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A new-patient exam, from the time of check in and filling out forms, through your initial workup, dilation and then the doctor seeing you, plus any other testing may take 1.5 to 2 hours. An existing-patient examination with dilation may still take more than an hour.
We try to give an appropriate amount of time to each patient commensurate with the complexity of his or her problem. As medical doctors for the eyes, this may involve complicated issues that could involve sight-threatening illnesses, neurologic problems and rarely life-threatening illnesses such as strokes and tumors. Unfortunately, we cannot always predict how long these evaluations will take. Our office tries to accommodate emergencies and urgent problems and these patients are “worked in” to the schedule.
We participate with most medical insurances including Medicare, Virginia Medicaid (DMAS), Aetna, Anthem BC/BS, Anthem Healthkeepers (not Healthkeepers PLUS), Coventry, Cigna, Humana, Optima, Tricare, Virginia Premier.
We do not participate with United Healthcare, Anthem Heathkeepers PLUS, Unicare Medicaid, Non Virginia Medicaid Plans, vision care plans.
Patients do not need a referral from another physician to schedule an appointment unless their insurance requires it. The most common insurance carriers that do require a referral from your primary care physician include Humana HMO, Commonwealth Coordinated Plans for Humana, Virginia Premier, Anthem – Medicare/Medicaid combined, Tricare.
To find out if your insurance requires a referral and if we are in its network, call your insurance company. Ultimately, the patient is responsible for knowing what benefits his or her plan offers, including deductibles, copays and co-insurance payments.
We do not participate with vision care plans such as Davis Vision. These plans pay for a basic eye exam and determination of glasses or contact lens changes. Usually optometry offices participate with these plans. Your insurance company can tell you who the network providers are.
If you have a medical condition that pertains to your eyes (for example, dry eye syndrome, cataracts or diabetes), we can submit your bill to your insurance company. You are responsible for any portion of its “allowed charge” that it does not cover including meeting your annual deductible or paying any co-pay or co-insurance that is required.
For a comprehensive new-patient examination, your eyes will be dilated. This may present difficulty with driving afterward; therefore, it may be best to have a driver with you.
For established patients who are being seen for comprehensive evaluations, your eyes typically will be dilated as well.
For urgent evaluations for sudden loss of vision, new floaters or flashes, your eyes will be dilated.
Refraction is the process of determining the need for a change in a glasses or contact lens prescription. Sometimes patients refer to this as the “eye exam,” even though it is only a part of a complete eye evaluation and more appropriately might be called the “vision exam.” The doctor or technician will show you different lens choices and often ask “which is better, one or two?” Medical insurance, with rare exceptions, does not cover the cost of determining the power needed in new glasses and dispensing a prescription for that. Vision care plans may cover this service with in-network providers, but we do not participate with these plans.
This depends upon your age, prior eye problems, your medical history and your family history.
Healthy adults who do not notice anything wrong with their eyes should see an eye doctor according to this schedule:
Ages 19 to 40: at least every 10 years
Ages 41 to 55: at least every 5 years
Ages 56 to 65: at least every 3 years
Over age 65: at least every 2 years
People with diabetes, thyroid eye disease, rheumatologic diseases such as lupus who take Plaquenil (hydroxychloroquine) should be seen at least annually.
People who are at high risk of eye problems should also be seen more often than other people. These include: [K: ANOTHER LIST. REPLACE NUMBERS WITH BULLETS?]
• People of African or Hispanic descent (higher risk for glaucoma)
• People with a tendency toward high intraocular pressure or a family history of glaucoma
• People with cataracts, macular degeneration or a history of retinal detachment
• Anyone with a previous eye injury
• People taking certain medications (Plaquenil, Prednisone, Ethambutol are just a few of the medications that can affect the eyes)
• People already experiencing poor eyesight from any other causes such as cataracts, glaucoma, macular degeneration, etc.
What are some of the medications that may affect my eyes or my eye surgery?
• Plaquenil can cause irreversible damage to the part of the retina called the “macula.” Your eyes should be checked annually and after a cumulative dose of 1,000 grams, typically at year seven, they should be checked every 6 months.
• Prednisone can cause increased eye pressure and promote cataract formation.
• Ethambutol can cause optic nerve damage.
• Flomax(tamsulosin), Rapaflo (silodosin), Hytrin (terazosin) and other medication to help men with enlarged prostate problems can lead to lack of pupil dilation, making eye surgery more difficult, and a condition known as Intraoperative Floppy Iris Syndrome (IFIS).
• Topomax (topiramate) can cause a change in your glasses prescription and can promote narrow angle glaucoma.
• Blood thinners such as warfarin (Coumadin), Pradaxa, Eloquis, Xarelto, Plavix and aspirin can increase the risk of bleeding with eye surgery and some laser procedures for glaucoma. Often, however, these are not stopped for cataract surgery done without an injection of anesthetic.
• Medications for erectile dysfunction have been linked to Anterior Ischemic Optic Neuropathy, but there have not been studies showing true causation with these medications.
Cataracts are a clouding of the lens in the eye. People are usually born with a clear lens and this normally becomes more dense and cloudy with age. Injury, increased blood sugar, inflammation, prior surgery and chronic steroid use (such as Prednisone) can promote cataract formation. Also, infants may be born with them.
Typically, cataracts are removed in an outpatient operating room (not the doctor’s office). The eye is anesthetized (made numb with drops and/or gel on the eye, medication put inside the front of the eye or injected next to the eye). Next, incisions are made in the sclera (white part of the eye) or cornea (clear dome over the colored part of the eye and pupil). Through these incisions the capsule that holds the cataract in place is opened and the cataract is either removed in one piece (extracapsular surgery) or broken into pieces with an ultrasound device (phacoemulsification).
The eye’s natural lens that becomes a cataract is responsible for approximately one-third of the eye’s focusing ability. Without replacing this with an implant, the eye would not focus clearly without VERY thick glasses or a contact lens. It is a standard procedure to put an implant in the eye. Usually these are made of acrylic. The lens implants will not lose their power over time and only in extremely rare cases will they have to be repositioned or replaced.
A cataract will not grow back. Removing a cataract is analogous to removing the appendix. Your appendix cannot regrow, but you may develop scar tissue where the operation was performed. If this happens and it causes blurred vision, an in-office laser procedure (YAG Capsulotomy) can be performed to clear the thin film of scar tissue and restore clear vision.
It is a common misconception that surgeons have and continue to use lasers as a standard procedure to remove cataracts. This is because patients often remember a laser procedure performed sometime after their initial surgery that can be required to remove a layer of scar tissue behind the lens implant.
Lasers are becoming available from some doctors to help assist with the surgery, but incisions still are required and an ultrasound device is still inserted into the eye to remove the cataract. The laser (femtosecond laser adapted from LASIK surgery) is used to initiate the incision in the eye and start dividing the cataract into pieces. The laser assistance is not covered by insurance and is paid for out-of-pocket by the patient. Patients who may benefit from this include those with astigmatism, those having special purpose lens implants inserted or those with pre-existing medical conditions of the eye that make surgery more risky.
No matter what lens implant (including special purpose “toric” and “multifocal” implants) is inserted in the eye, glasses are usually needed after surgery, sometimes, however, only for reading very small print. Typically, your current glasses will need to be remade with a new prescription roughly one month after your surgery.
The standard anesthesia procedure for surgery is to have an anesthesiologist administer a mild intra-venous sedative at the start of the procedure. This is gentle enough so that the patient is relaxed and comfortable but conscious and able to follow instructions. If the patient falls asleep during the procedure, he or she may awake startled and risk moving and having the eye injured. If a patient is claustrophobic and cannot tolerate having a light drape placed over the eye and face and has good heart and lung health, he or she may be a candidate for general anesthesia. This requires medical clearance by the primary care doctor and medical director at the surgery center.
Glaucoma describes a group of diseases that all can result in damage to the optic nerve in the back of the eye, loss of peripheral vision and ultimately blindness. This disease is usually but not always associated with elevated eye pressure. Risk factors for the disease include increasing age, a family history of glaucoma, elevated eye pressure, untreated high blood pressure, thin central corneas and having African or Hispanic ancestry.
The two broad categories of glaucoma include open angle glaucoma and narrow or closed angle glaucoma.
In open angle glaucoma, the fluid that the eye makes internally to nourish itself drains out of the eye and into blood vessels at the front of the eye (this is not where tears come from) between the iris (colored part of the eye) and the cornea (clear dome over the colored part of the eye). If the fluid cannot drain quickly enough, similar to water slowly leaving a sink with a clog in the drain, pressure increases in the eye and over time this can damage the optic nerve. Unfortunately, patients cannot usually sense increased eye pressure or mild loss of peripheral vision.
In narrow angle glaucoma, the fluid that the eye makes cannot access the drainage pathway and the eye pressure may suddenly elevate to very high levels. This is called “acute angle closure glaucoma” and is an emergency situation. Patients usually experience severe aching pain in the eye or brow, blurred vision and nausea.
Open angle glaucoma is usually treated with eye medications that are instilled as drops into the eye. There are a few different types of drops and these are inserted into the eye from 1 to 3 times a day. Sometimes only one type of drop is required, but in severe cases, multiple different types of drops are needed. An alternative or additional treatment involves using a laser to perform “laser trabeculoplasty.” If these treatments do not work well enough, surgery may be indicated. The standard procedure for this is called “trabeculectomy.”
It is hoped that narrow angle glaucoma is diagnosed before an attack of “acute angle closure” occurs. If your doctor recognizes that you are at high risk for this developing, he or she may recommend a preventive procedure called “laser iridotomy.” This is a low-risk in-office procedure that lowers the chance of a sudden attack of glaucoma. For patients who develop this, many drops and sometimes pills are required to lower the pressure and an iridotomy is performed. It is rare that this does not work and the patient requires surgery in an operating room.
People with diabetes, particularly those who have had poor blood sugar control, can develop “diabetic retinopathy.” Early findings your doctor may see include small spots of bleeding within the retina. Swelling called “macular edema” can develop and this often affects vision. In severe cases, abnormal blood vessels grow and these can rupture and bleed into the eye. This is called a “vitreous hemorrhage.” Scar tissue can also develop and lead to a retinal detachment.
Early recognition of these retina findings is important because if treatment is indicated, it will lower the risk of vision loss. If any of these findings are present, usually an exam is recommended more frequently than once a year. If needed, current treatments include the injection of medication into the eye or laser treatment or both.
There are two variations of age-related macular degeneration (ARMD). The sometimes more mild form is non-exudative ARMD, also known “dry” ARMD. The usually more sight-threatening type is exudative ARMD, also known as “wet” ARMD. Historically, there have not been treatments that were effective at stabilizing or improving vision loss from these diseases. In the past decade, however, new therapies have been developed.
The only known treatment that has been shown to benefit patients with dry ARMD if it is severe enough is the ingestion of high-dose anti-oxidant vitamins as determined by the Age Related Eye Disease Study (AREDS). The original study formula included vitamins C and E, zinc, copper and beta-carotene. Patients in this study were also taking a Centrum multi-vitamin in addition to the study formula.
More recently, the study formula was updated and is called AREDS 2. There is a substitution of lutein plus zeaxanthin for beta-carotene. Compared with the original formula, there may be some extra benefit particularly for people who have very low dietary intake of anti-oxidants (usually found in fresh nuts, fruits, leafy greens and orange/red/yellow vegetables, such as carrots, peppers, etc.). There may be as much as a 30 percent reduction in the rate of severe vision loss in patients with moderate to severe dry ARMD over the following 5 years. The current AREDS 2 formula can be found in over-the-counter Preservision AREDS 2 formula multivitamin made by Alcon. This includes the following ingredients:
500 mg vitamin C
400 IU vitamin E
10 mg lutein
2 mg zeaxanthin
80 mg zinc
2 mg copper
Wet ARMD used to be treated with laser therapy, but this often resulted in the immediate loss of vision. A more recent laser treatment called PDT was used briefly but not found to be particularly effective. Currently, this disease is treated with the injection of medication directly into the eye. These medications are called Avastin, Lucentis or Eylea. Studies have shown that as many as 40 percent of patients who develop vision loss from this type of macular degeneration may get some improvement in vision with treatment. These treatments usually have to be repeated every 1 to 3 months indefinitely. These are the same medications that are often used for retinal edema in patients with diabetes, retinal vein occlusions and retinal swelling after surgery.