Q: In today’s economy, I’m seeing more uninsured patients than ever. This may be fine for a routine eye exam, but what happens when the patient has a retinal detachment that needs an emergent repair to preserve vision?

Optometrist Trennda L. Rittenbach had such a patient. “A 55-year-old female presented to my office with sudden loss of vision in her left eye,” says Dr. Rittenbach, who is in private practice near Minneapolis. “Her visual acuity was hand motion in the left eye. A dilated fundus examination revealed a macula-off rhegmatogenous retinal detachment extending from 1 o’clock to 7 o’clock, with a flap tear at 2 o’clock. I sent the patient immediately to a retinal surgeon for repair. Since the patient was uninsured, I was informed the surgeon had limited options for the patient. Otherwise, the patient would have had to cough up a good amount of cash.”

What to do? Tackle this problem before you even encounter it, Dr. Rittenbach says. “Iron out the details with the referring surgeon concerning non-insured patients before an emergency walks into your office,” she says. “Surgeons understand the downturn in the economy, and most of them will be willing to work out a self-pay rate with the patient.”

Talk to your retinal surgeon before a patient with a retinal detachment—and no insurance—walks in. Courtesy: Asheesh Tewari, M.D., and Gaurav K. Shah, M.D. 
Start with the retinal surgeon you currently work with and ask him or her what the options are for a non-insured patient, Dr. Rittenbach says. If you don’t have a current retinal surgeon, ask a fellow O.D. for a recommendation. “Find a retinal surgeon who will do what is right, regardless of cost or convenience,” says vitreoretinal surgeon Jordan Graff, M.D., of Barnet Dulaney Perkins Eye Center in Arizona.

Other possibilities:
• Seek out community clinics that have a sliding fee scale based on the patient’s ability to pay for the treatment, Dr. Rittenbach says.
• Locate all resources that are available in your state, such as the IowaCare program in Iowa or the Arizona Health Care Cost Containment System, says Dr. Graff. These may direct you to refer your patient to certain providers who are on these plans or to a university setting for care. (For a list of programs by state, go to www.ncsl.org/?tabid=13878.)
• Sometimes, your surgeon’s practice may simply be willing to absorb the cost in order to do the right thing for patient, Dr. Graff says. But this is not always necessary and shouldn’t be expected if the other options haven’t been explored.

In addition to these financial options, certain surgical alternatives can also make the procedure more affordable, Dr. Graff says:
• A scleral buckle may be less expensive than a vitrectomy for retinal detachment repair (as long as there is no contraindication to the buckle procedure, such as extensive proliferative vitreoretinopathy [PVR] that requires a lot of manual peeling of membranes).
• Pneumatic retinopexy may be a very reasonable and cost-effective repair option in the right case (that is, a phakic patient with a single superior break, localized retinal detachment superiorly, and no PVR or lattice).
• If vitrectomy repair seems to be the best course, there are ways to reduce surgical costs (such as using a 20-gauge approach, or other techniques that require fewer disposable instruments and less expensive packs).

“My patient elected to undergo pneumatic retinopexy,” Dr. Rittenbach says. “In a week, she went from hand motion in her left eye to 20/40 corrected, and without any charge for a hospital stay because it was an outpatient procedure.”