Ophthalmologists from around the country gathered at AAO 2024 in Chicago to tackle the future of eye care. A trending topic was the use of oral sedation for ophthalmic procedures to combat the anesthesia provider shortage. Here is an overview of what was discussed in the course titled “Office-Based Surgery: Insights from Multiple Surgeons with Varied Practice Profiles”.
Over the next ten years, the number of anesthesia providers is expected to drop by 30%, and that will impact the ability of some outpatient facilities to perform surgery. Many regions across the country are already feeling the impact of the shortage. According to Becker’s ASC Review, some ASCs are testing a new anesthesia model that offers a stipend to anesthesia groups helping them maintain a reasonable profit margin while the surgeon takes the hit. Surgeons will be required to meet a minimum number of anesthesia cases during their block time or pay a fee to make up the difference.
When you consider the increased demand for cataract surgery coupled with the declining number of anesthesia providers, there’s certainly a supply and demand problem. The adoption of office-based surgery (OBS) is on the rise as a way for surgeons to increase surgical capacity and to gain more control in general. Having control over the entire surgical process is critical when managing external factors such as the anesthesia shortage and increased fees. With OBS, the level of anesthesia is based on the surgeon’s recommendation for each patient verses a facility’s anesthesia policy that was written for all patients.
OBS suites utilize either Class A or Class B anesthesia. Class A facilities are accredited for oral and topical anesthetics, while Class B facilities allow for monitored oral and intravenous (IV) sedation but not general anesthesia.
| Class A & B national accreditation standards |
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| Class A (Light oral sedation) | Patient monitoring is not required in any setting and there is no need for medical clearance. |
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| Class B (IV sedation) | Patients are monitored by a licensed anesthesia provider and must obtain medical clearance. |
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Most OBS cases are performed with mild sedation and do not require a licensed anesthesia provider. That’s without any tradeoff in safety, whereas higher classes of anesthesia are themselves associated with a higher risk of complications.
Alison Tendler, MD of ART Vision in Sioux Falls, SD presented OBS safety outcomes that match or exceed those in other settings. 99% of the cases utilized oral sedation and the average age of cataract patients was 69, negating the myth that oral sedation is most appropriate for younger patients.
This point was echoed by Dagny Zhu, MD of NVISION Eye Center in Rowland Heights, CA who presented a growing amount of research showing that mild sedation is typically a better course of treatment for the patient. “I’ve found OBS procedures just as safe as procedures performed in any other setting because the level of anesthesia is entirely appropriate to the level of care provided,” said Dr. Zhu.
The panel discussed how the office-based surgery setting reduces patient anxiety from the start. First, there are minimal pre-op or post-op requirements with oral sedation, whereas IV sedation requires medical clearance and fasting.
“Doing surgery in the office reduces anxiety which allows us to use less medication,” said Dr. Tendler.
“We’ve created a very personable and comforting experience in my office-based suite. We chat with patients during the procedure, sometimes I sing to keep the mood light. And before they realize it, we are done.”
Lance Kugler, MD of Kugler Vision in Omaha, NE stressed that you don’t have to sing for oral sedation to be effective but agreed that OBS lends itself to a more patient-friendly environment. “Patients do not feel like they are in a medical facility having a major medical intervention. They can eat and drink before their procedure. They do not change into a gown or start an IV. Most of the usual signals that surgery is about to happen are not there. It is much more of a LASIK-like experience, with less emotional stress,” said Dr. Kugler.
Ophthalmologists have the highest level of professional training of any physician regarding the eye. That said, they are uniquely qualified to provide medical clearance and determine the appropriate level of anesthesia for each patient. However, many ASCs or HOPDs do not allow oral sedation and surgeons face barriers that prevent them from choosing the most appropriate option. In an OBS suite, the surgeon decides the level of anesthesia for each individual patient.
For surgeons considering transitioning to oral anesthesia, some find it valuable to try it first in their current OR setting before moving to an office-based surgical suite. After several cases, comfort increases and the barrier to transition to an in-office setting is much less daunting. Some surgeons also gain confidence by using a CRNA for a while as they adapt to the new office OR. Before long, surgeons are pleasantly surprised to discover they need much less assistance than they thought they would.