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The Ultimate Guide: Optometry & Ophthalmology Co-Management

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21 min read

Part of being a successful optometrist lies in knowing when a patient should be referred and having a network of specialists. Implement the points in this guide to elevate your level of patient care through effective co-management.

The Ultimate Guide: Optometry & Ophthalmology Co-Management
In today’s medical climate, it is more important than ever to have a network of doctors ready and able to manage patients’ needs. Optometry continues to expand our clinical capabilities, and we have more and more conditions we can diagnose and manage with success. Part of that successful management lies in knowing when a patient should be referred out and in having a network of specialists with whom you can then co-manage.
Unfortunately, for some, the process of co-management evokes more feelings of stress than confidence. This frustration is often rooted in experiences of unclear or unmet expectations between the two parties, leading to disappointment over missing communication, patients not returned to the referring office, etc. If you are one of the many doctors feeling this way, don’t worry. You can be on your way to building a successful co-management network by implementing the guide below.
That said, before we can dive into how to make co-management work, it’s important to understand why you should implement the process in your office in the first place. The answer is simple:

Co-management is a significant practice builder when utilized correctly.

Co-managing surgical patients not only offers substantial opportunities for practice growth, but ODs at any level will benefit from diversifying their skill sets. Refractive surgery is an increasingly popular alternative to continued lens wear, there are constant new developments in the field of glaucoma surgery, and with an aging population, we’ll see many of our long-term eyecare patients become candidates for cataract surgery. Optometrists must be ready to discuss and manage pre-operative & post-operative care for cataract patients.
There are two main ways to incorporate co-management into your optometric journey: one, to work in a co-management practice, or two, to refer and co-manage with a surgeon outside of your own practice setting.

The benefits of working inside a co-management surgical setting

You'll build a partnership with a trusted surgeon

Each surgeon possesses their own method of serving their patients. Co-managing surgical patients or even working in a specialty surgery setting has the potential to enlighten a new grad on how a clinician may foster a positive working relationship with their patients.

You’ll learn firsthand that trust is the foundation to establishing a symbiotic professional relationship

The surgeon is an extension of you, and vice versa. As a co-managing doctor, you’ll be within close proximity to absorb the intricate details involved in ophthalmic surgery and disease. With the ability to customize treatments using both lens and laser-based options, optometrists and patients can build a cohesive treatment plan which the surgeon can subsequently execute—and execute on a surgeon’s well-built post-operative plan of care.

You’ll learn proper pre-operative & post-operative management of refractive and cataract surgery

While co-managing, you’ll observe key areas of the anterior & posterior segments. The first step to managing complications is to find ways to avoid them altogether or, at the very least, to decrease their likelihood. This starts with astute observations during your pre-operative exam. For example, dense cataracts can often result in a delayed return of acuity. This happens due to corneal edema from the heightened levels of phaco-energy used during the procedure. Increased levels of corneal edema are much more common in patients with Fuch's Dystrophy as well.
Additionally, pseudoexfoliation can result in an increased risk of glaucoma, dislocated lens material, and IOL dislocation due to loose zonules. Issues in the epiretinal membrane can result in increased risks of cystoid macular edema so prescribing an NSAID before and after cataract surgery can prevent cystoid macular edema. Assessment of the eye’s overall status pre-operatively can help you to anticipate when the patient will recover their maximal visual acuity.

The combined knowledge of the surgeon and optometrist makes for the best possible refractive outcome

When a cataract surgery patient enters our office, we must be able to explain, build, and execute a plan for them in a clear and concise manner. When a patient undergoes cataract surgery, for example, they have four options:
  • The first option is to have both eyes corrected for distance while still requiring reading glasses. This scenario is still the most common refractive preference for patients undergoing cataract surgery today.
  • The second option is to have monovision (in which one lens corrects for distance and one lens corrects near vision). This option works best when a patient has already experienced and adapted to monovision with contact lenses.
  • The third option is a multifocal lens that is corrected for both eyes (distance and near). The downside for patients with regards to multifocal lenses is that they can result in glare/halos at night and loss in contrast.
  • The fourth option is bilateral myopia for reading for jewelers or patients who perform a ton of near work. This scenario is typically the best surgical outcome for life-long myopic patients who are happy with their uncorrected near vision and habitually remove their glasses for reading/near work.
All of these options are presented to the patient who will then make a decision based on financial considerations, lifestyle, and preferences. With the refractive knowledge of the optometrist and the surgical power of the ophthalmologist, the potential is there to build a fantastic plan for the patient.

You will learn the new surgical options to be better equipped to educate and inform patients

New surgical options are constantly on the horizon. As a co-managing doctor, you have the privilege of being at the epicenter. For example, although Toric ICL has been used all over the world for many years, it has only just recently gained FDA approval in the US. Ophthalmologists are finally able to perform Toric ICL in the US and, now, eyecare providers can offer patients who are greatly nearsighted with astigmatism this incredible option here in the US. There are many new and exciting surgical options for refractive surgery, glaucoma surgery, and cataract surgery, from MIGS to premium IOLs and more.
Now, let’s look at how to co-manage with a surgeon outside of your own practice setting!
By handling post-operative care, giving thorough and accurate information regarding your patient’s referral and condition, and strengthening the relationships with surgeons and other doctors in your area, you elevate the level of care your patients believe you can provide.
When they have a good experience at the referred office, their confidence in you and your recommendations increases. This directly translates to more loyalty to you and your practice, which will in turn generate increased revenue and word-of-mouth referrals for you. Additionally, you will be adding office visits when doing post-operative care, which again adds to your bottom line. It’s truly a winning setup.
Let’s dive into how to get started!

Step One: Building your co-management team

One of the most important things in optometry co-management is establishing a communication line between you and the surgeon.

This is critical for both pre-operative care and post-operative care. You need to be confident that if there are problems post surgically, you can rely on your surgeon to help in the management and care of your patient. This level of trust is paramount in building your optometry co-management network.
Having good co-management processes and procedures will also ensure your patient has the most comfortable experience possible.
In order to be confident in the process of actually referring patients, providing post op care, and working with your surgeons, you first have to build a solid network . . . your “Dream Team” of sorts. You can do this by following these steps:

1) Make a list of needed contacts.

Ask yourself: what different conditions would you possibly need to refer a patient out for care? Common answers might include retinal conditions, glaucoma, cataract surgery, strabismus, oculoplastics, corneal problems, and refractive surgery. While that list does cover the majority of referral cases, try to also consider the more uncommon problems you might run across such as neurological cases. Don’t forget to look into radiologists/imaging centers if your state allows you to order that form of testing for your patients.
In addition, if there is a certain subspecialty of optometry that you are less comfortable treating or simply don’t want to manage, make sure you include those areas as well. A common example of this is pediatrics (though do consider forming a close relationship with a colleague in your community that might enjoy this area of our profession. This can often form a very symbiotic relationship with another OD, particularly if they have an area that dislike that you enjoy).

2) Educate yourself thoroughly on the surgeons/specialists in your area.

While it is true that some towns may only have one option when it comes to cataract, retina, or other specialty referrals, you should make a point to explore your options regarding surgeons. Sometimes this may mean looking slightly outside your immediate area, but if the results are finding a MD who is willing to fully work with you in the care of your patients—trust me, it’s worth it.
Some points that should be considered when selecting your preferred referral doctor include:
  • How do the practitioner’s results compare to his or her competitors? Do your research, ask your colleagues, and make sure you are comfortable with the level of outcomes that a surgeon has before putting your endorsement behind him/her. Your patients trust you, and while you can’t force them to go to any one MD, you can recommend whichever surgeon you think is best. Make sure it’s an educated recommendation.
  • Is this office and doctor optometry-friendly? Finding an optometry-friendly MD will make establishing a close working relationship much easier. Again, talk to your fellow optometrists. This will give you great insight into how easy or difficult someone is to co-manage with.
  • Is the referral office easy to communicate with? You want to make sure that you find someone who will not only communicate regarding his or her exams and surgeries, but also someone who will listen and be reachable to help if you have an outcome or problem that poses a challenge.

3) Select your choices for each co-management area and contact their office.

Once you have decided which offices you’d like to work with, this is a great time to reach out to them and let them know you would like to work with their doctor(s) to provide outstanding care for your patients. The easiest way to do this, in my experience, is to contact the office manager. This person will be able to add you to their office’s provider list in their system which will save time when your staff calls to make an appointment with them, as well as provide you with any information you need to know regarding their scheduling process, paperwork, etc.
Make sure that you are given you the names and contacts of their key people. You should be made aware of whom your office should contact to schedule an appointment, whom to call if a problem arises with a patient’s outcomes, whom to send referral and post-op letters to, and whom will be sending their office’s communications—consultation, surgery, and/or post-op reports—to you. Request that they send over any patient paperwork or other items, such as maps, that will make your patient’s process easier.
You can also use this conversation to ask if they have any networking opportunities that you could attend. For example, some offices host periodic events hosting local ODs and allowing their doctors to share any updates or new technology they might be utilizing. Participation in these happenings is an easy way to build your personal relationships with the doctors you are utilizing.

Note: Don’t be afraid to have more than one option for the same specialty. Maybe you have two cataract surgeons in your area that you feel confident in. Go ahead and refer to both. Over time, you’ll discern which is best for which patients and where each one’s strengths lie.

After you have completed part one and selected your desired network, you are ready to start…

Step Two: Utilizing your co-management team

While most practices are familiar with the nuts and bolts of referring a patient to another office, here we will look at what you should expect from your referring office, what they will expect from you, and tips on making the process as smooth as possible.

1) Know your co-managing doctor’s protocols.

Each specialist is different in the way they execute their care, particularly in post op schedules and medications. Some cataract surgeons may prefer to have a same-day post op, while others will demand a one day. Some will want a patient dilated at the one-week post op visit; others prefer dilation at one month. Depending on the surgery, there may be a combination of NSAIDs, steroids, antibiotics, or other topical meds prescribed, or the surgeon may have administered all meds during surgery. In some cases, post op meds simply are not required.
Due to these vast differences between doctors, it is essential to gain an understanding of the typical exam/post-op schedule, medications commonly used, and frequency of dosing for each medication. Typically, the MD’s office will be able to provide your practice with paperwork outlining all of this. In addition to the preferred medications used, it is also helpful to find out what medications the surgeon will substitute should the patient run into problems acquiring their drops. Having a working knowledge of the common substitutions that may be made for your patients will help you avoid curve balls in your chair.

2) Understand what findings your specialists, particularly surgeons, find normal vs. abnormal.

As referenced above, remember that every surgeon is different, and while results may eventually end up very similar at one month or three months post-surgery, the process to get to that end result may look very different from MD to MD. Especially early in the establishment of a co-management relationship, it is integral to communicate with the surgeon or the surgeon’s office to find out what his or her eyes typically look like in each post op. Make sure to find out the surgeon’s expectations regarding corneal appearance, IOP, visual outcome, and retinal findings.
While knowing what to expect will allow you more comfort in managing your post-operative patients, it is equally as necessary to know what your surgeon considers out of the norm and how he or she would like you to handle those situations. Some things may be as easy as adding another topical medication; for example, a surgeon may ask that you add an IOP lowering med to any post op patient with intraocular pressure over 25. Other findings may require an examination by the surgeon himself. Again, good lines of communication with the surgeon’s office will be key in acquiring this information.
If possible, consider shadowing the surgeon early in a co-management arrangement. It is an insightful way to establish a baseline of post-operative expectations, as well as form a stronger working relationship between yourself and the MD.

3) Prepare your patient for their visit.

This important step begins in the exam room. Following a detailed discussion regarding your findings and treatment recommendations, give your patient insight into the course of action and experience they will have at the office you are referring them to. As you have already familiarized yourself with the doctor’s protocols and surgical expectations, you will be able to articulate these points much more easily.
Make sure to walk them through what to expect during the consultation and/or surgery, any options they may be presented with (such as specialty intraocular lens implants), and answer any questions they may have. Actively listen to their concerns, if any, and try your best to address them. Remember, the better they feel about the process, the more trusting and confident they will be in you.
If possible, have your staff make the patient’s appointment while they are in the office for their exam with you. Have a designated person that is assigned to making referral calls and a back up staff member in case that employee is busy or out of the office. This will allow your staff member to form stronger relationships with the referring office’s scheduler as the two of them work together over time, as well as give the scheduler a point of contact within your office if there are any problems or questions.
After the appointment has been set, your staff person should go over any patient paperwork that you have for the specialist’s office, as well as maps, directions, and contact information should they need to change their appointment.

4) Effectively communicate.

Communication in co-management, like any other area of life, is key. In preparing to use the office you have chosen, you should have learned what that doctor will need from you for your patient’s appointment. Some request the patient’s full demographics in addition to your exam notes or letter. Others—most in my experience—just want your last exam notes. Regardless of what has been requested, strive to send those items in a timely fashion. Don’t make the other office have to call you for notes.
On the other hand, expect the same prompt communication from the co-managing doctor. Make sure to find out which reports they typically send as some will send notes on every visit, while others may only send notes for surgeries or post-operative encounters. If you are not getting these communications as preferred, contact the person in their office responsible for these letters. If you continue to see a lack of improvement in this area, talk to the surgeon or office manager directly or consider using a different office for that service if possible. We are unable to fully care for our patients if we do not know what has happened at their visits, so working with an office that respects you enough to provide reliable communication is paramount.

5) Maintain your co-management network.

It is important to make sure that you don’t become complacent with your network. New specialists join or open practices daily, so make sure that you are aware of any new options you might have and familiarize yourself with his or her work. This will ensure that your patients are being offered the best possible care that you can provide them.
Successful co-management is born out of mutual respect and effective communication. Building the right arsenal of referral options that emulate those two pillars and can work hand-in-hand with you allows you to elevate your level of patient care and strengthen trust and loyalty to you and your practice. By implementing the points reviewed in "The Ultimate Guide to Optometry and & Ophthalmology Co-management," you will be well on your way to achieving this goal.
Sidra Qadri, OD
About Sidra Qadri, OD

Dr. Sidra Qadri OD grew up in Houston, Texas where she attended the University of Houston and double-majored in Psychology and Biology with a minor in Health Sciences. Dr.Qadri served as the President of the Pre-Optometry Organization and also held the title of campus ambassador for Princeton Review. Post-graduation, Dr. Qadri enlisted in a rigorous summer research program at University of Houston College of Optometry to initiate her career in Optometry.

Dr. Qadri commenced Optometry school at the Rosenberg School of Optometry in San Antonio, Texas where she earned her doctorate of optometry degree.

Dr. Qadri went on to complete her externships in ocular disease at Community Eye Care Clinic in Fort Worth, Texas, primary care optometry and ocular disease management at the Veteran Affairs Hospital in Peoria, Illinois, and refractive surgery co-management in San Antonio. While enrolled in Optometry School, Dr. Qadri was the recipient of the 2016 faculty clinical award; an award which recognized students who excelled during their clinical rotations.

While off duty, Dr. Qadri enjoys spending quality time with her family, friends and husband. In addition to family time, Dr. Qadri enjoys fitness activities, dancing, and discovering new restaurants.

Sidra Qadri, OD
Patricia Fulmer, OD, FAAO
About Patricia Fulmer, OD, FAAO

Dr. Fulmer is the sole owner of Legacy Vision Center, a cold start, medically focused practice in Huntsville, AL, which launched at the end of 2020. A graduate of the UAB School of Optometry, she completed an ocular disease and primary care residency at the Thomas E. Creek VA Medical Center before returning to Alabama to serve as the Center Director and consultative optometrist for a referral-based, tertiary care facility and then as an associate at a multi-doctor family practice. Her clinical interests include disease management, particularly glaucoma, uveitis, dry eye, and neurology-related cases, as well as educating students and colleagues through lecturing and writing. She is an active member in the American Academy of Optometry and American Optometric Association and currently serves her profession as a member of the Board of Directors of the Alabama Optometric Association and as President of the North Alabama Optometric Association. In her free time, Dr. Fulmer enjoys spending time with her husband and family, spoiling their fur-babies, traveling, attending concerts, and exploring the outdoors while kayaking and hiking. She also loves giving back through volunteering, including serving on the Board for HEALS, Inc, an organization that focuses on providing healthcare to local in-need youth.

Patricia Fulmer, OD, FAAO
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