Comanagement

Box 5-1 Example Protocol for Postoperative Comanagement of Cataract Patients... 

Should the optometrist be negligent while acting within the scope of the comanagement protocol, both... 

Adams CM, Alexander LJ, Bartlett JD, Classe JG. Comanagement of patients with glaucoma. Optom Clin 1992 2 143-156. Alexander LJ. Vision care for the patient with diabetes [editorial]. 

Herpes simplex infection in the immunocompromised host, especially the patient infected with the human immunodeficiency virus (HIV), requires careful comanagement with the patients physician. 

Before directly treating dry eye, any comorbid conditions should be treated to the best extent possible. As previously mentioned, any associated ocular disease, such as blepharitis, MGD, ocular allergy, infections, and contact lens-related problems, should be appropriately addressed. Local or systemic disease, such as thyroid orbitopathy and orbital inflammatory pseudotumor, can cause exophthalmos and proptosis and should be comanaged with the patient s primary care physician or appropriate specialist. Neuroimaging is often required to exclude orbital tumors in these cases. 

All patients with suspected or confirmed chlamydial conjunctivitis should be tested for other sexually transmitted diseases and evaluation and consideration given to comanagement with a gynecologist or urologist. If left untreated, chlamydial vaginitis can result in severe pelvic inflammatory disease, ectopic pregnancy, and infertility. Sexual partners of infected individuals should also receive systemic antibiotics, even if no symptoms are present. In preadolescent children, sexual abuse must be considered in cases of confirmed chlamydial infection. 

Therapy depends on etiology. In individuals who are suspected of having tuberculosis, diagnosis should make use of a purified protein derivative skin test, chest radiograph, and sputum cultures if necessary. These individuals should be referred for comanagement to their primary physician or to an infectious disease specialist. Though antituberculin agents are systemically administered, the ocular lesions are appropriately treated with topical steroids. In most instances, patients respond to 1% prednisolone acetate every 3 to 4 hours for the first day, subsequently tapered rapidly on the basis of the clinical response. 

If exposure keratopathy is the result of an ocular or systemic abnormaUty, the underlying condition should be addressed. Patients with exposure keratopathy resulting from Bell s palsy or Graves disease often are comanaged by a physician caring for the systemic problem together with the eye care practitioner attending to the ocular complications. 

Patients may not be compliant with drug therapy due to side effects, the need for follow-up visits, and a lack of perceived need. Thorough patient education is critical. The 5-year mortality rate associated with scleromalacia perforans is as high as 73% therefore appropriate and timely referral and comanagement with the appropriate medical specialist is important in minimizing mortality. 

Although most eye care practitioners are capable of ordering laboratory tests directly, it is often more prodne-tive to commnnicate with the patient s primary care physician before proceeding, snch that all aspects of the systemic history may be taken into account. Shonld the patient be diagnosed with a contribntory systemic disease, comanagement with the primary care physician becomes paramonnt. 

Primary eye care providers may collaborate with ophthalmic surgeons to comanage the cataract patient. This method of eye care delivery provides quality care for the patient in convenient familiar surroundings. In addition, it is efficient and cost-effective. The goals of the comanagement team during postoperative care are those of everyday optometric practice to educate and reassure the patient, to prevent infection, to control inflammation, to maintain desired intraocular pressure (lOP), to manage complications if they arise, to control pain, and to optimize vision. 

This appendix provides an expanded discussion of the pharmacokinetics of psychotherapeutic agents presented in chapter 3. It is intended for therapists with a special interest in this area or for those who actively comanage medication-treated patients. 

A brief outline below explains the nature of IPMA s recommendations. Some of its recommendations apply to every bond issue, while others only apply to comanaged deals. 

Each comanager must have the right of refusal on any additional issues which they are entitled to take based on a pro rata share of their original holding. 

---