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Up Front | Aug 2008

Should You Include Vitreoretinal Surgery in Your ASC?

Advice on what you should consider before adding retina to the mix.

The recent changes to Medicare reimbursement rates for vitreoretinal procedures have increased the interest of owners of ambulatory surgery centers (ASCs) in offering these procedures, when traditionally, this specialty was not profitable in the ASC setting. When making this decision, however, it is important to evaluate all of the factors surrounding vitreoretinal procedures (see Tips on Costs and Equipment). Efficiency, outcomes, the surgeon's personality, case selection, and—possibly most important—operating times are all components to consider when determining the suitability of a vitreoretinal surgeon for the ASC environment. This article describes the necessary conditions for successfully adding vitreoretinal procedures to an ASC.

First and foremost, look for a surgeon who is a calm, resourceful, pleasant team player. Second, a retinal specialist who operates slowly is probably better suited to a hospital setting. In general, you want a retinal surgeon who will avoid potentially unpredictable cases that could slow turnover and displace anterior segment procedures (see Speed in Procedures, Not Patient Care). In addition, an ASC is not suited for the treatment of patients who are ill with concomitant conditions, because support from a medical consultant, a cardiac catheterization laboratory, intensive care units, cardiac pacing, and interventional radiology is not available.

In an ASC, surgeons should avoid scleral buckling with vitrectomy, because this practice increases operating time and labor costs but has not been shown to improve outcomes.1-4 Buckles cause pain, significant refractive error, strabismus, and ptosis.5 Other procedures that are ineffective and should not be performed in any setting include radial optic neurotomy and branch retinal vein decompression (sheathotomy). Submacular surgery for age-related macular degeneration and retinal translocation are never indicated. The owners of ASCs should avoid retinal surgeons who perform any of these procedures.

Another procedure that is problematic for the ASC setting is combined phacoemulsification and vitrectomy, which lengthens operating times, achieves worse refractive outcomes, and results in postoperative posterior synechiae and reduced visibility, if phacoemulsification is performed first. Patients may undergo phacoemulsification 1 to 2 weeks before vitrectomy, however, if their cataract obscures the surgeon's view such that a high-quality vitrectomy procedure is impossible. When the vitreoretinal surgery occurs before phacoemulsification, refractive outcomes improve, because more accurate eye A-scans and keratometry readings can be obtained for IOL implantation.

Vitreoretinal surgery in an ASC can be efficient and beneficial to the patient and surgeon. For many retinal specialists, however, this change in setting requires a significant change in attitude and approach. It is therefore important for the owners of ASCs to choose a retinal surgeon carefully.

Steve Charles, MD, is in private practice with the Charles Retinal Institute and is Clinical Professor of Ophthalmology, Hamilton Eye Institute, University of Tennessee, Memphis. He is a consultant to Alcon Laboratories, Inc., and is on the medical advisory board of Optimedica Corporation. Dr. Charles may be reached at (901) 767-4499; scharles@att.net; or on the Web at www.charles-retina.com.

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