men. "Compliance isn't 100%," he says. "By using intraoperative injec-
tions, I see all the medicine go into the eye, and don't have to worry
about whether patients will administer all of their drops."
Dr. Boyd hopes a J code for the intraocular injections will eventually
be added to cataract coding, allowing reimbursement for the medica-
tion. He says some surgeons are getting (ahem) "creative" in trying to
get reimbursed, but that's inappropriate and certainly not worth the
risk.
Ophthalmologist Neal Shorstein, MD, associate chief of quality at
Kaiser Permanente's Diablo Service Area in Northern California, says
endophthalmitis is one infection that looms in the mind of every
cataract surgeon, even though it's a rare occurrence. Incidence in the
United States ranges between 1 in 800 and 1 in 1,200 cases, says Dr.
Shorstein, adding that experienced surgeons may never face an infec-
tion, or go years without having one occur.
Dr. Shorstein says post-op complications are often identified as the
cause of endophthalmitis, and points out that posterior capsular rup-
ture is known to increase the risk. But, he says, "Many surgeries as
documented went perfectly well, and yet the patient still developed an
infection. There are still mysteries as to why they occur."
Kaiser's large, integrated health system has the ability to track and
trend infection rates across 21 ophthalmology centers. In 2007,
endophthalmitis rates at Dr. Shorstein's Walnut Creek location were
higher than normal. The surgeons and administrators couldn't find a
direct cause. They read evidence in the literature about dropless
surgery's prophylaxis potential, and since there were no studies that
show drops are effective at preventing endophthalmitis, they went
dropless to help lower the risk of infection.
The surgeons at Walnut Creek adopted the technique for several
months before rolling it out gradually over 5 years. By 2010, they
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