Ask any glaucoma patient to define the ideal ophthalmology practice and, arguably, most would say exceptional care and cutting-edge technology. Sacramento Eye Consultants, a 25-year-old, full-service practice in California, meets these criteria. Its proof is in their roughly 5,000 loyal glaucoma patients, some of whom travel from across the country.

“I’m proud that we provide a facility that stays current on the latest research, diagnostic equipment and treatments, while also keeping both the characteristics and needs of our patients top of mind,” says practice co-owner Richard A. Lewis, MD.

Here’s a look at how Sacramento Eye Consultants’ delivers its high level of patient care and service.

State-of-the-art diagnostics

Sacramento Eye Consultants’ utilizes the latest diagnostic technology. The practice focuses on proficient, expert technician training to ensure the patients have accurate test results every time. For most glaucoma testing, patient comfort is crucial to obtaining good test results. To ensure good patient comfort, Sacramento Eye Consultants utilizes adjustable chairs and tables. These allow the patient to sit in the appropriate position with their chin and forehead comfortably against the straps regardless of their body size. In addition to comfort, good patient instruction is imperative for proper test results. For example:

• Visual fields (VF). Comfort is particularly important for the HVF (Humphrey, Zeiss), as it can often take more than 20 minutes to complete the test. Techs instruct patients to sit comfortably in the chair, look into the device, focus on the center fixation light, and push the device’s button only when they see the peripheral lights flashing, says Whitney Northon, lead ophthalmic technician. Since it is a long, laborious test it is crucial to have a tech in the room to provide prompting to ensure the patient remains focused on completing the test.

• Optical coherence tomography (OCT). For OCT (Cirrus HD-OCT, Zeiss), ophthalmic tech Luis Campos says in addition to comfort, it is crucial for the patient to remain fixation-point focused. To reduce eye movement, one of the most common reasons that the test needs to be repeated, “reinforcing the directions during the test has helped tremendously on cutting down on false results,” says Ms. Northon. In addition, obtaining a high signal strength is important, as the device’s light waves must successfully penetrate the cornea and pupil to reach the retina and optic nerve, she says. An obstruction to the light will lead to a low signal strength. The technicians are instructed to use artificial tears to improve light penetration if a dry cornea is felt to be the cause of the poor signal strength.

• Pachymetry. To get an accurate measurement of corneal thickness, “it’s imperative that the standard deviation be as low as possible when using this device,” Mr. Campos says. “This requires the tech keep a steady hand, keeping the device located on the central cornea, while instructing the patient to look straight ahead.”

• Tonometry. For tonometry (Goldmann, Tono-Pen, Reichert), device calibration, a strong light source, patient positioning, the correct amount of eye-numbing medication and fluorescein (to prevent thick or thin mires, which are noted during IOP measurement), and directing patients to breath normally are all essential to accurate results, Ms. Northon says.

“Also, if a patient is a little overweight, heavy on top, or has mobility issues, we [ophthalmic techs] use a hand-held tonometer,” she says. “Finally, if the patient squeezed his or her eyes or moved to disrupt the results, we always put a note for the doctor to re-check the pressure for accuracy.”

Other diagnostic technology used by the practice includes fundus camera (Eidon, CenterVue), slit lamp camera (Topcon), endothelial camera (Cell-Check, Konan), topographer (Atlas, Zeiss), IOL Master (Zeiss), Frequency Doubling Technology Visual Field (Zeiss), and autorefractor (Zeiss).

Accurate patient history

From the day new staff members are hired, Sacramento Eye Consultants stresses precision when documenting the patient history.

“Asking the right questions is crucial to our ability to provide the most accurate care, so we’ll have a new hire follow an experienced ophthalmic tech for a couple days and also have him or her in the exam room to see why the information is so important,” Dr. Lewis explains. “We also have seasoned techs train new techs on how to transfer the patient’s history into our EHR system.”

To ensure all the required information for glaucoma patients is accurate, Sacramento Eye Consultants’ techs are instructed to be thorough when acquiring the patient history. Pearls include:

• Contact the referring physician. “Once the patient makes an appointment for a glaucoma evaluation, we [ophthalmic techs] ask the referring doctor for his or her notes. There are three reasons for this,” Ms. Northon says. “First, this information provides a guideline for the doctors, in terms of disease duration and potential progression. Second, there may be a language barrier that prevents us from getting the answers we need, and third, most glaucoma patients are elderly and may be unsure of their last IOP reading or, if the patient has already been diagnosed, what drop he or she is using.”

• Match the cap to the drop. In some cases, patients don’t know the specific drops they take. To help get answers, techs use a trick, taught to them by Jacob W. Brubaker, MD, practice co-owner and partner. “The ophthalmic tech will ask the patient, ‘What color is the cap?’ and the tech will rattle off the three different options that fall under that color,” Dr. Brubaker says. “Then the patient will respond, for example, ‘latanoprost! That’s it!’ This technique has worked well.”

• Ask about other conditions. Among these conditions are asthma, COPD, or a history of heart block. “This is something we [ophthalmic techs] always ask, because the use of beta blockers, which are often prescribed for glaucoma patients, can exacerbate respiratory problems or slow heart rate, putting them in danger,” Ms. Northon says. Staff also inquire specifically about family history of glaucoma, diabetes, steroid use, and previous ophthalmic procedures. “This is important for accurate diagnosis, because diabetes and these other conditions can lead to various types of glaucoma,” Mr. Campos says.

Preparation for patients

Having seen glaucoma patients for 25 years, Dr. Lewis and his staff have identified characteristics inherent in all glaucoma patients that can challenge testing accuracy and treatment compliance. To overcome these challenges, they have created practice patterns, which include:

• Screening VF. “When patients have not undergone recent VFs, the ophthalmic techs will perform a screening (double frequency) VF to reduce the time the patient needs to be in the office,” Dr. Brubaker says. “In addition, if a referred patient underwent a VF recently and we have that data, we’ll forgo an additional VF. This is another way we try to cut down on the typical one to two hours new patients must be in the office, which I think they appreciate.”

• Patient mobility. Mobility can be an issue for some glaucoma patients, so the ophthalmic techs employ wheeled swivel chairs to facilitate movement among the various diagnostic devices, says Mr. Campos.

Patient education

Sacramento Eye Consultants uses in-office videos, reading materials and links, via the practice’s website, to educate patients about glaucoma and the surgeries the practice’s doctors perform. (See “Glaucoma surgery” at below.)

“As glaucoma is often a silent disease, right up until blindness begins to occur, it is crucial to educate the patient,” Dr. Brubaker says. Having a firm understanding of their disease will increase compliance. He will often show patients the results of their VF, “which really brings it home for them. This allows then to truly visualize all the parts (of the VF) they are missing.”

Mr. Campos says that the ophthalmic techs also play a role in educating patients, especially about the importance of complying with their prescribed drops. “I’ll tell them [patients] what can happen if they’re not compliant and their IOP is still above the desired range,” he says.

Another method that helps with education is inviting the caregiver into the exam room. “This is very important because these patients — many of whom are elderly — may not be so good at taking drops on a regular basis, or they might have disabilities that make it impossible for them to instill their own drops,” Dr. Lewis says. “Getting the support of their caretakers in understanding why, when, and how to use the drug can make a huge difference in the quality of these patients’ lives.”

Ongoing clinical trials

Sacramento Eye Consultants typically conducts three glaucoma clinical trials simultaneously (along with studies on other eye conditions, such as dry eyes). These in-house clinical trials enable staff to educate patients about what devices and treatments are in the pipeline. This reinforces to patients that the practice stays current on the latest developments.

The practice employs two research coordinators who scrutinize each trial’s protocol, recruit patients, complete all regulatory documents, keep pristine regulatory binders, and enter all data for sponsor review, says Jaime Phillips, one of the research coordinators.

“The ophthalmic technicians keep an eye out for patients who would possibly qualify for studies, ask these patients whether they’re interested in participating, and if it’s a ‘yes’ on both accounts, they are enrolled,” she says. “Typically, we [the research coordinators] conduct all the testing, though there are times when the doctors, ophthalmic techs, and front desk staff are needed — for example, masked IOP readings and treatments.”

Patient excitement

“Patients come here knowing they will receive the latest glaucoma care, whether it’s with diagnostics or with therapeutics. In addition to that, they have opportunities to be involved with research that allows them to potentially obtain therapies prior to FDA approval,” says Dr. Brubaker. “I don’t want to toot our own horn, but I think all those items make us stand out from the crowd.” OP