Abstract  Ocular surface, refractive, cosmetic, plastic, and reconstructive surgery can now be performed safely and efficiently in the office setting without the aid of an anesthesiologist. To make the transition to office-based surgery, an ophthalmologist must minimize anxiety in the conscious patient, manage anesthesia during surgery, and prevent postoperative pain and nausea. Pearls on patient selection, conscious sedation, and pain and nausea prevention will be discussed.

The Transition to Office-Based Surgery

Ophthalmology is a specialty which embraces advances in technology in order to deliver better, and faster, eye care. This transition is evident where surgical services are offered. Intraocular surgery has transitioned from an inpatient endeavor to an outpatient, ambulatory affair. The next transition is to perform the surgery in the office; many surgical services can be offered safely and efficiently in the office setting.

C.R. Bernardino (*)

Oculoplastics and Aesthetic Surgery, Vantage Eye Center, 2 Upper Ragsdale Drive, Suite B130,

Monterey CA, 93940

e-mail: rbernardino@vantageeye.com

Reasons to Transition

Many of the reasons for transitioning from the inpatient setting to the ambulatory setting apply to this transition. The first reason is convenience for the surgeon and patients. Since the surgeon will operate out of the office, patient flow and scheduling of procedures are better controlled. Patients are familiar with the office, and they can typically just show up for surgery in the office without any specific preparation. Given the convenience of office surgery, patient satisfaction tends to be quite high.

Since the surgeon controls scheduling and patient flow, the patient processing is very efficient, leading to faster surgical turnover rates. In turn, the surgeon relies less on anesthesia and hospital staff to care for patients; this gives the surgeon additional control and higher satisfaction rates. A final consideration is financial. For most billing codes, the reimbursement is higher for surgery performed in the office when compared to an ambulatory surgery center or hospital setting. The higher reimbursement is to cover the cost of supplies and overhead. If the surgeon is careful with planning, in-office procedures can be more profitable than doing the surgery outside the office.

Surgical Space and Equipment

In order to successfully transition some procedures to the office, this requires a space to perform the surgical procedures. This can be as simple as a large

eye lane or as involved as a dedicated minor procedure suite. Besides space, equipment is needed, including lighting (ceiling-mounted is ideal but not essential), microscope (if anterior segment procedures are performed), stool and surgical bed, surgical equipment, and supplies. The staff must be properly trained to assist and manage these office-based procedures including any postoperative and emergency situations that may arise.

State Regulations

Prior to offering surgical procedures in the office, one has to ensure that they comply with any state regulations which might govern surgery performed in the office setting [1]. As of 2009, there are 21 states which have legislation on officebased surgery. These states include Alabama, California, Colorado, Florida, Illinois, Kansas, Louisiana, Massachusetts, Mississippi, New Jersey, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, and Virginia. Although each state has nuances in the regulations, most have some common themes [2]. The first is based on level of sedation planned for a surgical procedure. Table 24.1 describes the level of sedation possible for a surgical procedure as originally defined by the American Society of Anesthesiology [3].

Surgery performed with minimal sedation is where oral medications are used for anxiolysis. At this level of sedation, patients have normal

responsiveness and their breathing and cardiac function is unaffected.

At moderate levels of sedation, often called conscious sedation, responsiveness is further depressed. Whether intramuscular, intravenous, or inhaled medications are used, patients can still respond to purposeful verbal or tactile stimulus. Respiratory and cardiac function remains unaffected.

At deep levels of sedation, only painful or repeated stimulation causes a purposeful reaction from the patient. The patient’s airway as well as spontaneous respiration can be affected, but cardiac function is intact.

General anesthesia, the deepest level of sedation, involves complete loss of patient responsiveness, even to painful stimuli. Respiratory and cardiac function can be compromised without direct intervention.

At a minimum, office-surgery regulations require that the surgeon and staff be prepared for emergency situations [4]. Therefore, the office must be equipped with a “crash cart” which should include an oral airway with positive pressure, and basic medications including epinephrine and atropine. The surgeon and staff should also be trained with the surgeon typically needing a minimum of Basic Cardiac Life Support certification. In some states, this is required even if one is only using local anesthetics or oral antianxiety medications; therefore, it is important to check local regulations. There should also be a dedicated transfer plan arranged with a local hospital in case of emergencies; the surgeon needs to have admitting/surgical privileges at that hospital. Documentation is also key when performing

surgical procedures in the office. Informed consent should be well documented in the medical record as well as a surgical procedure note. Finally, infection controls must be in place.

For many states, moderate sedation is defined as sedation which is delivered by intravenous, intramuscular, or inhaled medications. Regulations require the monitoring of vital signs (oxygen saturation, blood pressure, and level of sedation) preoperatively and during the procedure. For IV sedation, a running ECG strip and body temperature monitoring is also required. The surgeon should also be certified in Advanced Cardiac Life Support. Postoperatively, the patient needs to be evaluated by a dedicated staff member who documents O2 saturation, blood pressure, pain control, and level of consciousness. Once a patient is stable for discharge, discharge instructions must be given and documented.

Procedure Selection

Many surgeries can be performed safely and efficiently in the office setting. However, certain surgeries may be better served in the ambulatory surgical center (ASC) or in the in-patient setting. Table 24.2 summarizes reasons why a surgery should be performed outside the office setting. In short, if you cannot provide a comfortable and safe environment for the patient’s procedure in the office, then the surgery should be offered elsewhere. When considering appropriate surgical procedures for the office, the more complex the surgery, the less amenable it may be for the

Table 24.2  Reasons to operate in an ASC or in-patient setting

Table 24.3  Possible procedures performed in the office setting

Cornea/anterior Pterygium excision, refractive surgery, segment simple corneal laceration or wound

dehiscence repair, cryotherapy

office; these issues of surgical complexity may include the presence of multiple surgical sites, the difficulty to anesthetize the surgical site, the risk of blood loss, and the risk of infection. Table 24.3 highlights some of the procedures that an ophthalmologist may consider performing in the office setting.

Patient Selection

Like surgery selection, patient selection is important; the right patient can have surgery with minimal discomfort and risk of complication. Factors to be considered when offering surgery in the office include age and mental status of the patient, language barriers, comorbidities, ability to position the patient, and medications the patient is taking.

It is important to consider a patient’s mental status when offering surgery in the office. The patient must be able to follow simple commands and be able to express pain or discomfort during the procedure. If there is any language barrier between the surgeon and the patient, this may limit the ability to successfully perform surgery on the patient in the office.

Comorbidities which make office-based surgery potentially unsafe include significant cardiovascular problems, sleep apnea, and latex allergies. Also, patients who cannot be

comfortably positioned in the office including pregnant patients or those who cannot lie still for the procedure may not be optimal office surgery candidates. Furthermore, abnormal vital signs, and, in particular, uncontrolled hypertension can be a problem. Not only is hypertension a risk for bleeding during surgery, it is also a risk for cardiovascular events during surgery including stroke or myocardial infarction. Patient with systolic blood pressure ³180 mm Hg and/or diastolic blood pressure ³110 mm Hg should be rescheduled and referred to their medical doctor or emergency department for urgent evaluation.

Patient medications are the final piece of the puzzle when selecting the appropriate patients for office surgery. The main medications, which may alter the ability to offer safe surgery in the office, are those which inhibit coagulation. A surgeon needs to balance the risk of discontinuation of the medicine (stroke or heart attack) versus the risk of hemorrhage. The main medications which fall into this group are aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), clopidogrel (Plavix, Bristol-Myers Squibb, New York, NY and sanofi-aventis US LLC, Bridgewater, NJ), and warfarin (Coumadin, Bristol-Myers Squibb, New York, NY) [5]. Table 24.4 lists these drugs and when they should be discontinued. Finally, herbal medications

Table 24.4  Medications which inhibit coagulation

a Manufactured by Bristol-Myers Squibb, New York, NY b Manufactured by Sanofi-Aventis U.S. LLC, Bridgewater, NJ

Table 24.5  Common herbal supplements and associated risks

should be considered since many patients take these supplements without realizing that they can affect their risk for bleeding during surgery. Table 24.5 covers the most common herbal supplements that might affect surgery. In general, these should be stopped 7–10 days before surgery and may be resumed a day after surgery.

Evaluating Patients at Risk for Anxiety

The first task is recognizing that patients undergoing any invasive procedure can experience anxiety. Patients may not be able to completely describe what they are feeling, but often report a feeling of uneasiness or fear. This sensation is associated with an adrenergic response, leading to increased blood pressure and pulse, and dryness of the mouth. These symptoms can be exacerbated by pain or situations that are overstimulating.

When interviewing patients for a possible surgical procedure, it is important to prescreen them for anxiety. Factors that may be a sign of risk for anxiety around surgery include previous intolerance to surgical procedures or sitting still, history of pain intolerance, medical history of anxiety or other mental illness, or a medical condition leading to lability of blood pressure or heart rate. Patients who may be at risk for anxiety may benefit from techniques to reduce anxiety, or may be better candidates for surgery outside the office setting.