Making Cataracts More Profitable

Improving profitability in an already efficient operation has its challenges. However as the saying goes, when one stops improving, one stops growing.  The key to improving is to continually evaluating your efficiencies when it comes to patient & staff scheduling, doctors block time, labor mix and related costs, disposable costs and anesthesia expenditures.

Scheduling patients at the right time to make certain you have the right amount of patients in the queue for your staff and surgeon is crucial. Avoiding lateness (whether it’s the patient, surgeon or staff) is the key, along with making sure your surgeon and/or staff do not take breaks between cases.

Efficient staffing of your pre-op, operating room(s) and post op often times involves hiring part-time staff who can pick up the extra load whether it be prepping the patient, scrubbing or circulating in the OR, cleaning instruments, etc…  Staffing your center with more part time staff can reduce your benefit costs and staff overhead. Each function in the center should be done by someone with the proper skills and appropriate pay scale.  It has proven to be very economical to utilize outsourcing services, such as Vantage Outsourcing. They not only provide staff, but also all the equipment, micro instruments and disposables used in a cataract procedures.

Disposable costs are a major cost of doing cataract procedures. Every six months to a year, asking your surgeon/owner to evaluate his/her surgical preferences and consider alternative disposables and/or suppliers can prove to be very profitable. When surgeon asks for a more expensive supply, provide the surgeon with a cost/benefit analysis of adding this supply and the impact of profitability on each of their cases. WIth the expertise of companies such as Vantage Outsourcing, they too can help you reduce our case costs by sharing with you what other facilities and/or doctors are doing and by recommending quality disposable items to use as an alternative to your current costly disposables.

2 OR set up may be good for some, but not for all.  Many surgeons like working in an environment where they go back and forth between two ORs. Vantage Outsourcing generally recommends to their clients that unless the surgeon is doing five or more cases an hour and at least 20 cases a day, we have found that the 2 OR set up to be inefficient. Keep in mind with 2 ORs, the center needs to equip each room with a phacoemulsification equipment and microscope, as well as staff. Unless a surgeon is fast and doing significant volumes, your paid staff and anesthesia person may be waiting on the surgeon to complete cases, which becomes very inefficient and costly to a center.

The easiest way to improving profitability is to increase case volume. This may mean taking time out of your busy day to visit with the area optometric businesses to find out to which surgeon they are referring their patients. Let them know what your center and surgeon have to offer their patients. As part of the outsourcing service, Vantage Outsourcing is able to share with you the referral patterns of ODs in a particular market, in relations to the various MDs. This information is extremely valuable and helpful in determining where a facility and/or doctor needs to put forth their efforts in terms of OD relationships.

In summary, you need to know, evaluate & improve your efficiencies and identify the sources of your surgeon’s referral base, in order to improve your cataract service profitability.

Increasing ASC Profits with Eye Procedures

The key to adding or providing eye services to a center is having a good surgeon, team-oriented staff, cost effective supplies & efficient scheduling. However, this is easier said than done, as if any of these components are deficient, the system runs inefficient and the profits are diminished. So let’s examine each of these four factors to see what a center needs to do in order to add ophthalmic procedures to their center or what changes are needed with existing ophthalmic services in order to improve the center’s profits.

SURGEON: Make sure your ophthalmologist is not only interested in performing eye procedures (i.e. cataracts, YAGs, blephs, etc…), but doing so in an efficient and profitable manner. The ideal surgeon is one who arrives to center on time, takes less than 10 minutes to do a case (“skin to skin”), uses topical anesthesia, operates using two ORs, takes no breaks between cases, schedules all non-cataract procedures either before or after cataract procedures and is conscience about both quality and costs when using IOLs, supplies, micro-instruments and equipment. If your surgeon averages more than 30 minutes (“skin to skin”) to perform a cataract procedure, he/she is probably not the surgeon for your center… that is, if you plan to make money doing eyes. The most efficient center our company has seen is one where by 7:25am first set of 6 patients are lined up in pre-op area with eyes fully prepped for surgery. At 7:30am, surgeon begins 1st surgery, finishes 1st case at 7:36am, and exits OR1 at 7:37am. At 7:38am, surgeon enters OR2, begins 2nd case at 7:39am, finishes 2nd case at 7:45am, and exits OR2 at 7:46am. At 7:47am, surgeon enters OR1 and process begins all over. This particular center is known to average anywhere from 35 to 50 eye cases in a given day (sometimes given morning). Their most efficient day was when they started their 1st case at 7:30am and their last case left the center at 1pm, doing a total of 37 cataracts and 10 YAGs. Talk about a “well oiled” eye machine!!! After hearing this, you’re probably questioning surgical outcomes with this surgical operation – have no fear, outcomes are superior and patients are coming from a 100+ mile radius to have their cataracts removed as they’ve heard wonderful things about this surgeon and the efficient center in which he operates. Remember our patients live in an impatient world where service & efficiency is king.

STAFF: At all times, the team objectives must be (1) quality service to patients and surgeon, (2) streamlined patient movement between stations, i.e. waiting room, pre-op, surgery suite, post op, releasing patient to family member, (3) maintain set system for instrument processing and room turnover and (4) never allow a surgeon to wait for you in the OR, and (5) never stop working until the last patient leaves the center and all paperwork is completed. As mentioned above, our company, Vantage Outsourcing, provides cataract outsourcing services to numerous surgery centers and hospitals We see a lot of variation in staffing for ophthalmic procedures. One of our centers referred to above (doing 35 to 50 cases in less than 6 hours) has the following staffing requirements:

1 clerical staff checking in patients
1 RN in Pre-op area
1 LPN floater in Pre and Post op area
1 circulator in each OR
1 scrub tech in each OR
1 Vantage Outsourcing technician (takes care of equipment and assists in room turnover)
1 RN in Post op
1 float person, who is capable of handling most positions, whether it be assisting in patients’ admissions, room turnover and/or patients’ dismissals

This center truly runs like a well-greased engine with surgeon and staff working like a team from start to finish. If every center staffed and operated like this group, all centers would welcome ophthalmic procedures and would significantly increase their profits in their centers.

SUPPLIES: Cost containment can be summed up in ten words. “Supply functionality & results are everything, brand name is secondary.” Too often, a surgeon and/or staff get caught up in thinking only one supplier can meet their needs or have the superior product. This is simply because this supplier is the only one they have ever used or the supplier’s marketing ploys have worked wonders on the surgeon’s psyche. Besides, who in the world has time to research alternatives to the numerous ophthalmic supplies that a surgeon uses in the surgical suite? One entity that prides itself in being vendor independent is Vantage Outsourcing, a cataract outsourcing company that provides all disposable supplies needed for any and all cataract procedures (including all IOL brands), as well as all brands of cataract equipment, microscopes and micro-instruments. Vantage has saved centers nationwide by significantly reducing their disposable costs and eliminating capital equipment outlays. Areas of costs that can get out of control are IOLs, viscoelastics, blades, procedural packs and drapes. For example, a center could increase their costs by as much as $15 in drapes alone. Another factor of this higher priced drape is that it lacks fluid pockets. So, not only is your center spending $15 more, but it’s incurring more staff time with clean-up and turnover because this higher priced drape doesn’t catch fluids. Keep in mind, a surgeon requests a particular drape simply because that’s what was used in their medical training days. So, sitting down with a surgeon and explaining all aspects of drape costs, could result in increased profits to your center.

SCHEDULING: A good scheduler works hard at having the patients arrive in time to properly prep them for surgery but not too early that they are sitting in the waiting room twiddling their thumbs. Another key function of the scheduler is to work tightly with the pre and post op staff to make sure that each station is fully equipment with the right number of patients in pre-op area getting ready for surgery and those fully prepped and waiting to enter the OR. Finally, the good scheduler will make a mental note of each patient’s family member(s). This helps in knowing who to contact when call arrives from post op nurse that patient is ready for family to join them. On another note, the surgeon can help in minimizing patient waiting room time by prescribing dilating drops to be taken at home the morning of surgery. Having the patient arrive to the center already dilated saves the center supply & labors costs. For one, the patient is paying for the drops and related supplies needed to administer drops, as opposed to the center. In addition, the staff saves time by not having to administer drops when patient arrives to the facility. Most importantly, the patient spends 30 less minutes at the center by administering dilating drops at home.

By evaluating these 4 important aspects of ophthalmic services, your center is guaranteed to provide quality eye service to your patients in an efficient and profitable manner.

Under the Microscope

Ambulatory surgery centers (ASCs) face a long, rigorous process to receive both state licensure and/or Medicare certification. So SurgiStrategies asked Patsy Powers, attorney at Waller Landsden Dortch and Davis, LLP, and Joshua Kaye and Jerry Sokol from McDermott Will and Emery, LLP, to answer some questions on the entire process. Below are their responses.

Are you seeing a great discrepancy in the time it takes for your clients to apply for and then secure a state license and/or a Medicare provider number? What factors are coming into play with each of these?

The time factor with new surgery centers getting enrolled in Medicare is really a function of the time it takes the Medicare carrier to process the Form 855 enrollment application. Some carriers are reasonably fast (20 to 30 days) and others take much longer. Usually the delay is a function of carrier workloads and sometimes a function of new personnel unfamiliar with the process.

KAYE & SOKOL: There are a number of variables involved. With respect to Medicare, it depends whether the provider number arises in the context of developing a new surgical facility vs. acquiring an existing surgical facility, and if it is the latter, whether the acquisition is structured in a manner that allows the buyer to continue to operate under the same Medicare provider number. With that said, ASC acquisitions by strategic buyers and private equity investors have continued at a robust pace (notwithstanding the economic downturn) and so the Medicare provider number is not typically a significant issue assuming the transaction is structured carefully to allow the facility to continue to operate under the same Medicare number. Obtaining a new Medicare provider number, particularly in the case of a start-up facility, can be a lengthy process and it is not unheard of for a start-up facility to have to wait four to six months from the date it submits the appropriate application to obtain its provider number. This can result in major cash flow issues since Medicare will not pay claims until a Medicare number is assigned to the facility although it may pay retroactively in certain instances or claims submitted after the date that the appropriate paperwork was submitted. State licenses are even more of a dice roll because it really depends on the specific state’s regulations. For example, due to some recent case law and guidance in California, it has now become much easier to operate an ambulatory surgical facility. Texas is also a fairly simple process. By contrast, New York has a very complicated and lengthy vetting certificate of need process that can easily take over a year and it is not unheard of to take multiple years.

If the application process becomes problematic, is it a matter of clients not doing their due diligence, or does it come down to specific parameters within the state licensure or Medicare certification, such as grandfathering, etc.?

KAYE & SOKOL: Both. Often, a client is unwilling to bring in the appropriate consultants until it’s too late and then a lot of additional time is spent undoing the errors and omissions previously submitted to federal or state regulators. Submitting forms with improper information or not working with architects, developers and other advisors experienced in the surgical center industry can create a lot of unnecessary issues. But regulators can unfortunately hold up the process as well, and so depending on their work load, the number of applications pending and/or specific guidance or changes established by their federal or state agency, an application can find itself in a regulatory lock-up.

POWERS: There are many reasons a Form 855 might not get approved. The applications take time and the provider enrollment department of a carrier often rejects an application for peculiar, unexpected reasons. In the 20 years I have been working in the surgery center industry, I have only seen one case where a facility license was not issued because the state determined that the facility could not be grandfathered into a new requirement, and in that case it was a life safety issue.

What, if any, new rules or regulations have the Centers for Medicare and Medicaid Services (CMS) added to certification?

POWERS: The main thrust of the changes in the Conditions for Coverage, not surprisingly, relate to ensuring ASCs provide high quality of care. From a business perspective, ASCs are now defined as entities that perform procedures in which the expected time for the procedure and recovery is less than 24 hours. The other changes to the conditions relate to quality improvement, patient rights, infection control and physician disclosure of ownership in the facility prior to admission.

The CMS also proposed seemingly cumbersome new rules governing patient admission, assessment and discharge. However, CMS ultimately tempered many of the more controversial proposals. For example, rather than adopting CMS’s proposal that ASCs ensure that each patient has a safe transition home — which would have implied that ASCs ensure that patients have adequate transportation, and actually make it home safely — ASCs now must merely ensure that “all patients are discharged in the company of a responsible adult with limited exception.”

KAYE & SOKOL: On Oct. 30, 2008, CMS published a long anticipated final rule substantially revising the Medicare ambulatory surgery center (ASC) Conditions for Coverage (CfCs) and updating 2009 payment rates. Perhaps the most controversial and widely opposed CfC that had been proposed by CMS in August involved redefining ASCs in a manner that would have limited the range of services that could be offered by ASCs by changing the rule that prohibits a stay of anything exceeding 24 hours to prohibiting an overnight stay (meaning anything beyond 11:59 p.m.) Additionally, CMS proposed prohibiting ASCs from furnishing procedures that require “active monitoring by qualified medical personnel, regardless of whether it is provided in the ASC,” which again departs from current policy that allows a facility to transfer non-Medicare patients to non-hospital settings (e.g., skilled nursing facilities, recovery care centers) for extended recovery. Finally, the proposed restrictions would apply to all patients regardless of payment source. After consideration of the public comments, CMS revised the proposed definition of “ASC” to retain much of the current flexibility towards patient discharge schedules, including allowing surgical services for Medicare patients that do not require hospitalization and in which the expected duration of services would not exceed 24 hours following admission. Consequently, Medicare patients may stay at an ASC for 23 hours, 59 minutes starting at the time of admission without constituting an overnight stay. Non-Medicare patients seemingly could be allowed to recover longer in a setting other than the ASC or a hospital. Beginning in 2009, surveyors will examine ASC patient records to ensure that ASCs do not, as a matter of routine, recover patients for more than 24 hours.

How do ASCs maintain compliance for certification when many government agencies usually do not give specific criteria?

KAYE & SOKOL: It’s not a matter that the guidance is not given, but rather knowing how to access such guidance. Compliance guidance takes on many forms including federal and state laws and regulations, agency rule-making, conditions of participation, advisory opinions, position statements and more. Additionally, complying with one set of rules doesn’t mean that the ASC is complying with other applicable sets of rules. For example, an ASC could be in compliance with the Medicare conditions of participation by allowing overnight stays as long as a patient is discharged in less than 24 hours from admission. However, certain states may still prohibit overnight stays under its licensing statutes. Here too, having experienced ASC health law advisors and consultants who have familiarity with the various rules and work regularly with regulators are the best source of ensuring continued compliance.

POWERS: Between the CMS Conditions of Coverage, the accreditation standards, licensure standards, and general standards of surgical practice, ASCs have plenty of regulatory guidance.

Cataract Products: Best of 2008

Both new products and the improvement of existing products in the ophthalmic marketplace made 2008 an exciting time for cataract surgeons all over the world. From advancements in phaco technology to OR safety ,this year has not only brought a fresh perspective to many old ways of thinking but these advancements have created a higher level of efficiency, patient safety, and positive outcomes.

Phacoemulsification systems continue to develop technology that can better the modern day cataract surgeon.  The AMO Whitestar Signature has brought forth the ability to switch from a fluid based system to a vacuum based system within the same case. The Signature also has with it the new Ellips handpiece that allows for transversal ultrasound.  Sleeves and tips developed by Microsurgical Technology can be used on the Signature to accommodate a 2.2mm incision.  Bausch & Lomb’s Stellaris allows for the switch between flow based and vacuum based fluidics as well.  The Stellaris also brings with it the ability to perform longitudinal phaco through a 1.8mm incision.  For the Alcon Infiniti system, the introduction of the more rigid “Intrepid” fluid management system created the ability to minimize the amount of post occlusion surge thusly creating a higher level of safety in avoiding additional risks of capsular breaks.  The Infiniti Ozil handpiece allows for torsional phaco and allows for 2.2mm incision.  Alcon also has continued to evolve the configuration of the phaco tips as well.  The Ozil 12 is a modified bent tip with a 12 degree angulation that comes in either a Kelman or reverse Kelman configuration.  This has been developed for those surgeons who are used to a straight tip but would like the benefits of torsional phaco.

Intraocular lenses are always on the mind of surgeons; therefore every enhancement and improvement brings a sense of anticipation waiting for the new technology to hit the market.  In the world of Presbyopia correcting IOL’s, Bausch and Lomb’s Cyrstalens HD was improved in 08’ to provide better near visual acuity due to the design that increased the effective focal range.  The next generation of the Alcon ReStor multifocal will feature a +3 add.  This will allow surgeons to tailor the multifocal selection based on the vision needs of the patients to accommodate for reading or intermediate dominance.  The release of the Akreos Advanced Optics IOL, by Bausch and Lomb, is a hydrophilic acrylic aspheric IOL that can be inserted through a modified 1.8mm incision.  Another IOL that has grown in popularity this year is the single piece Technis ZCB00.  Its benefits include a lower refractive index and the edged design to help protect against dysphotopsias.  It is also noted that its hydrophobic acrylic is not prone to glistening.  The down fall of this lens however is its inability to be inserted, at this point, through a micro incision. AMO is currently working on a new system, the Viper, which will remedy this issue.  Finally, the much anticipated AcrySert C preloaded injector from Alcon will begin to make its move to become more prominent in the market for 2009.  The preloaded injector will not only be an advantage for the surgeon’s efficiency but it will also avoid unnecessary damage or contamination to the IOL.

An important tool of the trade is of course the surgical microscope.  The biggest breakthrough this year was the OPMI Lumera and Lumera T by Carl Zeiss Meditec.  Its stereo coaxial illumination and beam paths create a red reflex that is unmatched by anything that was previously offered.   These scopes also allow for a greater visualization of intraocular structures and depth perception as well.  Carl Zeiss has also developed the Callisto eye which is a data management/documentation system.  It allows for a combination of OR processes, surgical planning, documentation of disposables/IOLS through a barcode scanner, and even has video documentation possibilities.  One surgeon stated that “it will be like having a satellite office in the microscope”.

Other noteworthy products for 2008 were the development of Healon D (AMO) and the Malyugin Ring (Microsurgical Technology).  Healon D is a dispersive hyaluronic OVD.  It is very similar to Alcon’s Viscoat but it is reported that it has better clarity since it doesn’t contain chondroitin sulfate.  AMO will also be introducing a Dual Pack similar to the approach Alcon takes with its Duovisc line.  It will allow a surgeon to have viscoelastics differing in there characteristics to better accommodate surgeons needs throughout the procedure.

Some products may not have advanced in technology but have shown innovations in safety for not only the patients but for those in the OR as well.  Alcon will launch in 2009 a disposable irrigation-aspiration tip made of a soft polymer material.  This product is riding on the coat tails of the success of the silicone I/A tips that have helped improve potential risk factors for capsule rupture.  BD Health, the leaders of the movement for improved surgical blade safety, have expanded there current line of safety blades to include surgical blades as small as 1.4mm all the way up to 3mm.  The protective sheath they had developed is a significant advancement in the quest to shield healthcare workers from unnecessary risks.

Cataract surgery continues to make great strides in the advancement of technology, surgical techniques, and safety. 2008 has been a year that has brought new high quality products into the ophthalmic market place.  Hopefully, 2009 will too result in products that will continue to aid surgeons in achieving the desired outcomes and happiness of their patients.

A New Light in Surgical Microscopes

Carl Zeiss Meditec of Jena, Germany has introduced an exciting new technology in the OPMI Lumera® surgical microscope.  The new technology is centered on the revolutionary red reflex capabilities.  The OPMI Lumera® microscope is equipped with Stereo Coaxial Illumination or SCI^TM.  SCI^TM is the revolution in illumination quality, which you benefit by the unique detail recognition of high-contrast brilliance and stability of the red reflex.  Even strong pigmented, decentered and ametropic eyes can be viewed with exquisite detail.

When you turn on the light, the illumination floods the eye with a deep view even in dense mature cataracts.  The high contrast and excellent detail recognition supplied by SCI^TM enables you to reliably see and completely remove tissue residues in the capsular bag with unparalleled accuracy. 

The surgical microscope appears to be well thought out.  The days of trying to manipulate the microscope head to aid an additional viewer, appears to be conquered.  The add on features in today’s digital media is present with video recording and image documentation.  All in all the OPMI Lumera® is catching the attention of many surgeons as the High Definition TV to the public.

Is everything the same with Small Microincision?

Is everything the same with microincision surgery today,….. yes and no.  For the people who work in eye surgery but not up on the new techniques, why are we saying “yes and no”? 

Many surgeons are pleased with the outcome of surgery with a larger incision size.  But if you are a surgeon wanting to gain market share in a competitive market, or wanting to gain advantage on your competitor, a possible avenue is to look at lowering your incision size.  The day of “no shot no stitch” is passé today, we hear of microincision cataract surgery.  The procedure is the same but is it the same for everyone? 

To perform surgery at incision sizes in the zone of 2.4mm and less has the manufactures jumping as well as the surgeons.  The microincision size helps to eliminate surgically induced astigmatism for better post-operative visual acuity thus capturing more happy patients on post-op day.  We also have faith that with smaller incision sites we will protect our outcomes with less chances on endolphamitis. We gain all of this without changing anything in the surgical procedure…….yes and no.

The procedure will be performed in the same step by step procedure but this is where the surgeon and the surgical team will take different paths.  Many of the old instruments will carry same titles and will be needed for our procedure but because of the incision size our instruments now have been reengineered. The new reengineered product can look very similar, but it is not, and this small slight change in instrument(s) can create big problems.

We now need to have additional colors on phaco tip sleeves to assure us that we have the correct sleeve on the correct phaco tip.  This color change can lead to big problems if the uninformed are working in the procedure.  Just as the hub of a needle has a color to represent the gauge size so to a sleeve for a phaco tip. 

Some of the instruments will change in orientation and size.  Instruments will have the distal shafts altered on outside diameters for better entry and maneuverability.  The incision now has become a very tight fit and if the incisions continually get compromised will lead your surgeon to look at new alternatives on the instruments of I/A, capsularhexis forceps and lens injectors.

Our Discovery of potential changes with micro incision is as follows:

Lens Injector =  Injectors have changed

Lens cartridges = The cartridges may enter into incision site or some may eject through incision.  Educate to lens manufacturer guidelines.

I/A tip sleeves = The sleeves are color coded for protection, stay educated on purposes of new colors.

I/A tips = Tip size for outer dimension or gauge size has changed.

I/A handle = New to industry and few new handles on market.

Phaco tip = Smaller gauge size requires special irrigating sleeve.

Phaco tip sleeve = Stay educated on colors of irrigation sleeves, not all phaco tips can be used with sleeves

Capsularhexsis forceps =  Forceps appears the same but distal end smaller in diameter to manipulate easier.

Keratome blade = dropping in size

Stab blade = different blade to maintain chamber 

Machine settings =   new settings on many parameters

Phaco machine = new machines reaching new parameters not capable on older version equipment

So if you have worked in eye surgery before and would be observing from the back of the room, everything would appear the same.  If you would be asked to help scrub into the procedure and help your surgeon you might notice under the view of the microscope things have changed.  So yes everything looks the same but no it is not the same.

Cash in on Cataracts Through Outsourcing

What a sweet deal – “perform, bill & receive payment for cataract procedure, prior to paying for any supplies, equipment &/or technical labor!”, at least that’s how Ronda Chambers of Physician Surgery Center sees it.

Here’s how it works.

When you contract with Cataract Outsourcing companies, such as Vantage Technology, all you have to do is schedule the case with the patient & call Vantage Technology – THAT’S IT! ”

What’s so wonderful is Vantage takes care of all the ordering of supplies & IOLs. They make sure all equipment (phacoemulsification & microscopes), handpieces, instruments are here on day of surgery. Prior to surgery day, Vantage (not me) coordinates all purchases from custom paks to drapes to blades, etc… (the entire grocery list of disposables needed for the cataract cases) and provides all necessary supplies/IOLs for each and every cataract procedure scheduled on that particular day. Vantage not only takes away my headaches, but they free up valuable storage space at our center, as we don’t have to house all the cataract equipment and supplies. What I like most is that my staff and I can just focus on patients and OR procedures. I used to dread “eye day”, but now with Vantage, I actually look forward to it.”

The added benefit that often times is overlooked is the fact that Vantage pays for all supplies and the surgical center pays for nothing, until center collects from Medicare. If the surgical center is on top of their game, they will bill for their cataract procedures within 24 hours of surgery. Medicare will then pay the surgical center within 14 days of billing. Only after the money is in hand, does the surgical center pay Vantage for their service, i.e. within 30 days of date of surgery. It doesn’t get any better than that!

How to get the Most out of Cataract Outsourcing from Outpatient Surgery

Day 6 April 9th

We were so happy to have local Ophthalmologist attend procedures with us today. This local Ophthalmologist was attending the hospital for a procedure of a local individual. We thought that he had been informed of our arrival and came in to learn the new equipment but he was never informed of our visit and had no clue we were performing cataract surgery. The young surgeon brought in his own equipment, which consisted of his own microscope, nothing else. The local Ophthalmologist said he would loan to us his microscope, after my request, so we could pick up more speed. Working with two beds helps the surgeons stay focused on continual procedures but also requires us to keep up with supplies and movement of patients. Most procedures in the States the surgeon is dictating to patient the “Do’s and Don’ts” after the procedures as patient is leaving but we always need our translators to make sure they understand.We informed the local Ophthalmologist that the equipment and all products would be left behind and we would enjoy teaching him on the techniques of phaco. He had practiced somewhere before with phaco but not in Guatemala. He was surprised we were working on such hard cataracts. The young ophthalmologist watches the surgeons performing phaco on the patients. He is impressed with the equipment but appears to be standoffish to the technology. We keep informing him this will stay behind and he will be allowed to use the equipment but his body language reflects that he feels no need.

The day continues and young local surgeon witnesses our crew perform extra capsular technique. He explains that this is his caliber of surgery. We accept the fact that not all phaco is worth the effort on some of the lenses we have witnessed. The day grows long and we work slow and steady. We are treated by an elderly patient with another super cataract. The amount of time to perform capsulorexis takes minutes not seconds. The surgeon is finally through the capsule and starts to phaco. The surgeon stops dead in his tracks. He informs us that the tip of his chopper has just snapped off into the lens. Our surgeon works through the unique situation but we term the cataracts “super cats”.