H o r i z o n L a s e r V i s i o n C e n t e r

Transcription

1 H o r i z o n L a s e r V i s i o n C e n t e r Technology Quality Education Care October 2017

2 Horizon Laser Vision Center is an established premium refractive surgery clinic with facilities in Saskatoon and Regina. We have a unique patient care system that involves the optometrist, and the participating ophthalmologists. We provide the safest technology at our center and the highest quality of care through this care system. Our Mission Our mission is to provide the highest quality care to our refractive surgery patients. We aim to achieve this mission by providing the latest and safest technology in a top quality facility, with the highest quality pre and post operative eye care. Our Goal Our goal is to provide a center of excellence for surgery and for continuing education for both the doctor and patient.

3 Refractive Surgery: General Information We feel it is important that the patient be educated fully on all aspects of the surgical process so that they are properly equipped for informed consent. At Horizon the patient has a consultation preoperatively to discuss procedure options (ilasik, ilasik Xtra, PRK, PRK Xtra or KAMRA Vision) and logistics. RLE referrals are forwarded to the surgeon s office. Included in this book you will find all the tools you need to refer your patient to Horizon Laser Vision Center. The information includes protocol on referrals, follow-up, patient fees and reimbursement. It will also provide you with important information on patient selection and counseling. We hope you find this book of use to you and your practice and we look forward to working with you. Feel free to contact us anytime if you have questions or if you have a situation with a patient where you are unsure of the next steps. Toll-free phone number: Regina: Phone: Fax: regina@horizonlaser.com Saskatoon: Phone: Fax: saskatoon@horizonlaser.com Web-site Doctor s Portal Log -In: your office phone number (with dashes) Password: 123 Board of Directors: Dr. Warren Toews Dr. Renatta Varma Dr. Bill Thatcher Dr. Stefanie Yea Dr. Bob Neumann Dr. Jim Kerr Dr. Ravi Nrusimhadevara

4 Our Surgeons Our surgeons maintain private ophthalmology practices, and some maintain teaching appointments at the University of Saskatchewan Dr. Ravi Nrusimhadevara graduated as an Ophthalmologist and has been in practice since He underwent a Fellowship in Diseases of Retina and Vitreous at the University of Toronto. He started practicing in Saskatoon in 2004 and has extensive surgical experience. His special interests are diseases of retina, advanced cataract surgery, pupillary reconstructions, sutured and sutureless scleral fixation of intraocular lenses and refractive surgery. Dr. Ravi holds an academic appointment with the University of Saskatchewan as Clinical Assistant Professor in Ophthalmology and is actively involved in training residents and medical students. He has written chapters in textbooks, journal articles in medical literature and presented in various national and international meetings. He is a member of the Canadian Ophthalmological Society, American Academy of Ophthalmology, the American Society of Retinal Specialists, American Society of Cataract and Refractive Surgery. Apart from Ophthalmology Dr. Ravi has a strong interest in computer science, and solid-state electronics. His other interests are Badminton, Tennis and Swimming. Dr. Ravi and his wife Vasudha have two young boys and he enjoys spending time with his family the most.

5 Dr. Renatta Varma graduated from medical school in 1998 with Great Distinction. She completed her residency in ophthalmology at the University of Saskatchewan in Saskatoon and holds a fellowship from the Royal College of Physicians of Canada. She then completed a subspecialty fellowship in vitreo-retinal surgery in New Orleans under Dr. Gholam Peyman, who holds the patent for LASIK surgery. She completed a second fellowship in vitreo-retinal surgery in Victoria, BC. She has been performing refractive surgery since Dr. Varma is a member of the Canadian Ophthalmology Society, the American Academy of Ophthalmology, and the American Society of Cataract and Refractive Surgeons. She practices in Regina and has a special interest in retinal, cataract and refractive surgery. Dr. Jeffrey Judelson has been in practice in Regina since He holds fellowships from the College of Surgeons of South Africa, the Royal Colleges of Surgeons of Edinburgh and Canada. The main focus of his practice is cataract, corneal and refractive surgery and he has been performing refractive surgery in Saskatchewan since Dr Judelson has run the corneal transplant program in Regina since He is a member of the Canadian Ophthalmology Society, America Society of Cataract and Refractive Surgeons and the Lions Eye Bank of Saskatchewan. When not working Dr Judelson s interests include reading, photography, computers and is a keen golfer and tennis player.

6 Referral Protocol Patients will require a recent full examination which should include a complete history including refractive history, complete medical history, a peripheral retinal examination (either dilated fundus examination or Optomap imaging), a thorough review of macula including when necessary macular OCT. Topography and pachymetry should be performed if possible. Dry eyes should be treated and controlled before assessment at Horizon. Referral forms should be completely filled out and sent to Horizon. 1. You are not REQUIRED to have a separate visit for a laser consult with the patients contact lenses off. 2. You are not REQUIRED to perform a cycloplegic refraction in all cases. Cycloplegic refraction is still required for all hyperopes but this can be performed at the time of the full examination. This can be done at Horizon if this is more convenient for the patient or the doctor. The Horizon Optometrist will do the laser consult at Horizon after the patient has been out of contact lenses for the appropriate time. The surgeon will make the final determination of patient suitability. The Horizon Optometrist will inform the referring doctor of the outcome of the assessment and recommended treatment. Horizon will notify the referring doctor if a candidate is rejected. The HLVC consultation process is smoother for the patient and for referring doctors. This does not preclude you from doing any testing that you feel necessary for your screening and counselling of the patients, including the cycloplegic use your clinical judgment to determine what is necessary to determine if a patient is a good candidate. Note: Please counsel your patients on both ilasik, PRK and RLE procedures. The Horizon Optometrist will discuss treatment options with the patient and help the patient understand which procedure best suits their unique eye.

7 P r e v i e w C o n s u l ta t i o n Industry surveys have shown that the average time from when a patient first becomes curious about laser eye surgery until they become serious is about 22 months. Preview consultations can be done early in the decision-making process. Preview consultations can be done to pre-screen patients and to find out if refractive surgery is an option, prior to the patient being out of their contact lenses. Testing will be done and the Horizon Optometrist will look it over to give an opinion if the patient is a candidate or not. If the patient is a candidate, they will be advised to book an eye exam with their optometrist for a full eye exam, if required and pre-op. You will receive a note from HLVC to inform you of any testing results and opinions given by the HLVC Optometrist.

8 Patient Selection: At Horizon we feel it is the eye care professional who is best able to judge who is a suitable candidate for refractive surgery. It is our mandate to direct all patients towards their own eye doctors for the pre-operative exam and postoperative care. Here are a few guidelines for patient selection: Patients should be over 18 years of age Intelligent and motivated Stable refraction for at least one year with less than 0.50 diopter change Uncorrected acuity that is sufficiently reduced to ensure the risk/benefit ratio is desirable Have an understanding of the capabilities and limitations of the procedures Realistic goals and expectations Educated about presbyopia Patients with vision loss associated with lens changes should be referred as cataracts, for cataract surgery and not as RLE. Contact Lens Wear: Often the biggest inconvenience for patients is the discontinuation of their lenses. However, it cannot be stressed enough that it is imperative for a successful outcome. As contact lenses influence the corneal surface, great care will be taken to ensure the cornea is stable before surgery. Please inform your patient that prior to the refractive surgery assessment at Horizon they will need to discontinue their contact lens wear for 1 week and also 1 week prior to the surgery appointment. Rigid lenses should be discontinued 4-6 weeks minimum

9 Pentacam and Topography Images: Horizon Laser Vision Center is equipped with Pentacam technology. These images are captured on all patients. The advantage of the pentacam is that it not only captures pachymetry on the entire surface, but it is also able to image the posterior corneal surface which is not possible with regular topography. The pentacam has kerataconus screening software which is useful to exclude form fruste- or early keratoconus. Topography maps may be done by Horizon at the time of consultation, to help with diagnosis of asymmetrical steepening. Corneal Pachymetry: Pachymetry or corneal thickness measurement is a determining factor in whether your patient has ilasik or PRK. A sufficient amount of corneal tissue must remain untouched during the ilasik procedure and therefore an adequate amount of tissue must be present initially. Pachymetry is always performed by the clinic prior to surgery. If you have access to a pachymeter, it is often helpful in higher myopes to determine their suitability for ilasik.

10 K readings are very important as it tells us the shape of the patient s eye. Use this formula to calculate whether or not the eye would be too flat after surgery: Ex: 46.00/47.25 x x The treatment would be for 8 diopters ( (-1.00) = -8.00) 2. 8 diopters multiplied by 0.7 = The average of the K-reading is subtracted by 5.6 = This K reading is acceptable after surgery. The cut off for too flat is Corneal Thickness: Custom Treatments are Microns/Diopters 1. Patient s lowest pach reading = Subtract approximate flap= Subtract treatment= 40 Total= 386 Cutoff for residual corneal thickness is 275 to 300 microns.

11 Corneal Thickness (Microns) Correction Factor (mmhg)

12 Contraindications: OCULAR Significant ocular pathology Severe dry eyes Recurrent iritis/uveitis Corneal anesthesia History of herpes simplex keratitis Glaucoma Marginal corneal dystrophies Endothelial dystrophies Significant cataract development Monocular patients Unstable refraction SYSTEMIC Active collagen vascular disease Long ter m insulin diabetes Immune compromised patients Thyroid eye disease Pregnancy and lactation Any system disorder or medication likely to affect healing

13 T r e a t m e n t R a n g e s i L A S I K SURGEON MYOPIA HYPEROPIA CYLINDER PAST K S R. Varma microns and J. Judelson microns and R. Nrusimhadevara microns and T r e a t m e n t R a n g e s P R K SURGEON MYOPIA HYPEROPIA CYLINDER PAST K S R. Varma No microns and J. Judelson No microns and R. Nrusimhadevara No microns and 49.00

14 Our Laser Eye Surgery Technology The Visx Star S4 Excimer Laser System is a computerassisted, surgeon-controlled device that includes idesign, ActiveTrak, Iris Registration, VSS Refractive and VRR technologies.. The idesign technology uses light waves to identify and measure imperfections in the eye 25 times more accurately than standard methods used for glasses and contact lenses. The Wavefront map is a visual representation of how the patient s entire optical system processes light. idesign technology uses a high-definition sensor capturing over 1200 data points to more precisely measure your unique vision imperfections in each eye and deliver a truly personalized treatment. ActiveTrak 3D Tracker follows the fine motions of the eye instantaneously and automatically, in all three dimensions, continually repositioning the laser to ensure accuracy. Iris Registration (IR) is an enhancement that works by recognizing the unique pattern of each eye and precisely aligning the laser so that the surgery is even more accurate. The VSS Refractive technology produces variable beam sizes from as small as 0.65 mm up to 6.5 mm, while VRR varies the laser's repetition rate from 6 Hz to 20 Hz. By continually changing the size and placement of the laser beam, the STAR S4 IR Excimer Laser rapidly delivers the precise ablation pattern required, significantly reducing ablation time. This capability minimizes thermal effects on the cornea and allows you to perform the procedure as quickly as possible.

15 . powered by idesign. The Intralase Method is a 100% blade-free approach to creating the thin flap of tissue that the surgeon folds back in order to perform the ilasik procedure. It can only be performed using the IntraLase laser. Traditionally, surgeons used a microkeratome for flap creation. Regular LASIK is safe but if complications occur, the microkeratome is frequently the cause. Our blade-free ilasik approach removes this possible source of complication. With the IntraLase Method, tiny pulses of laser light, a quadrillionth of a second each, pass harmlessly through the outer portion of the cornea and form a uniform layer of microscopic bubbles just beneath the surface of the eye. The exact dimensions of this layer of bubbles are determined by the surgeon based on each individual eye. The flap creation takes 12 seconds. With the ilasik procedure, patients experience fewer flap-related complications and fewer induced higher order aberrations that contribute to visual disturbances, such as glare and halos. It is the most advanced treatment available. ilasik is the approved procedure for NASA astronauts and pilots.

16 ilasik or PRK ilasik and PRK both use the excimer laser to reshape the front surface of the cornea. For ilasik, a flap is created, which preserves the corneal surface. For PRK, the front surface (epithelium) of the cornea must be removed, prior to the reshaping. As a result, the surface of the eyes treated with ilasik heals faster than those treated with PRK. Most patients achieve reasonable vision the day following the surgery. Furthermore, patients experience less discomfort with ilasik post-operatively than with custom PRK. While a patient s prescription MAY make them a candidate for either procedure, it is important to let the assessing doctor and the patient make the decision together based on a number of factors including risk vs benefit, expectation, k-readings and pachymetry. RLE The RLE referral will be passed along to one of the HLVC surgeons. The patient will be contacted for testing and consultation at the surgeon's office. If the patient opts to have surgery, it will be arranged by the surgeon's office to be performed at Prairie View Surgical Center in Saskatoon, or Saskatchewan Surgical Center in Regina. The patient will see the surgeon for their first post-op visit; all other post-op visits will be done by the referring optometrist. If a patient is referred for ilasik or PRK but is not a candidate, the HLVC OD may recommend RLE. If the patient is interested, the referral will be passed along to one of the HLVC surgeons and be handled as above. KAMRA VISION The outpatient procedure consists of implanting the corneal inlay in a pocket in the eye s outer layer that is created with the Intralase.. The procedure takes less than 20 minutes and patients can resume most activities the next day. Implanting of the KAMRA inlay can be done alone or in a two-step procedure following ilasik or PRK IPL Intense pulsed light (IPL) therapy is a treatment for evaporative dry eye. IPL uses a Xenon flash lamp that emits broad spectrum light. The light energy is converted to heat and induces ablation of fine vascular structures. A series of 4 treatments 4 to 6 weeks apart are scheduled, and maintenance visits may be necessary.

17 ilasik XTRA/PRK XTRA XTRA is a 3-minute procedure used in conjunction with a standard LASIK or PRK surgery to add biomechanical strength to the cornea through accelerated corneal cross-linking. In standard LASIK surgery, the creation of the flap affects the biomechanics of the cornea. A change in biomechanics may cause the refractive effect to regress and possibly necessitate an enhancement procedure. Adding biomechanical strength through cross-linking has been shown to halt refractive regression in conditions associated with weakened corneas. The indications/protocols for CXL and XTRA continue to evolve and surgeons are advised to keep up with the current literature on the subject, and provide appropriate counselling to patients prior to treatment. Indications for XTRA may include: Young patients (under 25 years of age). Patients with severe ocular allergies, due to the risk of heavy rubbing. Completely normal corneas, with no one sign of keratoconus, but family history. Thin corneas with complete normal preoperative evaluation (Risk of ectasia has been ruled out). High myopes (large resections) Hyperopes Retreatments

18 Focus on your life.. Not your reading glasses

19 Recommended Pre-op Testing AT OPTOMETRIST OFFICE: Patient History Ocular Medical Vision Assessment UCVA (distance and near) BCVA Dry MRx Cycloplegic Rx Eye Dominance TBUT Cover Test Lensometry AT HORIZON LASER VISION CENTER: Ocular Assessment: AcuTarget TM OCT Slit Lamp Exam Pupil Size Topography Tonometry Corneal Diameter (WTW) Dry Eye Assessment Pachymetry Posterior Segment Review Ocular Surface Assessment a dry eye test should be performed on all patients for selection. Moderate to more severe Dry Eye should be treated before a patient has KAMRA inlay. Continued dry eye even with treatment is contraindicated for KAMRA.

20 Follow-up care: After Surgery, all instructions and medications will be given to the patient before they leave Horizon. They will receive a written copy of the post-op instructions. The patient will follow these instructions until seen at your office for ONE WEEK POSTOP. If you have any questions, please call HLVC for guidance. The patient will be seen at HLVC following surgery; ilasik patients are seen on day 1 and PRK patients may be seen on day 1 to 5, depending on surgeon preference. If the patient has any inflammation/delayed healing, the time could be extended. The patient will then be seen at your office at 1WEEK, 1 MONTH, 3 MONTHS, 6 MONTHS AND 12 MONTHS postop. These visits are vital to the patient s success and happiness as well as to Horizon statistics. It is imperative that these visits be kept. At each of these visits a POSTOPERATIVE ASSESSMENT form must be completed and faxed to Horizon. These forms will be provided to your office with patient-specific information entered at the time the surgery is performed. This will save you or your staff from having to fill in the basic information. Please fill in the Post-op form as completely as possible, to give the Horizon doctors as much information as possible when they is reviewing the findings. They will respond and fax the form back to your office.

21 POST-OP PROTOCOL All lubricating eye drops are provided by Horizon Laser Vision Center for one month following surgery. Medicated eye drops are provided as long as the patient remains on the drops as prescribed by the surgeon. Sunglasses and eye shields are provided to the patient on the day of surgery and are to be used as outlined by the surgeon. For LASIK patients, driving is not recommended for 48 hours following surgery. PRK patients will need to refrain from driving for at least one week. The patient should be cautioned that they should not drive until they are comfortable to do so, even if this differs than the recommended time. The optometrist is to send in a note to the patient s license issuer to remove the glasses restriction. Horizon does not send these letters.

22 Medications for ilasik Post-Operative Recommendations Vigamox TID for one week and discontinue at the optometrist s one week visit. Maxidex as directed for one week and discontinue at the optometrist s one week visit. Artificial tears often Retreatments for ilasik are not considered until the 3 month mark. Shifting can occur until the 2-3 month time frame. Note: Please consult surgeon if any significant deviations from expected results occur OR if there is any significant rise in intraocular pressure. Modifying medications effectively can significantly modulate the effect of PRK but less so in ilasik.

23 Medications for PRK, please follow specific surgeon s recommendations: Normal Regime Following Surgery: * Vigamox 1 drop TID for one week * Flarex 1 drop QID for 4 weeks, TID for three weeks, BID for two weeks, then daily for one week * Artificial tears often * Bandage contact lens Day 3-4 Post-op: * The patient is assessed and if epithelium is well -healed, bandage lens removed. * Continue drops as above. One Week Post-op: * Assess epithelial healing * Complete postop assessment for m and fax to Horizon * Follow Surgeon s recommendations for tapering Flarex. You may wish to see the patient more often than usual. Feel free to do this in order to establish where the patient is refractively. This is often difficult to do during the early visits. Retreatments for PRK are not considered until the 6 MONTH mark. Stability is the most important factor in retreatment. Patients must be completely off steroids before considered stable.

24 Medications for KAMRA VIGAMOX (antibiotic) Day of Surgery, following surgery: suppertime and bedtime. Day One: 1 drop TID for 1 week, then stop. PRED FORTE: Starting Day One: QID for 1 week, then stop. LOTEMAX: Weeks 2 to 4: QID 2 nd Month: BID 3 rd Month: Once daily, then stop unless otherwise directed HYLO Drops and HYLO Gel (non-preservative tears) Use at least once every waking hour for the first week Continue to use as needed over the next 3 months

25 Recommended Schedule of Visits and Procedures following KAMRA 1 Day 1 Wk 1 Mo 3 Mo 6 Mo 12 Mo Ocular Surface Assessment ( eg Schirmer s Test and TBUT ) x x Uncorrected VA - Distance at 6m/20ft Intermediate at 80cm/32in. Safety VA x x x x x Near at 40cm/16in. Manifest Refraction (mid-point) x x x x x Distance-Corrected VA - Distance at 6m/20ft Intermediate at 80cm/32 in. Near at 40cm/16in. x x x x Distance-Corrected VA - (With Add): Near at 40cm/16 in. x x x x Slit Lamp Examination w/fluorescein x x x x x x Computerized Corneal Topography x x x x x Pachymetry x x x Intraocular Pressure x x x x x Cycloplegic Refraction x Dilated Fundus Exam x SLIT LAMP EXAMINATION: Inspect inlay and cornea closely for: Areas of irregularity or damage Stromal inflammation (DLK) Epithelial ingrowth Stromal haze Side-cut misalignment or epithelial defects Striae: Use retro-illumination/red reflex to assess presence of striae Most important to assess for striae within the central aperture of the inlay Dilation may be required if suspicious Manage as soon as it is identified

26 PRICING: ilasik or PRK $2,295/Eye or $4, OU Xtra is no additional cost. KAMRA (no LASIK needed) $4,800. KAMRA following LASIK $3,250. RLE fees are determined according to the type of lens chosen for implant and for two eyes: Standard $5,500 Toric $7,650 Multifocal (Symfony) $8,500 IPL is $300/treatment. 4 treatments are booked, 4 6 weeks apart and maintenance visits may be necessary RETREATMENTS: Within two years of procedure, there is no charge for retreatment Two to five years after procedure, the patient will pay $500/eye. ($250 for the OD and $250 for the surgeon) Five years or more after the procedure, the patient will be responsible for paying new treatment fees, whatever that might be at the time., reduced by 25%. Retreatment rate is less than 5% Co-Management Fees: for ilasik or PRK, the OD receives $300/eye, surgeon receives $325/eye. For RLE, the OD receives $300/eye. For KAMRA, the OD receives $300 and surgeon receives $500. Patient Financing is available at Medicard.com $500 down, $200 per month over 24 months.

27 DISCOUNT POLICY CLASSIFICATION NO CHARGE INCLUDES: 1.) Optometrist, their Spouse and all their immediate dependent (< 25 years) children All fees will come from HLVC General Revenue 2.) HLVC Full Time staff, their spouse and all their immediate dependent (< 25 years) children. HLVC Part-Time Staff. All fees will come from HLVC General Revenue. CLASSIFICATION PARTIAL CHARGE INCLUDES: 1.) Optometrist and Surgeon office staff Each office staff member is responsible for paying a Facility Fee of $ It is suggested that the staff member have a minimum of ONE year commitment to the referring office before this benefit be extended to the staff member 2.) Optometrist and Surgeon Office Staff Spouses and dependent Children Each office staff member s spouse and their immediate dependent (<25 years) children will be responsible for paying 50% of the Facility fee. The surgeon and optometrist fee is paid for by the patient. 3.) Healthcare practitioners Each healthcare practitioner will receive a 25% discount. This fee will be allocated as follows with the surgeon and optometrist receiving their Full Fee. The balance will be the Facility Fee. 4.) HLVC Part Time Staff s spouse and immediate dependent children. Responsible to pay 50% of the total cost

28 Horizon sponsors Dinners with the Surgeons and other Continuing Education events throughout the year. These are your opportunity to come meet the Board, the surgeons and other optometrists in the province. You can also come to HLVC and follow one of the surgeons on a surgery day. They are happy to meet with you and share their knowledge.

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30 Regina Clinic Hamilton St. Regina, SK S4P 3N Saskatoon Clinic Spadina Cres. East Saskatoon, SK S7K 3H horizonlaser.com P age 30 T o O r d e r, C a l l :