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March 3, 2010

March 3, 2010

SECO

SECO

Updates in Corneal

Updates in Corneal

Refractive Laser Vision

Refractive Laser Vision

Correction

Correction

Welcome!

Welcome!

Eugene M. Smith, Jr., M.D.

Eugene M. Smith, Jr., M.D.

Surgeon & Medical Director

Surgeon & Medical Director

Lasik

Lasik

Plus

Plus

Vision Centers

Vision Centers

Atlanta, GA

Atlanta, GA

Education & Training

Education & Training

COLLEGE:

COLLEGE:

 US Air Force Academy,US Air Force Academy, Colorado Springs, CO Colorado Springs, CO 

 University of Georgia,University of Georgia, Athens, GA Athens, GA B.S. Microbiology, 1986 B.S. Microbiology, 1986 MEDICAL SCHOOL: MEDICAL SCHOOL:

 Medical College of Georgia,Medical College of Georgia, Augusta, GA Augusta, GA Medical Doctor, Medical Doctor, M.D. 1991 M.D. 1991 INTERNSHIP: INTERNSHIP:

 University of Hawaii IntegratedUniversity of Hawaii Integrated Transitional Residency Program Transitional Residency Program Honolulu, HI 1991

Honolulu, HI 1991--9292 RESIDENCY: RESIDENCY:

 Brown University School ofBrown University School of Medicine, Dept Ophthalmology Medicine, Dept Ophthalmology & Surgery, Providence, RI 1992 & Surgery, Providence, RI 1992--95

95

Arizona Centre Eye & Facial Plastic Surgery,Arizona Centre Eye & Facial Plastic Surgery,

Tucson, AZ 1995 Tucson, AZ 1995 -- 19961996

ASOPRSASOPRS -- American Society of Oculo Facial Plastic &American Society of Oculo Facial Plastic &

Reconstructive Surgery Approved Fellowship Reconstructive Surgery Approved Fellowship

Preceptor: Robert M. Dryden MD, Assistant ClinicalPreceptor: Robert M. Dryden MD, Assistant Clinical

Professor, University of Arizona, Tucson, AZ Professor, University of Arizona, Tucson, AZ

Fellowship involved Diagnosis, Management andFellowship involved Diagnosis, Management and Treatment of complicated External Disease of the Treatment of complicated External Disease of the Face, Eyelids, Conjunctiva and Cornea

Face, Eyelids, Conjunctiva and Cornea

Board Certification in Ophthalmology 1997Board Certification in Ophthalmology 1997

Fellowship:

Fellowship:

External Disease / Oculoplastic Surgery

External Disease / Oculoplastic Surgery

Fellowship:

Fellowship:

Cosmetic Plastic Surgery

Cosmetic Plastic Surgery

Plastic Surgery Center of the PacificPlastic Surgery Center of the Pacific Honolulu, HI 1996

Honolulu, HI 1996 -- 19981998

American Society of Cosmetic SurgeryAmerican Society of Cosmetic Surgery Approved Fellowship

Approved Fellowship

Preceptor: Robert S. Flowers, MD,Preceptor: Robert S. Flowers, MD, Assistant Clinical Professor, Dept of Assistant Clinical Professor, Dept of Plastic Surgery, University of Hawaii, Plastic Surgery, University of Hawaii, Honolulu, HI

Honolulu, HI

Fellowship involved full body cosmeticFellowship involved full body cosmetic surgery with emphasis on cosmetic surgery with emphasis on cosmetic surgery of the eyes and face. surgery of the eyes and face.

American Board of Cosmetic SurgeryAmerican Board of Cosmetic Surgery --Board Certification 1997

Board Certification 1997

Authored Journal Articles &

Authored Journal Articles &

Book Chapters

Book Chapters

Co

Co--Managing Doctors

Managing Doctors

Laser Vision Correction

Laser Vision Correction

Cosmetic Plastic Surgery

Cosmetic Plastic Surgery

Thank you!

Thank you!

(2)

Corneal Refractive

Corneal Refractive

Laser Vision Correction

Laser Vision Correction

FLAPS:

FLAPS:

Which is better?

Which is better?

Microkeratome

Microkeratome

vs.

vs.

Femtosecond

Femtosecond

(IntraLase)

(IntraLase)

Thank you!

Thank you!

FLAPS:

FLAPS:

Which is better?

Which is better?

Microkeratome

Microkeratome

vs.

vs.

Femtosecond

Femtosecond

(IntraLase)

(IntraLase)

Thank you!

Thank you!

POLL QUESTION:

POLL QUESTION:

In the hands of an

In the hands of an experienced

experienced surgeon

surgeon . . .

. . .

Who believes a

Who believes a

Microkeratome is

Microkeratome is

as precise / accurate as

as precise / accurate as

Intralase (Femtosecond laser)?

Intralase (Femtosecond laser)?

POLL QUESTION:

POLL QUESTION:

In the hands of an

In the hands of an experienced

experienced surgeon

surgeon . . .

. . .

Who believes an experienced cataract

Who believes an experienced cataract

surgeon can make as accurate

surgeon can make as accurate

incisions (size/shape), capsulorhexis,

incisions (size/shape), capsulorhexis,

POLL QUESTION:

POLL QUESTION:

Experienced cataract surgeon

Experienced cataract surgeon

versus

versus

Femtosecond laser

Femtosecond laser

(3)

FLAPS:

FLAPS:

Is precision and accuracy

Is precision and accuracy

important when making a

important when making a

LASIK flap?

LASIK flap?

FLAPS:

FLAPS:

Is precision and accuracy

Is precision and accuracy

important when making a

important when making a

LASIK flap?

LASIK flap?

YES!

YES!

Flap Shape

Flap Shape -- Meniscus

Meniscus

Consequences of the Bulge

Consequences of the Bulge

The blade exits the cornea

The blade exits the cornea

Button Hole

Button Hole

(4)

Epithelial Ingrowth

Epithelial Ingrowth

Flap Shape

Flap Shape -- Planar

Planar

Consequences of a Meniscus Flap

Consequences of a Meniscus Flap

Accentuated Mudcrack Striae

Accentuated Mudcrack Striae

(Concentric compression of the thinnest flap area) (Concentric compression of the thinnest flap area)

planar

planar

meniscus

meniscus

BIOMECHANICS

BIOMECHANICS

(5)

ECTASIA RISK ?

ECTASIA RISK ?

LASIK

LASIK

1:1000

1:1000 -- 1:8,000 ?

1:8,000 ?

PRK

PRK

1:100,000

1:100,000 -- 1:500,000 ?

1:500,000 ?

Theoretically,

Theoretically,

SBK / LASIK affect on corneal

SBK / LASIK affect on corneal

strength approaches that of PRK

strength approaches that of PRK

as corneal flaps become

as corneal flaps become smaller

smaller

in diameter

in diameter and

and thinner.

thinner.

Intralase flap video

Intralase flap video

(6)

LASIK Side Cut

LASIK Side Cut

SIDE CUT:

SIDE CUT:

 

ANGLE

ANGLE

 

DEPTH

DEPTH

LASIK Side Cut

LASIK Side Cut

SIDE CUT:

SIDE CUT:

 

ANGLE

ANGLE

 

DEPTH

DEPTH

Intralase side

Intralase side--cut illustration

cut illustration

video

video

FLAP

FLAP

COMPLICATIONS

COMPLICATIONS

(7)

FLAP COMPLICATIONS

FLAP COMPLICATIONS

Schallhorn SC, et al AJO April

Schallhorn SC, et al AJO April

2006:

2006:

 

0.3% TO 5.7%*

0.3% TO 5.7%*

30 per 10,000

30 per 10,000

570 per 10,000

570 per 10,000

**100 of 10,000 = 1.0 %

100 of 10,000 = 1.0 %

What constitutes a

What constitutes a

FLAP COMPLICATION?

FLAP COMPLICATION?

Intra

Intra--Operative

Operative

Partial Flap

Partial Flap

Button Hole

Button Hole

Free Flap

Free Flap

 

Corneal

Corneal

Abrasions?

Abrasions?

Post

Post--Operative

Operative

 

DLK?

DLK?

 

Ectasia?

Ectasia?

 

Epithelial

Epithelial

Ingrowth?

Ingrowth?

 

Striae?

Striae?

Button Hole

Button Hole

DLK: Stages

DLK: Stages

1 3

1 3

2 4

2 4

DLK:

DLK:

Stages 1

Stages 1 –– 22

POLL QUESTIONS:

POLL QUESTIONS:

Has anyone

Has anyone

managed

managed

a patient with a large

a patient with a large

Post

Post--LASIK

LASIK

CORNEAL

CORNEAL

ABRASION

ABRASION??

(8)

FLAP COMPLICATIONS

FLAP COMPLICATIONS

Schallhorn SC, et al AJO April

Schallhorn SC, et al AJO April

2006:

2006:

 

0.3% TO 5.7%*

0.3% TO 5.7%*

30 per 10,000

30 per 10,000

570 per 10,000

570 per 10,000

**100 of 10,000 = 1.0 %

100 of 10,000 = 1.0 %

11

stst

10k MK

10k MK Last 10k MK

Last 10k MK 11

stst

10k IL

10k IL

Free Flaps Free Flaps -- -- --Partial Flaps Partial Flaps -- -- --Button Holes Button Holes -- --

--Abrasions (Vis Sig)

Abrasions (Vis Sig) -- --

--DLK DLK >> Stg IIStg II -- -- --Ectasia Ectasia -- -- --TOTAL TOTAL

Flap Comp with loss

Flap Comp with loss -- --

--BCVA BCVA >> 2 lines2 lines ABORTED 2

ABORTED 2ndndeyeeye -- --

--(bilateral case sched) (bilateral case sched)

IntraLase Cases requiring action different from

IntraLase Cases requiring action different from

normal procedure (First 10,000 cases):

normal procedure (First 10,000 cases):

Suction Loss Suction Loss

(during flap creation): (during flap creation): 22 Response:

Response: immediate repeat creation of flapimmediate repeat creation of flap Post Op result:

Post Op result: 20/20 for both cases on POD #1 and beyond20/20 for both cases on POD #1 and beyond Vertical gas

Vertical gas 11 breakthrough:

breakthrough: size/location: small, at flap peripherysize/location: small, at flap periphery Response:

Response: flap lifted with manual dissection inflap lifted with manual dissection in this area

this area Post Op result:

Post Op result: 20/20 on POD#1 and beyond20/20 on POD#1 and beyond Aborted 2

Aborted 2ndndeye (bilateral case scheduled): 0eye (bilateral case scheduled): 0

TOTAL: TOTAL: 3 (0.03%)3 (0.03%) LOSS OF BCVA LOSS OF BCVA 00

Femtosecond (IntraLase)

Femtosecond (IntraLase)

ADVANTAGES

ADVANTAGES

PRECISE CONTROL of FLAP PARAMETERS:PRECISE CONTROL of FLAP PARAMETERS:

Diameter, Thickness, Shape (

Diameter, Thickness, Shape (PLANARPLANAR),), Side

Side--cut anglecut angle

EXTREMELY LOWEXTREMELY LOW FLAPFLAP COMPLICATION RATE:COMPLICATION RATE:

Experienced surg: LESS THAN 1:10,000? Experienced surg: LESS THAN 1:10,000?

LOW RISK of need to ABORT PROCEDURE:LOW RISK of need to ABORT PROCEDURE:

Experienced surg: LESS THAN 1:10,000? Experienced surg: LESS THAN 1:10,000?

LOWER RISK OF ECTASIA?LOWER RISK OF ECTASIA?

Femtosecond (IntraLase)

Femtosecond (IntraLase)

DISADVANTAGES

DISADVANTAGES

Caution with corneal scars: post RKCaution with corneal scars: post RK

Transient Light Sensitivity and interfaceTransient Light Sensitivity and interface

inflammation may occur if energy set too high inflammation may occur if energy set too high

Not readily portable (rollNot readily portable (roll--on/rollon/roll--off is difficult)off is difficult)

Higher COST Higher COST

Microkeratome:

Microkeratome:

DISADVANTAGES

DISADVANTAGES

Higher FLAP COMPLICATION RATE?

Higher FLAP COMPLICATION RATE?

Partial Flaps, Button Holes, DLK, Abrasions, Partial Flaps, Button Holes, DLK, Abrasions, Epithelial Ingrowth: (1:1000

Epithelial Ingrowth: (1:1000 –– 1:5000?)1:5000?)

UNABLE TO VARY FLAP PARAMETERS:UNABLE TO VARY FLAP PARAMETERS:

Diameter, Thickness, Shape (

Diameter, Thickness, Shape (MeniscusMeniscus), sidecut), sidecut

ABORT PROCEDURE: ABORT PROCEDURE:

(9)

Microkeratome:

Microkeratome:

ADVANTAGES

ADVANTAGES

INEXPENSIVE

INEXPENSIVE

Hardware ($50k vs. $300k)Hardware ($50k vs. $300k) Maintenance costs

Maintenance costs $30 per flap $30 per flap

PORTABLEPORTABLE(easy to carry to different locations)(easy to carry to different locations)

May use with Corneal Scars (post RK)May use with Corneal Scars (post RK)

Low Complication rate in hands of EXPERIENCEDLow Complication rate in hands of EXPERIENCED

SURGEON ( SURGEON (1:3,0001:3,000?)?)

surgeons often say . . . surgeons often say . . .

““In my hands a microkeratome is safer than theIn my hands a microkeratome is safer than the IntraLase IntraLase . . .. . .””

Which

Which

EXCIMER

EXCIMER

laser is

laser is

BEST?

BEST?

FDA Data of Approved

FDA Data of Approved

CONVENTIONAL Lasers

CONVENTIONAL Lasers

0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00%

B&L LADAR Nidek

20/40 or better 20/20 or better

LASIK and PRK for low to moderate myopia (less than 7D) and low to moderate astigmatism (less than -4D).Source: www.fda.gov 1996

99.7% 87.3% 97% 58.6% 93.7% 56.9% 85.4% 53.1% 84.4%47.4%

VISX LSX

LEADING LASER SYSTEMS

LEADING LASER SYSTEMS

LASER

LASER CONVENTIONALCONVENTIONAL ABERROMETERABERROMETER WAVEFRONTWAVEFRONT

VISX

VISX STAR S 4STAR S 4 WAVESCANWAVESCAN CUSTOMVUECUSTOMVUE ALLEGRETTO

ALLEGRETTOWaveLightWaveLight Wavelight Wavefront GuidedWavelight Wavefront Guided Optimized

Optimized ALCON

ALCON LADARVisionLADARVision LADARWAVE CUSTOMCORNEALADARWAVE CUSTOMCORNEA B & L

B & L TECHNOLASTECHNOLAS ZYWAVEZYWAVE ZYOPTIXZYOPTIX

Which one?

Which one?

Which excimer laser is best?

Which excimer laser is best?

Can we use ONE laser for everyone?

Can we use ONE laser for everyone?

IRB Approved*

IRB Approved* –– Multicenter Trial at LasikPlusMulticenter Trial at LasikPlus Moderator: Dr. Dan Durrie

Moderator: Dr. Dan Durrie

3 centers3 centers

Minneapolis Dr. Matthew SharpeMinneapolis Dr. Matthew Sharpe

Washington, D.C. Dr. Neil WillsWashington, D.C. Dr. Neil Wills

Atlanta Dr. Eugene SmithAtlanta Dr. Eugene Smith

180 eyes180 eyes(60 eyes of 30 patients in 3 centers)(60 eyes of 30 patients in 3 centers)

ContraContra--lateral eye studylateral eye study (eyes “matched”)(eyes “matched”)

eyeseyes randomizedrandomized to receive:to receive:

WLO, WFG, VISX S4, CV, B&L, Zy WLO, WFG, VISX S4, CV, B&L, Zy

(10)

IRB Approved*

IRB Approved* –– Multicenter Trial at LasikPlusMulticenter Trial at LasikPlus Moderator: Dr. Dan Durrie

Moderator: Dr. Dan Durrie

**IRB granted authority by FDA to ensure safe and effective research.IRB granted authority by FDA to ensure safe and effective research.

Study has been accepted for presentation andStudy has been accepted for presentation and

publication at ASCRS 2011 Spring meeting publication at ASCRS 2011 Spring meeting (March 29, 2011) San Diego, CA.

(March 29, 2011) San Diego, CA.

CONCLUSIONS

CONCLUSIONS

No single laser is best for all treatmentsNo single laser is best for all treatments

WaveLight Optimized results and CustomVueWaveLight Optimized results and CustomVue

results are equal in most cases. results are equal in most cases.

Wavelight Optimized is usually better thanWavelight Optimized is usually better than

conventional treatments conventional treatments

Wavelight Optimized is preferred to Custom in someWavelight Optimized is preferred to Custom in some

situations. situations.

Custom is preferred to WLO in some situations.Custom is preferred to WLO in some situations.

We now use VISX and Wavelight systemsWe now use VISX and Wavelight systems

Lasik

LasikPlus

Plus

No single Excimer is the best for every patient.No single Excimer is the best for every patient.

No single treatment delivery (Custom vs. Optimized vs.No single treatment delivery (Custom vs. Optimized vs.

Conventional) is best for every pt. Conventional) is best for every pt. Sometimes: Sometimes:

Custom treatment is preferredCustom treatment is preferred

Wavefront Optimized treatment is preferredWavefront Optimized treatment is preferred

Conventional treatment is preferredConventional treatment is preferred

LEADING LASER SYSTEMS

LEADING LASER SYSTEMS

LASER

LASER TREATMENT RANGETREATMENT RANGE VISX

VISX

STAR S 4

STAR S 4 -- 14 to + 6, Astig 6 D14 to + 6, Astig 6 D CUSTOMVUE

CUSTOMVUE -- 8 to +4, Astig 3.5 D8 to +4, Astig 3.5 D

ALCON ALCON

(WAVELIGHT) (WAVELIGHT)

WaveLight Optimized

WaveLight Optimized -- 14 to + 6, Astig 614 to + 6, Astig 6 Wavefront Guided Wavefront Guided Topography Guided Topography Guided

Infections

Infections

 

2001

2001

Most common

Most common

 

Atypical

Atypical

Mycobacterium

Mycobacterium

Now rare due to use of

Now rare due to use of

 

2011

2011

Most common

Most common

Methicillin Resistant

Methicillin Resistant

Staphalococus Aureus

Staphalococus Aureus

(MRSA)

(MRSA)

Corneal Topography

Corneal Topography

Pentacam

Pentacam

vs.

vs.

(11)

What is the most important

What is the most important

reason for

reason for

Topography?

Topography?

Most important reason for

Most important reason for

Topography

Topography::

To identify signs of

To identify signs of

INTRINSIC CORNEAL WEAKNESS

INTRINSIC CORNEAL WEAKNESS

forme fruste

forme fruste

KERATOCONUSKERATOCONUS

PELLUCID MARGINAL DEGENERATIONPELLUCID MARGINAL DEGENERATION

**

TYPICAL FEATURES of CORNEAL ECTATIC DISEASESTYPICAL FEATURES of CORNEAL ECTATIC DISEASES

KERATOCONUS (KC)* KERATOCONUS (KC)*

 Young pt: 15Young pt: 15 -- 3939 

 Usually INFERIOR corneaUsually INFERIOR cornea (temporal, nasal or superior (temporal, nasal or superior also possible)

also possible) 

 Usually BilateralUsually Bilateral (may be asymmetric) (may be asymmetric) 

 ParaPara--central thinning withcentral thinning with protrusion in area of thinning protrusion in area of thinning 

 Pach: THINPach: THIN 

 Retinoscopy: scissoringRetinoscopy: scissoring 

 ATR AstigmatismATR Astigmatism   PrevalencePrevalence (1:2,000?)(1:2,000?) PELLUCID MARGINAL PELLUCID MARGINAL DEGENERATION (PMD)* DEGENERATION (PMD)*

 Manifest age 40+Manifest age 40+ 

 INFERIORINFERIOR 

 Bilateral (may beBilateral (may be asymmetric) asymmetric) 

 Peripheral band of thinningPeripheral band of thinning with protrusion above band with protrusion above band 

 Pach: NORMALPach: NORMAL 

 ATR AstigmatismATR Astigmatism

PrevalencePrevalence(1:20,000?(1:20,000?

--50,000?) 50,000?)

Ectasia Risk Factor Analysis

Ectasia Risk Factor Analysis

Orbscan versus Pentacam Orbscan versus Pentacam   Rabinowitz (1999)Rabinowitz (1999)   KylceKylce   GrodenGroden   RandlemanRandleman 

I:S differenceI:S difference 

AgeAge 

AsymmetryAsymmetry 

Posterior floatPosterior float 

Posterior shapePosterior shape

Ectasia Risk Factor Analysis

Ectasia Risk Factor Analysis

  Rabinowitz (1999)Rabinowitz (1999)   KylceKylce   GrodenGroden   RandlemanRandleman

(12)

Normal

Normal

Keratoconus

Keratoconus

Pellucid Marginal Degeneration

Pellucid Marginal Degeneration -- advanced

advanced

KC PMD

KC PMD

PMD

(13)

FF PMD?

FF PMD?

CLASSIC KC

CLASSIC KC

FFKC?

FFKC?

FFKC?

FFKC?

KC

KC -- 31 yo

31 yo

FFKC?

FFKC?

(14)

KC

KC

FFKC progression to KC

FFKC progression to KC

PMD

PMD

FF PMD? “LOBSTER CLAW”

FF PMD? “LOBSTER CLAW”

KISSING FISH

KISSING FISH

(15)

MUSTACHE / KISSING FISH / KEYHOLE

MUSTACHE / KISSING FISH / KEYHOLE MUSTACHE / KISSING FISH / KEYHOLEMUSTACHE / KISSING FISH / KEYHOLE

FFPMD? “kissing fish” “fish mouth”

FFPMD? “kissing fish” “fish mouth”

0.5 D SCALE 1.5 D

0.5 D SCALE 1.5 D

FFPMD? “Fat Lobster Claw?”

(16)

EARLY LOBSTER CLAW

EARLY LOBSTER CLAW FFFF -- KC vs FFKC vs FF -- PMD?PMD?

VERTICAL “D”

VERTICAL “D”

QUESTIONS?

QUESTIONS?

My cell phone:

My cell phone:

404.667.2003

404.667.2003

404.667.2003

404.667.2003

Co

Co--Mgt:

Mgt:

770.841.9282

770.841.9282

(17)

References

References

and

and

Co

Co--Management

Management

Information

Information

References

References

Ocular TRUST Study

Ocular TRUST Study

LASIK COMPLICATION RATES

LASIK COMPLICATION RATES

FDA: 1

FDA: 1 –– 5% of cases

5% of cases

Glare and sensitivity to light:Glare and sensitivity to light: 1.7%1.7%of patientsof patients 

Visual fluctuations:Visual fluctuations: 2.6%2.6%of patientsof patients 

Halos around light sources:Halos around light sources: 3.5%3.5%of patientsof patients 

Report vision worse than before LASIK:Report vision worse than before LASIK:3.0%3.0%of ptsof pts

LASIK SUCESS RATES

LASIK SUCESS RATES

AAO/Soloman review of 64 LASIK studies

AAO/Soloman review of 64 LASIK studies

since 2000

since 2000

ASCRS 2008 worldwide Satisfaction rate 95.4%

ASCRS 2008 worldwide Satisfaction rate 95.4%

Low to Moderate myopia

Low to Moderate myopia

99% 20/40 or better99% 20/40 or better

Low to High myopia

Low to High myopia

94% 20/40 or better94% 20/40 or better

High myopia

High myopia

89% 20/40 or better89% 20/40 or better

LASIK SUCESS RATES

LASIK SUCESS RATES

AAPECS (Am. Assoc of Profess. Eyecare Spec)

AAPECS (Am. Assoc of Profess. Eyecare Spec)

55.3% 20/20 or better55.3% 20/20 or better 

92.6% 20/40 or better92.6% 20/40 or better

LCAV Multi

LCAV Multi--center trial

center trial

93.3% 20/20 or better93.3% 20/20 or better 

100% 20/40 or better100% 20/40 or better

ASCRS 2008 worldwide Satisfaction rate 95.4%

ASCRS 2008 worldwide Satisfaction rate 95.4%

55.3% 20/20 or better55.3% 20/20 or better 

(18)

Co-Management Program - LCA

• Multiple laser systems allows customized patient treatments

• Unbeatable results (> 93% 20/20 or better) • Best value for patients (Best price guarantee for

same technology and same service/acuity plan) – SAME PRICE FOR CO-MGT AND OUR PATIENTS • Payment plan = 20% of price paid by patient • Primary care referrals: We refer patients to our

list of Co-managing doctors • Lifetime Acuity Plan

• Surgeon Accessibility (Cell #: 404-667-2003)

Co-Management Program

• Facility Fees

– Co-Management Fee =20%, amount depends on acuity plan patient chooses and price paid (insurance plan may change the price)

– Most patients choose life-time acuity plan

Co-Management Program

• Initial Contact:

Shanon: 770-841-9282

Co-Management

Coordinator, or

Tracy: 770-527-1921

Atlanta Area Director

• Credentialing Packet

• Fill out the EXAM FORM and FAX to Shannon – Please send form even if not entirely complete – Many tests will be repeated on treatment day

• (MR or CR, Orbscan, Pachymetry, Pupil diameters, K values, etc.)

• If needed, consult with Dr. Silver, Dr. Wright, Dr. Wild or Dr. Smith.

Figure

Updating...

References

  1. www.fda.gov 1996
Related subjects :