January 09, 2026
4 min read
Over the past decade, most ophthalmologists have become familiar with in-office cataract surgery, and more than 130 practices have begun offering the procedure.
Now, vitrectomy is also emerging as an option for office-based surgery (OBS).
Even before that idea stirred debate in the ophthalmology community, my practice became the first in the world to begin performing office-based vitrectomies at full scale. More than 3 years later, a dozen centers have adopted the strategy, including one in Ireland.
While conducting vitrectomy under oral sedation and a topical anesthetic is a disruptive idea, I have kept patients safe, comfortable and calm during thousands of these procedures, and soon-to-be-published data aggregated from participating practices will confirm that trend.
I am passionate about OBS because I believe it will revolutionize ophthalmology. By simplifying the regulatory environment, streamlining workflow and granting physicians more control over their surgical settings, this strategy is poised to generate significant benefits for our field and the patients we treat.
Fighting inefficiency
When I launched my practice 7 years ago, I found that slow hospital turnover times made it difficult to perform even three vitrectomies a day. And although ASCs were more efficient, I often needed to train staff there to use required machinery.
Most facilities are also affected by a shortage of anesthesiologists, which frequently disrupts the scheduling of ophthalmic procedures (Grebbin).
The good news is that, by my estimation, 95% of ophthalmic surgical procedures can be successfully performed under oral sedation with topical pain control. Without the need to schedule an anesthesiologist or the extra recovery time patients need after general sedation, I have found that I am able to perform five times more vitrectomies than I can in a hospital and double or triple the number I can conduct in an ASC.
Improving patient care
- providing the best technology, which I can choose without a capital budgeting committee or other bureaucratic processes;
- enabling emergency surgeries to take place as soon as an hour after diagnosis;
- making more people eligible for surgery, as preoperative histories and physicals are not always necessary;
- simplifying scheduling for those who have difficulty ambulating or navigating social or demographic issues;
- making surgery more accessible to people who are uninsured or underinsured. Because I receive sufficient reimbursement and have the freedom to make my own billing decisions, I have been able to prioritize charity care, which now comprises a significant portion of my practice;
- facilitating quicker recovery. Because some cases do not require a sub-Tenon block, my patients often leave my office without an eye patch and can return to their regular activities the next day; and
- avoiding the risks associated with sub-Tenon and retrobulbar blocks, which can include hemorrhage and injury to nerves or muscles.
OBS has also improved the surgical experience for my staff members, who better appreciate the complexity and life-changing applications of my procedures and have become enthusiastic advocates of the in-office approach.
Exploring a new protocol
To establish a protocol for in-office vitrectomy, I mirrored the principles I use in anterior segment OBS — most importantly by replacing general anesthesia with 5 mg of Valium (diazepam, Waylis Therapeutics). When that is not sufficient for my patients, I administer MKO Melt (ImprimisRx), which contains sublingual midazolam, ketamine and ondansetron.
Because I consider retrobulbar blocks too risky without an anesthesiologist, I instead administer lidocaine jelly followed by a Betadine (povidone-iodine, Atlantis Consumer Healthcare) wash for sub-Tenon blocks and, finally, a subconjunctival injection of lidocaine around the port sites for less complex vitrectomies. This protocol prevents my patients from feeling pain or pressure.
OBS vitrectomy can be adopted by any retina surgeon, and my colleagues tend to be open to the approach once they have seen it performed and reviewed the evidence.
Securing reimbursement
Surgeons often ask me if there is a mechanism for reimbursement for their OBS procedures. There is, and it brings returns that are generally on par with reimbursement for traditionally performed ophthalmic procedures.
Billing the professional component is straightforward with commercial insurers, which use the same procedural codes regardless of the site of service.
On the other hand, CMS does not have standard codes for in-office ophthalmic procedures. Rather, after paying OBS surgeons a professional fee, it reimburses physicians for their overhead expenses through a secondary-local reimbursement based on local Medicare Administrative Contractor codes in all 12 local jurisdictions.
Looking ahead, CMS is considering the establishment of standard non-facility codes for in-office ophthalmic procedures (Mott).
Garnering support
I constructed my surgical suite for $100,000, updating a break room with flame-retardant wall insulation, air filtration, an impenetrable floor, sterile storage and processing areas, and preop and postop spaces.
This is possible for any practice with 500 to 800 square feet of available space, and building to the standards of an ASC can be accomplished affordably due to the minimal regulatory environment surrounding attached surgical suites. It is also helpful that medical equipment such as vitrectomy machines can be paid off over time.
Although centers can create and run surgical suites on their own, I have found it worthwhile to work with iOR Partners, which helps ophthalmology practices develop and manage their OBS spaces.
I strongly advise colleagues to do the same because a knowledgeable consulting firm can help secure accreditation and malpractice coverage, oversee reimbursement and recordkeeping, and provide guidance about the proper disposal of medications. In addition, iOR gathers data about the safety and efficacy of in-office procedures from the practices in its network and lobbies for the most favorable federal reimbursement protocols.
Changing the future of surgery
I am convinced that OBS represents the future not only for our field but for surgery overall.
A growing number of ophthalmologists are proving that highly complex, sterile procedures such as vitrectomy can be done safely and comfortably in the office without anesthesiologists, and that is likely to inspire a similar trend across specialties from gastroenterology and general surgery to ear, nose and throat.
By bringing these innovations to care delivery, OBS will create life-changing opportunities not only for surgeons but for our patients who need better access to treatment.
For More Information:
Omar Shakir, MD, MBA, is a board-certified ophthalmologist and the founding partner of Coastal Eye Surgeons in Greenwich, Connecticut, where he specializes in cataract and vitreoretinal surgery. Shakir is also a clinical instructor at Yale University and serves as a principal investigator for many phase 2, 3 and 4 clinical trials. He was named the 2025 Operation Sight Volunteer of the Year by the ASCRS Foundation for providing free or reduced-cost ocular procedures to patients in need. He can be reached at omar.shakir@gmail.com.
Sources/Disclosures
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Disclosures:
Shakir reports being a strategic advisory board member and investor in iOR Partners.
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