Case Document 287-11 Filed 12/02/16 Page10f3 PageID Health EDUEGES #3840 OPHTHALMOLOGY GUIDELINES Ophthalmology MEDICAL POLICIES AND PROCEDURES Primary Rx I. *Unless emergent, conduct collegial review. Refraction Needs ?Refer to clinic if visual acuity is 20/40 or less in the worse NIA Conjunctivitis viral Cold compress, hand washing Optometry clinic referral if greater than 1 week duration (no antibiotics indicated) If worsening despite treatment, or greater than 3 weeks duration Conjunctivitis with Increased IOP Urgent referral to optometry clinic Increased IOP If pressure remains elevated despite therapy Corneal abrasion Rule out foreign body by ?uoresceine Polysporin or equivalent Rarely needed Corneal ulcer Urgent referral to optometry clinic If no improvement with on?site care Diabetes mellitus Optometry clinic referral on diagnosis yearly on all patients. Stress tight glycemic control, target HbA1c less than 7.0 For proliferative retinopathy Pterygium If less than 2.5 mm onto cornea. check visual acuity and monitor every 3 months. If greater than 2.5 mm onto cornea and affecting visual acuity Cataracts Check visual acuity; if best corrected is worse than 20140; evaluate every 3 months. Check co?morbid factors, ocular dominance, impact on ADL's If best corrected binocular visual acuity is 20/60 or worse, see Wexford position statement on cataract extraction. Chalazion Warm compress and gentle massage. If persists more than 8 weeks and has not responded to warm compress therapy. Post-surgery Ocular Conformer Wexford will consider the need for ocular conformer for enucleated patients on a case-by-case basis. Issuance of a prosthetic is cosmetic and not medically nes?asarIL. EXHIBIT I Adapted from THE UNIVERSITY OF TEXAS MEDICAL DEPT. OF CRIMINAL JUSTICE GUIDELINES, APRIL 1996 ORDER Approved by the Wexford Medical Advisory Committee: 02ID4: D7I07: 09I1 1DI21I11 CONFIDENTIAL PURSUANT TO PROTECTIVE OPH-2 WEXFORD 163 Case Document 287-11 Filed 12/02/16 Page20f3 PagelD #3841 gammy": snunc'es Ophthalmology MEDICAL POLICIES AND PROCEDURE THE MANAGEMENT OF CATARACTs A cataract may be de?ned as any opacity of the ocular lens that may or may not be associated with visual problems and manifests as an obstruction of the red orange re?ex on funduscopy. Cataract is the leading cause of blindness worldwide and remains an important cause of blindness and visual impairment in the United States. Cataract may be congenital or acquired. The following is a list of the most common risk factors for the development of acquired cataract: Diabetes mellitus and high glucose levels Regular corticosteroid use (both systemic and inhaled) Advancing age (multifactorial) Female sex Truncal obesity African-American race Over-exposure to ultraviolet radiation Excessive consumption of alcohol Smoking Not all cataracts are The of cataract involve diminished or altered vision: . Blurred vision, double vision, ghost images, the impression of a over the eyes 0 Glare The need for frequent changes of eyeglass prescriptions, which may not improve vision Most individuals have one dominant eye. Our dominant is the that most ef?ciently views distance objects. Greater than 90% of the vision we require for our activities of daily living involves our dominant eye. Based upon the current medical literature regarding generally accepted indications for cataract removal, including subjective objective reproducible clinical ?ndings and the presence of co?existing conditions, it is Wexford's position that: Consideration of cataract surgery is indicated when maximally corrected binocular Snellen visual acuity is 20/60 or worse in the dominant and such surgery offers a reasonable likelihood of improvement in visual function 0 Consideration of cataract surgery is indicated when the lens opacity inhibits optimal management of posterior segment ocular disease or the lens causes in?ammation, angle closure, or medically unmanageable open-angle glaucoma . Consideration of surgery for visually impairing cataract is not indicated if: 0 The patient does not desire surgery 0 Maximally corrected binocular Snellen visual acuity is 20150 or better 0 Surgery will not likely improve visual function 0 The patient is able to satisfactorily carry out his or her activities of daily living with or without changes in eyeglasses, lighting, or other non-operative means CONFIDENTIAL PURSUANT TO PROTECTIVE ORDER 14-CV-00941-NJR-DGW Approved by the Wexford Medical Advisory Committee: o4ro4; osros; 04m; 1110?; 10m; 10m; can 0; 1or21r11 OPH - 3 WEXFORD 164 Case Document 287-11 Filed 12/02/16 Page30f3 PagelD #3842 gamers Health saunas: menu-nan?: Ophthalmology MEDICAL POLICIES AND PROCEDURE 0 The patient cannot safely undergo surgery because of co?existing medical or ocular conditions 0 Appropriate postoperative care cannot be arranged. Activities of daily living refer to those functions or activities which are performed by individuals without assistance, thus allowing for personal independence in everyday living. They include eating, bathing, dressing, toileting, transferring. and continence. Decisions regarding patient suitability for consideration of cataract surgery must be made on a case-by-case basis. These recommendations are intended only as a guide for the site physician and are not intended to replace hands-on clinical judgment. CONFIDENTIAL PURSUANT TO PROTECTIVE ORDER 14-CV-00941-NJR-DGW Approved by the Wexford Medical Advisory Committee: 04i04: 09l06; 04m; 11107; 10i08: 10:09; 09i10; 10l2?li?l1 OPH - 4 WEXFORD 165