Outpatient Vitreoretinal Surgery

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Outpatient Vitreoretinal Surgery
Steve Charles
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Types of Outpatient Facilities

• CMS Definition
• Hospital-Operated (separately operated ORs and
  support facilities physically located within
  hospital)
• Free-Standing (ownership is not part of the
  definition)

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Economics of Outpatient Surgery

• Advances in Vitreoretinal Surgery Add Cost But
  Improve Outcomes Surgical Efficiency
• 23 25-Gauge Sutureless Surgery
• Perflurocarbon Liquids (Perfluoron)
• Disposable Forceps (Alcon DSP), Scissors (Alcon
  DSP), Illumination Tools, Advanced Laser Probes,
  Subretinal Fluid Drainage Cannulas
• Silicone Oil
• tPa (off-label)
• ICG (off-label)
• Kenalog (off-label)

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Facility Fees
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From Bill Rich, MD

• 717 rate remains the same in 2007
• In 2008, there is a 50/50 blend of the old and
  new fees
• In 2009, the fee will be at least 1409 for 67038
  is the most frequent Medicare retinal code
• 67036 would move from approximately 630 to a
  proposed 1464

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Advantages of Free-Standing ASC

• Logistics
• Faster Turnover Time (this is a process issue,
  not an intrinsic issue)
• Smaller Facility Often Improves Access to Parking
  and Requires Less Walking
• Physician Participation in Facility Fee Profits
• Branding/Marketing Opportunity If Doctor or
  Single Group Ownership
• Patient Perception of Safety (actually less safe
  for patients with any significant medical problem)

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Operating Time Issues

• Vitreoretinal Operating Times Average
  Considerably Longer Than Cataract
• Longer OR Times Drive Higher Labor Costs and
  Overtime
• Longer Operating Times Affect ASC Logistics,
  Post-Anesthesia Care, Block Time for Cataract
  Surgery and Other Faster Procedures

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Safety of Hospital-BasedOutpatient Surgery

• 50 of VR Surgery Patients Have History of
  Diabetic Complications, Coronary Artery Disease,
  Cerebrovascular Disease, COPD, Hypeertension, and
  Obesity
• I did 647 Vitrectomies in 2005, 303 Required
  Medical Consultation
• Access to Medical Consultants Technology Can
  Save Lives
• Cardiologists, Pulmonologists, Fiberoptic
  Intubation, Hyperthermia Management, ICU,
  EP/Pacing, Interventional Cardiology/Radiology,
  Endocrinology, tPa, MR, CT, Nuclear, PET

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Cases Suitable for ASC

• Healthy Patients
• Epimacular Membranes
• Macular Holes
• Dislocated Lens Material
• Dislocated IOL
• Endophthalmitis (rarely need PPV)

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Cases Not Suitable for ASC

• Sick Patients
• Diabetic Traction Retinal Detachments
• Some PVR
• Complex Trauma
• Vit-Buckles
• ROP

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Intra-Operative Complications in ASC

• Management of Intra-Operative Complications in
  Straightforward Cases May Require Advanced Tools,
  Laser, Gas, Silicone Oil, etc.
• Suprachoroidal Infusion
• Retinal Breaks, Retinal Detachment
• Bleeding (diabetic retinopathy, CRVO, BRVO)
• Lens Touch

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OR Time

• Many VR Surgeons Operating Times Excessive for
  ASC
• Vit-Buckles
• Labor Costs Driven by OR Time
• Potential Competition with Cataract
  Surgeon/Referring Doctors for OR Time

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Capital Equipment Costs

• Advanced Vitrectomy System (not phaco machine)
• Laser
• High-End Microscope with XY, Video Stereo
  Observer Tube
• Wide-Angle Viewing System

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Not-for-Profit Economics

• Not-for-Profit Means No Taxes No Dividends
• Not-for Profits Are Often More Likely to Accept
  Indigent, Medicaid and Other Patients Without
  Medicare or Commercial Insurance
• Many VR Patients Are Blind, Need Urgent Surgery,
  and Are Unemployed
• Few Free-Standing ASCs Accept Indigent Patients
  or Can Afford To

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Investment Issues

• Participation of Outside Corporation
• Remember the PPMCs
• Loss of Control Over Equipment, Disposables,
  Policies
• Pressure to Use Suboptimal Equipment
  Disposables
• Pressure to Not Operate Medicaid, No Pays,
  Managed Care, etc.
• Little Added Value, Especially After Startup

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The Vitreoretinal OR
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Location of Accurus Console

• Console at Patients Left Hip
• Anesthesia on Right Because Physicians Are All
  Taught to Examine Patients From the Patients
  Right Side
• Console Over Patient is Dangerous
• Could Fall on Patient
• Airway, CPR Access Limited
• Surgeon Cannot See Accurus Display

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Accurus, EyeLite cart
Assistants Stool
OR Table
Surgeons Stool
Anesthesia Stool
Anesthesia Machine
Scope
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Surgeon Seating

• Chair Requirements
• Back Essential To Prevent Back Pain
• Not U-Shaped Because Back Support Pushes
  Surgeons Arms Forward
• No Armrests Because They Constrain Forearm
  Movement Which is Dangerous If Patient Moves
• Front Edge of Seat Should Not Impinge On Sciatic
  Nerves
• Drape Chair Back So Elbows Mayo Stand Will Not
  Get Contaminated

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Wrist Rest

• Wrist Rest Should Never Be Used for Surgeon
  Wrists Because They Constrain the Surgeons
  Hand/Arm Which Can Result in Severe Ocular Damage
  If Patient Rotates Head Side-to-Side
• What Are They Really For?
• Create a Pouch for Fluid Collection Although
  Fluid Collection Drapes Solve This Problem
• Prevent Dropping Tools Damage to Reusables,
  Higher Disposables Cost, Sterilization Delay

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Surgeon Posture

• Raise Microscope Until Surgeon Sitting Up
  Straight
• Foot Pedals Just Outboard to Table and Angulated
  Outward Unless Short Surgeon
• Hands Should Rest on Patients Forehead

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Microscope Drape

• Microscope Drape is Absolutely Necessary
• Prevents Contamination of Tools, Tubing, Laser
  Endoilluminator Fibers, Bipolar Cable, Surgeon
  Assistant Hands/Arms
• Prevents Bioburden (dust) on Microscope from
  Falling on Eye

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Prep

• Povidone Iodine 5 (Betadine) is Essential
• We Use Betadine Unless Very Specific History of
  Allergy to Topical Betadine
• Pre-Op Skin Testing Can Be Used
• Clean Lid Margins with Betadine 5 on Cotton Tip
  Applicators or Pre-Packaged Betadine Swabs, Do
  Not Put Pressure on Lids Because It Expresses
  Meibomian Glands
• Do Not Trim Lashes, It Disperses Bacteria in Tear
  Film

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Patient Drape

• Always Use a Drape Without a Hole, Drape Must
  Fold Over Lid Margins Lashes
• Dry Skin Before Draping
• Apply to Brow First, Use Folded Drape to Lift
  Upper Lid at Lid Margin with Lashes Rolled Up,
  Then Medial Canthus, Then Lower Lid with Eye Wide
  Open
• No Sticks to Hold Eyes Open
• Need Assistant at Foot of table to Keep Drape
  Taut and Lifted
• Surgeon Cut Slit in Drape With Blunt Wescott
  Scissors Under Scope by Sliding Scissors
• Squirt BSS Under Drape Before Inserting Speculum
• Use Heavy Wire Speculum

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General versus Local MAC

• Local MAC Decreases Medical Risk
• Local MAC Saves Time Reduces Cost
• Almost All My Cases Done w/ Local MAC
• Anesthesiologist or CRNA Should Be Present During
  All Local Cases
• General Anesthesia Patient Preference,
  Claustrophobia, Uncooperative, Mental Deficiency,
  Children, Airway Issues, Note Use Translator for
  Language Problems
• Some VR Surgeons Have Excessive Operating Times
  (gt1.0 hr)

MAC and GET Require Careful Pre-Op Evaluation,
Preferably Not On Day Of Surgery
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Monitoring for Local MAC

• EKG
• Blood Pressure (automated)
• Pulse Oximetry
• pAO2
• pCO2
• AccuCheck or Equivalent, If Diabetic

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Monitoring for General

• EKG
• Blood Pressure (automated)
• Pulse Oximetry
• pAO2
• pCO2
• End Tidal CO2
• Temperature
• AccuCheck or Equivalent, If Diabetic

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Blood Pressure Considerations During General
Anesthesia

• Some Ophthalmic Surgeons Become Angry If Patients
  Move During Surgery
• Unintended Consequence - Deeper Anesthesia to
  Prevent Movement Results in Low Perfusion/Blood
  Pressure (often recorded as higher)
• IOP Should Be Maintained at 35-45 mmHg During
  Vitrectomy (my VGFI Setting 45 mmHg)
• Ocular Ischemia/Central Retinal Artery Occlusion
  Can Occur, If Low B/P

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Sedation for Local MAC

• Patient Should Have Minimal Sedation, Preferably
  Only During Block
• Large Amplitude Respiratory Motion Using
  Accessory Muscles (sternocleidomastoid,
  trapezious), If Patient Asleep
• Sudden, Large Amplitude Motion (myoclonic jerk,
  startle reflex) Upon Awakening
• Propofol causes Pain from IV Injection Unless
  Lidocaine at IV Site First, Some Patients Move
  Arms/Head With Propofol
• Anti-Emetic

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Route of Administration

• Topical Viscous Lidocaine
• Too Much Ocular Movement for Membrane Peeling,
  Seg/Delam, SRF Drainage, Macular Surgery
• Intra-Conal (retro-bulbar)
• Low Risk of Ocular, Vascular, Optic Nerve/Sheath
  Penetration Bleeding
• Fast Easy to Administer
• Extra-Conal (peri-bulbar)
• No Evidence That Peri-Bulbar Needles Safer Than
  Retrobulbar Needles
• Multiple Needle Insertions Increases Risk
• Sub-Tenons Cannula Has Virtually No Risk
• Must Be Administered in Sterile Manner Thru
  Incision, Logistics Issue

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Intra-Conal Block

• Use 27-Gauge, 1.25 inch Needle
• Do Not Use Retrobulbar (blunt) Needle They Are
  More Dangerous Because of Much Greater Insertion
  Force Sudden Movement Through Lid Septum, More
  Pain Causes More Patient Motion, Blunt Needles
  Have Not Been Shown to Be Safer
• 23 25-Gauge Needles Too Painful
• 1.5 inch Needle Too Long

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Myopic Eyes
Majority of Patients
Anti-Coagulated
Sub-Tenons Cannula
Peri-Bulbar
Topical Intra-Op Cannula Supplementation
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Hyaluronidase (Wydase) Issues

• Half the Randomized Trials Have Shown Drug to Be
  Ineffective, No Effect on Analgesia, Slight
  Improvement in Akinesia in Some Reports
• Several Reports Concerning Blind Eyes After
  Inadvertent Intraocular Injection
• Bovine or Ovine Source Prions?
• Thimerosal Preservative in Some Preparations

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Hyaluronidase Has No Benefit

• Abelson MB, Mandel E, Paradis A, George M. The
  effect of hyaluronidase on akinesia during
  cataract surgery. Ophthalmic Surg.
  198920325-326
• Bowman RJ, Newman DK, Richardson EC, Callear AB,
  Flanagan DW. Is hyaluronidase helpful for
  peribulbar anaesthesia? Eye. 199711385-388
• Crawford M, Kerr WJ. The effect of hyaluronidase
  on peribulbar block. Anaesthesia. 199449907-908
• Prosser DP, Rodney GE, Mian T, Jones HM, Khan MY.
  Re-evaluation of hyaluronidase in peribulbar
  anaesthesia. Br J Ophthalmol. 199680827-830

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Hyaluronidase Has Benefit

• Guise P, Laurent S. Sub-Tenon's block the effect
  of hyaluronidase on speed of onset and block
  quality. Anaesth Intensive Care. 199927179-181
• Kallio H, Paloheimo M, Maunuksela EL.
  Hyaluronidase as an adjuvant in
  bupivacaine-lidocaine mixture for
  retrobulbar/peribulbar block. Anesth Analg.
  200091934-937
• Morsman CD, Holden R. The effects of adrenaline,
  hyaluronidase and age on peribulbar anaesthesia.
  Eye. 19926290-292
• Nathan N, Benrhaiem M, Lotfi H, Debord J, Rigaud
  G, Lachatre G, Adenis JP, Feiss P. The role of
  hyaluronidase on lidocaine and bupivacaine
  pharmacokinetics after peribulbar blockade.
  Anesth Analg. 1996821060-1064
• Rowley SA, Hale JE, Finlay RD. Sub-Tenon's local
  anaesthesia the effect of hyaluronidase. Br J
  Ophthalmol. 200084435-436

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pH Adjustment

• Some Randomized Trials Have Shown That Pain is
  Less If Bicarbonate Used
• Other Randomized Trials Have Shown No Effect on
  Pain, If Bicarbonate Used
• We Had Two Cases of LR Palsy When Using, No Cases
  Before or After Using (19,000 vitrectomies) Both
  Completely Resolved, Many Other Cases Have Been
  Reported

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Suction Line Under Drape

• Vacuum Line Under Drape Reduces pCO2 by
  Increasing Egress of Exhaled Air
• Patients Often State Cannot Get Air, Patients
  Are Then Often Told That O2 Saturation is OK,
  Patient is Really Complaining About High CO2,
  Over-Sedation Can Occur If Hypercapnia is
  Interpreted as Anxiety
• If Cautery Use Air, Not Oxygen to Prevent Fires

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Air/Gas and General Anesthesia

• Turn Off Nitrous Oxide at Least 10 Minutes Before
  Air or Gas Infused/Exchanged or Bubble Will Be
  Much Smaller Post-Op IOP Will Be Too Low
• Rule Applies to Air and Air/Gas Mixtures
• If Nitrous Oxide is Used for Non-Ophthalmic
  Procedure Air/Gas Bubble Is In Place From
  Previous Vitreoretinal Procedure Procedure,
  Bubble Will Expand, Increase IOP, and Potentially
  Cause a Central Retinal Artery Occlusion During
  Procedure

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Anti-Coagulation Issues

• Cannula-Based Sub-Tenons Anesthesia Virtually
  Eliminates the Risk of Orbital Bleeding
• Ocular Bleeding is Not an Issue with VR or
  Cataract Surgery
• I Never Stop Anti-Coagulants Before Surgery
• Risk of Morbidity Mortality Myocardial
  Infarction, Pulmonary Embolism, DVT, Stroke
  Risk Increased
• Risk of Significant Ocular Bleeding Greatly
  Exaggerated

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Efficiency Issues

• Immediate, Nearby, Easy to Find Access to All
  Reusable Disposable Tools, Laser, Laser
  Probes, Pharmaceutical Products, Silicone Oil,
  Gas, PFO, Etc. is Essential
• Faster Response to Change in Plans Less
  Turnover Time Reduces Labor Costs
• Faster Response Better for Patient Team
• Well-Trained, Experienced Team is Crucial

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Contact Information

• Steve Charles, MD
• 800-423-0404
• Pager 800-670-5186
• Cell 901-277-2595
• scharles_at_att.net
• www.charles-retina.com