incisions that are comparable if not superior to that made by the sharpest scalpel.  Clinically, this setting is referred to as the “cut” mode.

The fully rectified modulated waveform dissipates some lateral heat that is useful in hemostasis. This mode is referred to as the “blend” mode (cut/coag).  Because of its combined efficacy at simultaneous cutting and coagulation when used with a large-diameter needle electrode, this blended waveform is excellent for subcutaneous tissue dissection.

The third option is the partially rectified-modulated waveform. This waveform significantly increases lateral heat transmission, resulting in excellent hemostasis. This mode is clinically referred to as the “coag” mode.

The fourth waveform is the fulguration setting, also known as the spark-gap waveform. This most destructive setting is never used on the eyelid, for cutting skin, or on any tissue in which scar formation is to be minimized or avoided.

 

FREQUENCY

Modern radiosurgical devices operate at frequencies of 3.8-MHz to 4-MHz compared to electrocautery and electrosurgical devices which operate at much lower frequencies, in the 300-KHz to the 500-kHz range. The higher RS frequencies result in less lateral distribution of heat from the incision and a more precise application of energy.

ADDITIONAL COMMENTS

The ability to control the degree of lateral heat dissipation is a great advantage to the optometric surgeon in that damage to the adjacent periocular tissues is minimized while at the same time procedural hemostasis is enhanced.  RS devices can be fine-tuned to generate controlled amounts of lateral heat to seal not only small vascular vessels but also lymphatics, reducing intraoperative and postoperative edema. RS electrode wires of varying thickness and shapes are used in combination with the different waveform options to maximize these beneficial effects.

Two final considerations are the need for a high-efficiency smoke evacuator and overall equipment cost. As of this writing, RS devices run anywhere from $6000 – $60,000, depending on the options and global capabilities of the devices purchased.  A known disadvantage of radiosurgery is that particulate smoke is generated during the procedure. An OSHA-compliant electrosurgical smoke evacuation system must be utilized. Care must be taken to avoid using alcohol or other flammable substances when preparing skin if RS electrodes will be employed.

 

CONCLUSION

Today’s optometric physicians have several alternatives for making incisions during office surgery. Consideration as to the methods employed and instruments used will be based on the surgeon’s preferences and experience, the particular tissue to be cut, the procedure to be performed, and the cost of equipment.  Radiosurgery offers the optometric surgeon the advantages of efficient incision making along nonlinear contours in highly deformable tissues.  The added benefit of enhanced hemostasis provides a practical solution to creating incisions in highly vascular tissues, such as the eyelids and periocular skin, which in turn contributes toward minimizing complications and maximizing functional and cosmetic outcomes.

 

Richard E. Castillo, OD, DO

Executive Director, ASOS

The Optometric Procedures Institute

www.odslt.com

Offering the best visual solutions to your patients can have a tremendous effect on your practice growth by bolstering your reputation as a “vision problem-solver” in your community. Dr. Britney Caruso of Caruso Eye Care in Lake Worth, Florida recently spoke with us about the impact Biofinity® multifocal has had on her practice growth. Here’s what she had to say.
What initially made you start fitting Biofinity and then continue fitting it based on the experience you had with it?

Dr. Caruso: Well, I was truly reluctant to get into this multifocal market, because monovision seemed so easy. I was afraid that I would not have the same experience with the multifocal. Then my contact lens rep introduced me to other doctors who were having successes with multifocals. I figured if all of these other people are having so much success, I should be able to do the same. I was introduced to some of the clinical pearls, and some basic tips on how to fit the lenses. As soon as I started, I saw how happy the patients were with the lens… it was almost contagious. I saw my practice start to grow, and I realized that fitting Biofinity mulltifocal was linked to practice growth.

Do you find that monovision patients adapt well and are happy with the multifocal versus their old monovision setup?

Dr. Caruso: Absolutely. The younger the patients, the more adaptable they are. But even for my more mature patients who have been wearing monovision lenses for some time transitioning them to the Biofinity multifocal lens is actually quite simple. They are happy with the range it gives them and adapt easily.

What do you think the biggest challenge is then in fitting a multifocal patient?

Dr. Caruso: The biggest challenge is trying to figure out which lens to pick. For most multifocal fit sets, it seems like you have to understand a huge, complex equation: +.025/-0.25, D, N. It is just seems so complicated. With the Biofinity multifocal, as long as you understand a few basics from the fitting guide, fitting the lens is pretty simple.

What features of the Biofinity multifocal were most important to you? What do you think resonates the most from a practitioner’s standpoint in terms of lens features to make it a lens of choice?

Dr. Caruso: Well for one, it is a comfortable lens on the eye. It feels like the Biofinity sphere. Two… there seems like there is a nice range of clarity. My patients report that they can see clearly at a full range from distance to near. And three… like I said, is the ease of fitting the lens.
What overall impact did Biofinity multifocal have on your practice?

Dr. Caruso: It is incredible. I work in a somewhat rural area. There is nothing by my office. Many people do not realize that my office even exists. The main way that people find me is through referrals. When I started fitting Biofinity multifocal lenses, people would go out in the community and say, “My doctor fit me in this lens, and now I do not need reading glasses.” It really creates a wow factor.

As I started to fit these lenses, I found that more people were being referred to my practice by other patients in the area. Or patients came in and said, “My friend got multifocal lenses, and she was fit by you. I would like to try it too.” It was almost contagious. I found that, specifically, my multifocal contact lens practice has grown exponentially since I began using Biofinity multifocal.

And then with the clariti® 1 day multifocal, my practice has grown even more… because with the clariti 1 day multifocal, I fit the patients who may just want a lens for going out on the weekends or doing fun activities or just want the convenience of a daily without giving up their multifocal setup. It is also a super easy fit and has been a great addition to our practice for continued growth.

Read more about Biofinity multifocal and clariti multifocal on their product pages and ask your sales rep how offering these options can benefit your practice. Additionally, visit ECP Viewpoints℠ for monthly updates from CooperVision Professional and Academic Affairs.

The specialised tissue at the back of the eye, known as the retina, captures light and transmits a signal to the brain to allow for the sensation of vision. Remarkably, the central area (4%) of the retina, known as the macula, is responsible for up to 90% of our vision and all of our colour vision. Nutritional pigments, known as carotenoids, are concentrated in the macula where they are known as macular pigment. The three carotenoids which make up macular pigment are meso-zeaxanthin lutein, and zeaxanthin. This pigment plays a vital role for human vision because it optimises the use of light at the macula (via its short wavelength light-filtering properties) and keeps the macula healthy (via its antioxidant properties).

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The number of presbyopes continue to rise, but currently only 46% of presbyopes are fitted with a contact lens option[1].  By 2020, the number of presbyopes in the U.S. is expected to reach 123 million[2], creating a tremendous market opportunity for optometrists who provide multifocal contact lens options.  At the same time, the demand for 1-day lenses continues to rise as do the number of silicone hydrogel 1 day lens fits.   With a full family of 1-day SiHy options, clariti^® 1 day enables you to take advantage of this growing market segment and fit your presbyopic patients with a lens that is convenient, highly oxygen transmissible, and affordable.

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Of all the specialties, ophthalmology practices have been hit the hardest in terms of diagnostic code changes. The grand total comes in at just over 100 updates, so we’ve got a lot of ground to cover!

In addition to new neoplasm codes, you’ll have several more options for disorders of the eyelid, lacrimal system, and orbit — including paralytic ectropion, cicatricial lagophthalmos, rosacea conjunctivitis, meibomian gland dysfunction, and others. As with most code changes this year, CMS is aiming at greater specificity.

For more, read on at CodingInstitute.com:

https://blog.codinginstitute.com/icd-10/2019-icd-10-cm-code-changes-part-4/