accessibility ACCESSIBILITY

Eye Physicians and Surgeons of Ontario - Saving Money in Eye Care

 

  

1.  Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications.

For many, preoperative tests are not necessary because eye surgeries are not lengthy and don’t pose serious risks. An EKG should be ordered if patients have heart disease. A blood glucose test should be ordered if patients have diabetes. A potassium test should be ordered if patients are on diuretics. In general, patients scheduled for surgery do not need medical tests unless the history or physical examination indicate the need for a test, e.g., the existence of conditions noted above. Institutional policies should consider these issues.

Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, Petty BG, Steinberg EP. The value of routine preoperative medical testing before cataract surgery. N Engl J Med [Internet]. 2000;342:168-75.

Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 2012, Issue 3. Art. No.: CD007293. DOI: 10.1002/14651858.CD007293.pub3.

Bartley GB, Narr BJ. Preoperative medical examinations for patients undergoing ophthalmic surgery. Am J Ophthalmol 1991;112(6):725-7.

Keay L, Lindsley K, Tielsch J, Katz J, Schein O. Routine preoperative medical testing for cataract surgery. Cochrane Database of Syst Rev. 2009, Issue 2. Art. No.: CD007293. DOI: 10.1002/14651858.CD007293.pub2.

Imasogie N, Wong DT, Luk K, Chung F. Elimination of routine testing in patients undergoing cataract surgery allows substantial savings in laboratory costs. A brief report. Can J Anesth [Internet]. 2003;50(3):246-8.

Bass EB, Steinberg EP, Luthra R, Tielsch JM, Jowitt JC, Shoukey PD, Petty BG, Feldman MA, Steinwachs DM. Do ophthalmologists, anesthesiologists and internists agree about preoperative testing in healthy patients undergoing cataract surgery? Arch Ophthalmol [Internet]. 1995;113(10):1248-56.

2.  Don’t order antibiotics for adenoviral conjunctivitis (pink eye).

Adenoviral conjunctivitis and bacterial conjunctivitis are different forms of infection that can be diagnosed by the ophthalmologist by clinical signs and symptoms, and if needed, by cultures. Antibiotics are useful for patients with bacterial conjunctivitis, particularly those with moderate to severe bacterial conjunctivitis. However, they are not useful for adenoviral conjunctivitis, and the overuse of antibiotics can lead to the emergence of bacteria that don’t respond readily to available treatments. In cases of diagnostic uncertainty, patients may be followed closely to see if their condition resolves on its own, or if further treatment is required.

American Academy of Ophthalmology Retina Panel. Preferred Practice Pattern® Guidelines. Conjunctivitis - Limited revision [Internet]. San Francisco, CA: American Academy of Ophthalmology; 2011 [cited 2012 Sep 28]. Available from: www.aao.org/ppp.

Sheikh A, Hurwitz B. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database Syst Rev 2006 Issue 2. Art No: CD001211. DOI: 10.1002/14651858. CD001211.pub2.

3.  Don’t routinely provide antibiotics before or after intravitreal injections.

The routine use of antibiotics before or after intravitreal injections is unnecessary because research has shown that topical antibiotics don’t prevent the occurrence of eye infection. The risks of antibiotic eye drops include allergic reactions. The overuse and repeated exposure to antibiotics can lead to the emergence of bacteria that don’t respond readily to available treatments. Routine antisepsis is appropriate and important for prevention of eye infection.

American Academy of Ophthalmology, Practicing Ophthalmologists Learning System. Intravitreal injections [Internet]. San Francisco: American Academy of Ophthalmology, 2008 Nov. [cited 2012 Sep 28]; Available from: one.aao.org/CE/PracticeGuidelines/ClinicalStatements_Content.aspx?cid=404813e9-b3dc-4d6d-a2c5-d1f1e78a926b#section4.

Bhavsar AR, Googe JM, Stockdale CR Bressler NM, Brucker AJ, Elman MJ, Glassman AR. Diabetic Retinopathy Clinical Research Network. Risk of endophthalmitis after intravitreal drug injection when topical antibiotics are not required. The Diabetic Retinopathy Clinical Research Network Laser-Ranibizumab-Triamcinolone Clinical trials. Arch Ophthalmol [Internet]. 2009 Dec;127(12):1581-3.

Scott IU, Flynn HW. The role of topical antibiotic prophylaxis for intravitreal injections. Arch Ophthalmol [Internet]. 2007 Jul;125(7):974-6.

Bhatt SS, Stepien KE, Joshi K. Prophylactic antibiotic use after intravitreal injection: Effect on endophthalmitis rate [Internet]. Retina. 2011 Nov;31(10):2032-6.

Kim SJ, Toma HS, Midha, Cherney EF, Recchia FM, Doherty TJ. Antibiotic resistance of conjunctiva and nasopharynx evaluation study: A prospective study of patients undergoing intravitreal injections. Ophthalmol [Internet]. 2010 Dec(12):117-2372-8.

Kim SJ, Toma KS. Ophthalmic antibiotics and antimicrobial resistance. A randomized, controlled study of patients undergoing intravitreal injections. Ophthalmol [Internet]. 2011 Jul(7);118:1358–1363.

Cheung CSY; Wong AWT, Kertes PJ, Devenyi RG, Lam WC. Incidence of endophthalmitis and use of antibiotic prophylaxis after intravitreal injections. Ophthalmol [Internet]. 2012 Aug:119(8):1609-14.

Milder E, Vander J, Shah C, Garg S. Changes in antibiotic resistance patterns of conjunctival flora due to repeated use of topical antibiotics after intravitreal injections. Ophthalmol [Internet]. 2012 Jul:119(7):1420-4.

4.  Don’t routinely order imaging tests for patients without symptoms or signs of significant eye disease.

If patients do not have symptoms or signs of significant disease pathology, then clinical imaging tests are not generally needed because a comprehensive history and physical examination will usually reveal if eye disease is present or is getting worse. Examples of routine imaging include: visual-field testing; ocular coherence tomography (OCT) testing; retinal imaging of patients with diabetes; and neuroi maging or fundus photography. If symptoms or signs of disease are present, then imaging tests may be needed to evaluate further and to help in treatment planning.

5.  Where feasible, consider selective laser trabeculoplasty as a primary or early

treatment option in the treatment of open angle glaucoma. 

Several large RCTs have demonstrated the safety and efficacy of selective laser trabeculoplasty for the treatment of open-angle glaucoma.  Furthermore, other studies including an influential Ontario-based study, have demonstrated that primary treatment of open angle glaucoma with laser is more cost effective than the more commonly used approach of topical medications.  Eye surgeons should consider selective laser trabeculoplasty as a primary or early treatment intervention when appropriate.

McIlraith I, Strasfeld M, Colev G, Hutnik CM. Selective laser trabeculoplasty as initial and adjunctive treatment for open-angle glaucoma. J Glaucoma 2006;15:2:124-30.

Melamed S, Ben Simon GJ, Levkovitch-Verbin H. Selective laser trabeculoplasty as primary treatment for open-angle glaucoma: A prospective, nonrandomized pilot study. Arch Ophthalmol. 2005;123:1:127.

Lee AC, Mosaed S, Weinreb RN, Kripke DF, Liu JHK. Effect of Laser Trabeculoplasty on Nocturnal Intraocular Pressure in Medically Treated Glaucoma Patients. Ophthalmology 2007;114:4:666-670.

The Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial (GLT): 2. Results of argon laser trabeculoplasty versus topical medicines. Ophthalmology. 1990; 97:11:1403-13. 

 Source for 1-4, AAO Five Things Patients and Physicians Should Question, www.choosingwisely.org

Contact Us.We encourage you to contact us with any questions or comments you may have. Please call our office or use the quick contact form.