Increase your surgical efficiency

Methods range from modern integrated technology to scheduling and patient flow improvements.

When it comes to surgical efficiency, the philosophy of Vance Thompson, MD, founder of Vance Thompson Vision in Sioux Falls, S.D., and professor of ophthalmology at the University of South Dakota Sanford School of Medicine, quotes a famous phrase from legendary UCLA basketball coach John Wooden: “Be quick, but don’t hurry.”

A flowing, well-running surgical environment functions almost like a ballet. Team members work in unison to deliver an efficient procedure and optimal patient outcomes.

Even if you are pleased with your surgical efficiency, there is always room to tweak your methods to see more patients or aid your staff — and odds are that you are or soon will be seeing more patients. As baby boomers age and the Medicare population grows, “we are seeing an increased number of patients who enter the cataract age group,” says Ravi Goel, MD, clinical spokesperson for the AAO and cataract surgeon at Regional Eye Associates, Cherry Hill, N.J.

Another reason to shore up your workflow processes: “In the year 2020, our [cataract surgery] reimbursement will continue to face challenges,” Dr. Goel says. More specifically, the AAO calculates that physician reimbursement for cataract surgery (CPT 66984) will decrease approximately $100 beginning in January 2020. For these reasons, workflow processes and productivity will become increasingly important.

In this article, industry experts offer various ways they have increased efficiency — some involve advanced, integrated technologies, while others focus on more basic techniques.


Integrated devices

One major way to improve surgical efficiency is to leverage technology that integrates with various devices in the practice. For instance, Larry E. Patterson, MD, medical director of Eye Centers of Tennessee, Crossville, Tenn., uses the Zeiss IOLMaster 700 with FORUM software and CALLISTO eye markerless alignment.

If, for instance, Dr. Patterson needs to provide a patient with a toric lens centered at 165 degrees, that information is taken from the IOLMaster, transferred into the FORUM software then wirelessly transmitted to CALLISTO connected to his microscope. Through the oculars of the microscope, he sees an overlay of lines in the proper orientation the toric IOL should align. “There’s no inexact ink marking. We know exactly, to the degree, how to line up the implant,” he says, with “spectacular” results.

In addition, if a patient needs manual limbal-relaxing incisions (LRIs) and requires a 40-degree LRI that’s placed on the eye at 35 degrees, “I look through my microscope and will actually see that line at the limbus at the perfect length, at the perfect axis, and I know exactly where to cut,” says Dr. Patterson. “I just cut on the line that’s already shown in that virtual display. And again, we’re getting great outcomes with that.”

The formulas that Dr. Patterson uses are built into the IOLMaster as well. His staff can print out information such as the formulas, axial length and the different refractive outcomes he would obtain by using different types of implants. “It’s all printed out on one piece of paper; we can mark it up and sign it and move on.”

Dr. Patterson says that these integrated technologies save him much as an hour a week, including both preop planning and intraoperative time.

Integrated technologies also help Denise M. Visco, MD, MBA, president and medical director, Eyes of York (Pa.). She uses the Cassini Total Corneal Astigmatism, Oculus Pentacam HR and Nidek OPD-Scan III, which integrate with her LENSAR femtosecond laser. The Cassini, Dr. Visco notes, registers the iris and measures corneal astigmatism. This information can be transferred wirelessly to the femtosecond laser for treatment. “Transcription error has been virtually eliminated with that process,” she says.

Once in the operating room, no preoperative or intraoperative marking is required for a patient who is having a toric lens or astigmatic incisions. Data is pre-programmed so she can start immediately. “Then you have 2 minutes or less of treatment time for the patient.”

Intraoperatively, another huge time-savings is having her nomogram in the femtosecond laser. This eliminates the need to make a detailed plan for arcuate incisions before going into the OR and avoids any intraoperative adjustments. “A few years ago, I put the nomogram in the laser, decided on my own modifications once or twice, and it’s done.” Treatments populate automatically based on the amount of cylinder correction desired, the patient’s age and so forth.

Furthermore, the laser also automatically marks her steep axis for toric IOLs with an iris registration maneuver. “I know my toric IOL alignment is spot-on every case, and I never once have had to mark the patient; it’s completely no stress.”

With these integrated technologies, the preop stage of cataract surgery is much more efficient. “I know how much time I used to spend when I had to plan arcuate incisions preoperatively. I would say it’s probably cut about 70% of my time down in planning the surgery.”

She sees a similar time savings with toric IOL patients intraoperatively as well. “My toric cases take less than half the time they used to.”

The Veracity software also helps save time. All of the surgical planning data is in one place for review and stored in the cloud; surgeons can access the program remotely anywhere, anytime and have the full range of analysis easily viewed in one area for efficient evaluation and decision making. Furthermore, from the workflow standpoint, data is uploaded directly from the topography and biometry devices, which saves time for technicians — Dr. Visco estimates they spend 30% less time preparing refractive cases. “All of these systems are a huge time saver. And that’s before we even get into the OR. If you don’t do all these things before you get into the OR, then you inevitably will have delays at the time of surgery,” Dr. Visco says.

Along with the benefit of time savings, removing as much of the data input on the day of surgery as possible helps to avoid errors. “You should be taking care of the task at hand and just applying the treatment that you’ve planned,” Dr. Visco says. “Altering, adjusting or marking a surgical plan is a different task than performing a surgical plan. Having to do both on the day of surgery creates an opportunity for mistakes.”

Disposable technology

Another example of technology boosting efficiency is the Zepto capsulotomy system (Mynosys), which Dr. Thompson says has dramatically increased the number of cases he can handle. Zepto allows surgeons to perform anterior lens capsulotomies in a disposable format. It features a collapsible, elastic nitinol capsulotomy ring element designed to create a unique and strong capsulotomy edge, the company says.

Prior to using Zepto for his premium cataract surgeries, he had to move to a separate room to perform part of the surgery with his femtosecond laser. When he incorporated Zepto, he could perform the capsulotomy portion in the OR under the same microscope as the rest of the surgery. The result: He added six more cases in a half day of surgery — a major increase, as 40% of his surgeries are premium.

While perhaps not as high-tech as some of the previously discussed methods, custom procedure packs can also boost efficiency. These packs can contain all single-use instruments and accessories required for surgery, including surgical gowns, gloves, etc., which reduces prep time and helps with surgical flow.

However, custom packs, says Dr. Patterson, should contain “what you’re absolutely certain you’ll need on every single case. It doesn’t make sense to pay the extra cost, or to create the extra waste, to have custom packs of anything more than what you absolutely need on each case.”

EMR in the OR

Optimally, an EMR system increases efficiency by providing a single place for patient information and data to reside that can easily travel with the surgeon.

For Haresh Ailani, MD, with Eye Consultants of Northern Virginia, having an EMR that allows him to view information, such as preoperative testing, on an iPad in the OR is a benefit — he uses Modernizing Medicine’s EMA. With this mobile solution, he can review images or measurements on the day of surgery before a case and confirm the decision making, IOL and surgical plan. The alternative would require the use of many channels (paper, fax, email, phone calls), which would take more time for the surgeon and involve staff.


Improved scheduling and workflow

Another key to efficiency is scheduling. For example, Dr. Patterson performs his tests and determines whether a patient is a candidate for cataract surgery all in one day. To start, tests performed include the Marco OPD-Scan III, IOLMaster 700 and a macular OCT. Then, in a consultation that typically lasts less than 10 minutes, he determines whether the patient is a candidate for surgery. If it’s a go, he can discuss refractive options and his surgical coordinators, who are in the room with him, can complete the process and schedule the surgery.

Prior to this, it took his team about an hour or more to go through the charts for that next week. Now “we’re just doing it as we go while we’re thinking about the patient. They’re right in front of us. We’re not trying to remember, ‘Who is this?’”

While taking advantage of the increased efficiency that technology can offer, don’t neglect other lower tech methods that can boost productivity. Cathleen M. McCabe, MD, chief medical officer at Eye Health America and medical director at The Eye Associates in Bradenton, Fla., uses simple laminated cards that let her know where to go next. Her day involves a mix of standard cataract surgery and femtosecond laser surgery in two ORs and a separate femto room. Typically, she sees 45 to 50 patients in a surgical day.

“The way we organize patients isn’t by trying to stagger standard surgery with femtosecond laser surgery in a particular pattern,” Dr. McCabe says. “We found that wasn’t as efficient for us, because sometimes patients come in late, or come in early, or need longer to dilate. If we’re really strictly trying to keep up a certain pattern, that gets disrupted too easily for that to be an improvement in efficiency.”

These cards applied with fabric fasteners to two OR doors keep her surgical day flowing, Dr. McCabe says. The signs might say “Laser,” “Mark patient” or “Laser and go mark.”

“We make sure that we have the flow moving in the right direction in between every single patient contact point, and the mechanism for us to do that is with the signs that go on the door,” she says. “By using these cards, the minute I leave a room, I can see where I need to be next.”

Other do’s and don’ts

Here are a few low-tech tips for surgical efficiency:

  • Employ lean management processes. Originally geared for manufacturing, lean management focuses on minimizing waste, says Dr. Goel. One example of lean management involves setting up your office layout to minimize the number of steps a patient has to walk. “We have to become more efficient. We have to become more lean in our processes. Having more lean processes increases the quality of care and decreases medical error.”
  • Use more than one set of eyes. Although the possibility of making an error in selecting an IOL or treatment plan is low, Dr. Visco finds it helpful to have one of her staff members gather the information and write up the surgical plan discussed with the patient. Then, she reviews it and makes adjustments and final decisions. “One set of eyes, I think, is not enough,” she says. Before this double-check system, Dr. Visco would be the only one to review materials for surgical planning; she personally double checked all of her own work, which slowed her down. Knowing back-up systems are in place, she is more confident and efficient.
  • Don’t skimp on equipment. Have enough preop and postop chairs and areas to handle patient flow, recommends Dr. Thompson. Also, he willingly invests in extra instrument trays to promote efficiency.
  • Don’t have the patient select the IOL. You, as the surgeon, should determine the best IOL for the patient, says Dr. Visco. It’s not the patient’s job to figure out which lens he or she should have. Certainly the patient might have questions and come into the visit with a good bit of knowledge. However, the surgeon should understand the technology behind the IOLs the surgeon offers and use his or her judgment to optimize the desired outcome for the patient. Confidently recommending and delivering outcomes for patients improves efficiency as the surgeon avoids wasting time on needless explanations of procedures/IOLs that are not good options for individual patients.


Advanced, integrated systems as well as lower-tech methods and processes are all worthy of consideration to improve surgical productivity.

Finally, remember one fundamental idea, as voiced by Dr. Thompson: It’s still all about outcomes. “Doing great surgery” he says, “increases efficiency a lot.” OM