Nancy Groves

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Ophthalmologists operating a small practice are looking for better patient relationships and independence.


	
	Running a solo or small practice today can be a challenge, and the question is whether it is sustainable. Judging from comments by experts, the short-term answer might be “no.” But not so fast, according to 

, who five years ago founded her own solo practice, 

Warrenville EyeCare and Lasik, Warrenville, IL

.
	
	She is also associate professor of ophthalmology, 

University of Illinois Eye and Ear Infirmary

. For one thing, young ophthalmologists deciding on their career direction have a distinct advantage over colleagues in most other specialties.
	
	“We are one of the few specialties in medicine that has the luxury of not being connected to a hospital in most cases, and therefore we have more ability to pursue a solo practice,” Dr. Nijm said. “If you want to build your own business and you have the drive and entrepreneurial spirit to hang you own shingle, you can do it. Studies show a decreased rate of burnout and greater physician satisfaction in solo or small group practices.”
	
	Dr. Nijm suggests that the first step when considering a solo practice is to do some serious soul searching. Physicians should consider what they are looking for in a practice day-to-day and whether this ideal is more likely to be found in an academic or private practice, a solo or group setting.
	
	“The more that you self-reflect and develop a clearer picture of what you’re looking for, the better prepared you will be to evaluate if your expectations match those of the practice settings that you’re considering,” she said.
	
	Dr. Nijm followed this advice when deciding to open her practice after having worked in both a small, ophthalmology-only group and a large multispecialty clinic. She was motivated by her desire to develop deeper relationships with her patients and maintain autonomy and independence while having the flexibility to adopt new technologies when she felt that it would best serve her patients.

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She outlined her formula for success in solo practice. “Imagine yourself like Han Solo in the Star Wars movies,” she said. Similar to the personality and actions this character displayed in the original trilogy, she recommends:

Being friendly, adaptable, and action-oriented

Building a squad or team with shared goals

Using various resources available to you to help establish your practice

Dr. Nijm suggested that a solo practitioner would ideally have an amicable personality, which would allow them to easily talk with patients and maintain good relationships with staff members.
	
	Other desirable traits would include the ability to adjust to new technology and regulatory requirements. As a business owner, they must possess the willingness to take action when problems arise. Physicians who fit this description also must focus on the concept of planning ahead.
	
	“It takes a lot longer than you may anticipate setting up a solo practice,” Dr. Nijm said.
	
	Before seeing the first patient, physicians need to create a business plan, understand the community they are working in, and be realistic about how long it will take to be accepted on insurance panels and obtain hospital credentials.
	
	Often, there is a lag time between opening a practice and 

. Therefore, a major consideration is obtaining the necessary funding ahead of time to purchase equipment, hire staff, and float a functioning practice for anywhere from three to six months.
	
	

 was constantly doing battle with Darth Vader and other villains, solo practitioners will confront their own particular challenges: insurance companies and Medicare, billing and coding-not something physicians should simply leave to their staff, Dr. Nijm emphasized-as well as government compliance requirements and human resources.
	
	Again, like Han Solo, who had help from an assortment of partners as he crisscrossed 

, solo physicians are leaders who must build a strong and compassionate supporting team, united around a core theme.
	
	“You want to send a message from the beginning that you put the patient first,” Dr. Nijm said. “When you put the patient first, everything else falls into place.”
	
	Resources such as the IRIS registry (Intelligent Research in Sight) can be extremely helpful to solo practitioners, she added, and advised doctors just starting out on their own to spend time interacting with other physicians in the community, which can result not only in a useful business network but lasting friendships.
	
	“I’m confident that if you follow these steps with the goal of providing the best care for our patients, the next big thing will be the return of the solo practice,” Dr. Nijm concluded.

This article was adapted from Dr. Nijm’s presentation at the 2018 meeting of the American Academy of Ophthalmology. Dr. Nijm did not report any relevant financial relationships.

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Technology extends beyond community outreach efforst directly to patients at home

This article was reviewed by Ying Han, MD, PhD


	
	New technology for taking the evaluation, diagnosis, and management of glaucoma out of the clinic and directly to the patient is influenc-ing not only community outreach efforts but the feasibility of using teleglaucoma tools in the home.
	
	Tools for home use have been developed for

 measurement and visual field testing, according to Ying Han, MD, PhD, associate professor of oph-thalmology, co-director of the glaucoma service, and director of the glaucoma fellowship program at the University of California San Francisco.
	
	

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	Devices for IOP monitoring include the Icare HOME tonometer and the Triggerfish Contact Lens Sensor. The Icare tonometer provides information on IOP, time and date of measurement, which eye is being tested, and the quality level of the measurement.
	
	In a 2017 study, Takagi et al. concluded that the device was feasible for use in self-monitoring of IOP but that the measurements tended to overes-timate IOP relative to the Goldmann applanation tonometer (GAT). The mean 

 of the 128 participants was 12.2 mm Hg as measured by a glaucoma specialist performing GAT, 12.8 mm when patients used the HOME
	
	The Triggerfish contact lens sensor (Sensimed AG) is a soft disposable silicone contact lens with an embedded microsensor. It automatically re-cords continuous dimensional changes and IOP. De Moraes et al. conducted a study (

 2018) in 445 patients and found that the contact lens sensor recordings may have a better association with visual field progression than Goldman mean IOP measured multiple times during office hours.
	
	The authors concluded that the CLS may be useful in assessing the risk of func-tional loss, even when insufficient visual field information is available.Several methods of performing visual field tests at home are avail-able. The most applicable to home use at this time are the Visual Fields easy and the Melbourne Rapid Fields (MRF), which are iPad apps, and Peristat, an online perimetry test. Visual Fields easy is used for performing supra threshold paramet-ric screening and can be downloaded free from iTunes.
	
	The 3.5-minute test covers 30° of the vIsual field.
	
	According to Dr. Han, it showed good correla-tion with the Humphrey Visual Field testing ,and about 80% repeatability in a 2017 study in the 

 by Johnson et al, who evaluated the app’s performance in Nepal. The MRF glaucoma app can be used to assess the central and peripheral visual field, using a seven-step process that tests 34 x 25 degrees of field and requires four to six minutes per eye.False positives, false negatives, and fixation loss can be monitored, and the app will send a notification to a desig-nated clinician if a significant change has been detected.
	
	A 2016 study in 

Translational Vision Science and Technolog

y demonstrated good test-retest reliability. Another option for patients is Peristat, a free web-based perimetry teat that can be performed on any computer with a 17-inch or larger screen and an Internet connection via keepyoursight.org.
	
	This test maps 24 degrees of visual function and ensures reliability through measurement of fixation losses, false positives, and false negatives.
	
	In a study comparing Peristat online perimetry with the Humphrey perimetry in a clinical setting, Peristat exhibited a reasonable ROC curve as well as significant correlation with the conventional HVF, said Dr. Han, who was the corresponding author of the 2016 study in T

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	In the analysis of Peristat’s ability to distinguish patients with moderate and severe glaucoma from those with normal vision, the area under the curve was 0.87-0.88, sensitivity was 80%, and specificity was 90%.
	
	While the availability of teleglaucoma tools indicates a growing interest in allow-ing patients to be more involved in managing their care, Dr. Han pointed out several barriers that need to be resolved. First, it’s more challenging for physicians to manage large-scale data points from testing conducted in homes than in an of-fice setting.
	
	“Doctors may have low confidence in their ability to make decisions based on images alone,” Dr. Han said. Then there are the nonclinical issues that need to be addressed, such as reimbursement and state licensure requirements that currently may limit a physician’s ability to provide care via teleglaucoma. Teleglaucoma, and particularly home-based screening, are still in the early stages, and time will determine which approaches and tools are most effective and convenient, Dr. Han concluded.
	
	

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Providing patient-centered care is one component of improving the quality of health care, and this becomes more challenging in pediatric ophthalmology since both the child’s and parents’ perspectives on the eye condition and how it affects their lives have to be considered.

The new Pediatric Eye Questionnaires (PedEyeQ) were developed through a collaborative effort by researchers in Minnesota and Texas to address this challenge and make outcomes measures more useful.

The PedEyeQ has three components: a child questionnaire, a proxy questionnaire completed by the parent regarding the child, and a parent questionnaire completed by the parents regarding themselves, said Jonathan M. Holmes, MD, Joseph E. and Rose Marie Green Professor of Visual Sciences, 

Dr. Holmes and Eileen E. Birch, PhD, of the 

 in Dallas, led the teams that developed the questionnaire, designed to help clinicians gather patient-reported outcome measures (PROMs) on health-related quality of life and functional vision in childhood eye conditions.

In the past, many instruments assessing health-related quality of life were just “made up,” Dr. Holmes said, with a group of physicians devising a list of questions that in essence told the patients what should bother them rather than starting by asking more open-ended questions and allowing patients to express what actually bothered them.

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A more valid approach would be to use patient-derived concerns to generate questions that are broadly applicable across populations.

Drs. Holmes and Birch and their teams took up the challenge of crafting an improved pediatric vision questionnaire by interviewing parents of children with eye conditions but also interviewing the children themselves if they were older than age 5.

They asked a series of open-ended questions to 180 children across 10 diagnostic categories, as well as 328 parents. From the recorded and transcribed sessions, they identified 6,824 concerns, subsequently reduced to 569 questions that were sorted into 37 categories.

Questions that were too specific were eliminated, while new summary questions were written to reduce the questions to a manageable number. This left 97 questions in the master child questionnaire.

The team’s objective from this point was to create three components or master questionnaires: one to be delivered to the child in two age-specific versions (5- to 11-year olds and 12- to 17-year-olds), 1 proxy questionnaire for parents to report how they perceive their child’s experience (with three age-specific versions, 0-4 years, 5-11 years, and 12-17 years), and one for the parents themselves to express their own concerns.

These questionnaires were then administered to a new cohort of 277 children and 444 parents.

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To analyze the results, the researchers used factor analysis to determine unidimensional domains within each questionnaire. This was done to avoid a pitfall common in questionnaires in which combining two factors, such as visual acuity and intraocular pressure.

Functional vision and psychosocial concerns produce a hybrid score that would not make sense because a condition or treatment may affect one component and not the other, and therefore they need to be scored separately.

The next step was using Rasch analysis, a mathematical model to convert non-linear questionnaire scores into a linear measure, which weights each question appropriately. Working with children in preceding pilot studies, the teams found that they responded better to questions when given choices related to frequency rather than to difficulty or severity.

The PedEyeQ questionnaire was subsequently designed with the choices of “never,” “sometimes,” or “all of the time.” The process of factor analysis and Rasch analysis led to establishing several domains: functional vision; bothered by eyes and vision; social; frustration/worry; eye care (proxy), and treatment.

Using the example of the scores of one child with esotropia and the proxy score from the parent’s perception of the child, Dr. Holmes observed that the numbers were substantially different. In most domain categories, the child’s score was in the middle of the 0 to 100 range (where 0 is worst and 100 is best), but the parent’s proxy scores were at or near the top of the scale. In this case, the parent apparently hadn’t perceived that the child was bothered by his or her vision problems.

The child’s score for this “bothered by eyes and vision” domain was 55, and the parent’s proxy score was 100.

“I think this is an important clue that we’re going to get different answers from how the parent thinks that the eye condition is affecting their child than from how the child responds,” Dr. Holmes said.

Analysis of the parent questionnaire revealed that the parents were, however, extremely worried about every aspect of their child’s eye problems and treatment.

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The development of this questionnaire is ongoing, Dr. Holmes said. It is being administered to additional cohorts of children and parents and undergoing validation to evaluate sensitivity to the severity of conditions, responsiveness to treatment, and test-retest reliability. It is also being compared with the generic PedsQL questionnaire (Pediatric Quality of Life Inventory), which is focused on overall quality of life.

The PedEyeQ is freely accessible in English and Spanish versions online at www.pedig.net. Rasch lookup tables are also on the site.

“Hopefully, this will move us into a world where patient-reported outcome measures are commonly used in pediatric eye care, not just for research but also clinical practice,” Dr. Holmes said.

The process of development of the PedEyeQ is published as Hatt SR, Leske DA, CastaÃ±eda YS, Wernimont SM, Liebermann L, Cheng-Patel CS, Birch EE, Holmes JM. Development of pediatric eye questionnaires for children with eye disease. Am J 


	This article was adapted from Dr. Holmes’ presentation at the 2018 meeting of the American Academy of Ophthalmology. The investigators have grant funding from the National Institutes of Health for this study.

Researchers hope questionnaire will lead to a world where patient-reported outcome measures are commonly used in pediatric eye care, not just for research but also in clinical practice.

Questionnaire assesses vision in pediatric eye cases

Capsulorhexis-guided lens confirms intended axis during surgery, decreases astigmatism


	
	Approximately half of the population 60 years of age and over exhibits more than 1.0 diopter (D) of corneal astigmatism,

 and one of the challenges surgeons face in treating pre-existing astigmatism is ensuring precise alignment of the toric 

If the lens is not accurately aligned along the intended meridian, the desired astigmatic correction may not be achieved, leaving a very unhappy patient, according to cataract surgeon P. Dee Stephenson, MD, FACS. Dr. Stephenson is in private practice at Stephenson Eye Associates in Venice, FL, and is president of the American College of Eye Surgeons.
	
	

In a recent retrospective analysis of 54 eyes in which laser iris-registered femtosecond laser-assisted anterior capsular marks (IntelliAxis Refractive Capsulorhexis, LENSAR) were used to guide alignment of the Trulign toric IOL (Bausch + Lomb) and ORA (Optiwave Refractive Analysis, Alcon) was used to confirm intended axis during cataract surgery, astigmatism decreased significantly postoperatively (p<0.001), said Dr. Stephenson, who performed the procedures.

The mean preoperative corneal astigmatism was 1.01 D, while the mean residual refractive astigmatism was 0.11 D.

In addition, 94.6 % of eyes were within 0.5 D of postoperative refractive cylinder and 81.1% were within 0.25 D or less of postoperative refractive cylinder. No capsule complications were noted at any time during the study.

Postoperative uncorrected distance visual acuity of 20/30 was achieved in 97.3% of eyes, targeting for -0.50 in non-dominant eye, and none of the toric IOLs required repositioning at the time of surgery
	or afterward. Data for the analysis was collected in follow-up visits four to six weeks postoperatively.

“The Intelliaxis Refractive Capsulorhexis is a safe and effective tool in aiding the alignment of toric IOL at the desired axis, thus reducing astigmatism and reducing postoperative spectacle dependence,
	which leads to optimal patient satisfaction,” said Dr. Stephenson.
	
	

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The LENSAR system uses iris registration to accurately place the capsular marks on the intended axis while preforming the capsulotomy. Iris registration, based on high definition preoperative infrared
	images obtained with numerous corneal diagnostic instruments in the clinic, allows precise correlation of corneal topographic and total corneal astigmatic
	data with laser treatment, opening the way for accurate correction of astigmatism.

The capsular marks have the advantage of eliminating error due to the shortcomings inherent in marking the ocular surface, including surgical parallax, and do not impact the strength or extensibility of the capsulotomy, Dr. Stephenson said. These biochemically stable and permanent capsular marks may also help in postoperative rotation of the IOL and realignment procedures if needed.

"LENSAR’s iris registration-guided femtosecond laser-assisted capsular marks are precise and are vital to achieving accurate toric IOL positioning,” Dr. Stephenson said. “If the IOL rotates by 30 degrees, the astigmatism will remain the same but aligned at an axis other than the original steep axis.”

Capsular marks based on iris registration technology (to account for cyclorotation) are effective in aiding toric IOL alignmentmof IOL at desired axis, thus reducing astigmatism.

“These features can enhance precision and help improve outcomes during cataract surgery, thus improving patient satisfaction,” Dr. Stephenson concluded.
	
	

This article was adapted from Dr. Stephenson's presentation at the 2019 meeting of the American Society of Cataract and Refractive Surgery in San Diego, CA. Dr. Stephenson is a speaker for Lensar, Alcon, and Bausch + Lomb. 

1. Venkataraman A, Kalpana. Visual outcome and rotational stability of open loop toric intraocular lens implantation in Indian eyes.

2013; 61:626-629.
	2. Mallias I, Mylova P, Tassiopoulou A. Correction of astigmatism with toric intraocular lenses.

Author | Nancy Groves

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Teleglaucoma lets patients be more engaged in care

Questionnaire assesses vision in pediatric eye cases

Precise alignment helps surgeons focus on best toric IOL post-op results

Flying solo poses challenges, flexibility and support vital