2. Angle closure and normal IOP
• 60 year old female, pain, nausea and blur OD
over weekend after dilated eye exam on
previous Friday
• 2+ NSC OU
• Pupil fixed
• LASIK OU x 10 yrs
• Grade 0 angle
• 3+ corneal edema
• IOP 13 OD, 14 OS
• DX? Mgmt?
4. Glaucoma and ocular perfusion
OHTS - Incr. risk for long term progression
with greater fluctuations in mean ocular
perfusion pressure
• Diastolic OPP below 50 mmHg = high risk
• Treatment with HT meds and nocturnal
systemic hypotension are risk factors
6. Blue Mountains Eye Study
• Ophthalmology Jan 2013
• 77% greater risk of developing glaucoma
within 10 years for those with narrowed
retinal arterioles
7. Ocular Perfusion Pressure
• OPP only an estimate using brachial BP
• Can have good OPP and still show progression
• Recently, low CSF pressure and LTG linked
Rev. of Ophth. 2011
• CSF-P and trans-laminar pressure gradient not
easily managed or measured
8. Biomechanical
Factors - Collagen
• IOP related connective tissue
stress within the nerve head
based on indiv. anatomy
• Compression, deformation
of lamina cribosa
• Restricted axoplasmic flow
and GC axonal damage
• Cupping is not just a sign
9. Corneal Hysteresis - Collagen
• Condon, Weinreb, Sullivan-
Mee, others – lower CH
increased VF loss/prog.
• Glaucoma risk factor
• Reichert ORA $14,500
• True IOP’s, CH measure
• Not yet standard of care
10. Neuroprotection
• Low-pressure Glaucoma Treatment Study
• A2 selective agonist vs B-blocker
• 0.2% brimonidine vs 0.5% timolol
• No significant IOP or VF differences for up
to 24 months
• After 24 months, still same IOP’s, but
better VF’s with brimonidine group
11. Myth: Pachymetry allows for
adjusted IOP readings
• Too many biomechanical variables
involved to assign a specific value
• Nonlinear relationship between CCT & IOP
• Best to simply use low CCT (<500) as a
biomarker/structural risk factor
12. Common Practice: OCT’s and
VF’s are each done yearly for
glaucoma patients
• Should give greater weight to structural tests
(OCT) early, and functional tests (VF) later
Early - OCT GCC and possibly Matrix FDT
Moderate - OCT and SITA STD 30-2 VF
Severe - 10-2 VF
16. Common Practice:
Monocular trials
Now mostly an abandoned practice
Long established crossover effect of beta blockers
Substantial PA fellow eye effects -- ARVO 2011
IOP variations differ eye to eye and day to day
Better to get multiple pre and post treatment IOP
measurements on different days and times
17. • ARVO 2011
• Peaks and valleys
different day to day
• Single day serial
tonometry not clinically
relevant other than
finding mean or peak
daytime IOP’s
Myth: Single-day serial
tonometry characterizes future
IOP readings
18. • OHTS – Single target IOP or % often too
aggressive. Target range a better option
• Thicker corneas responded less well, but
were lower risk
• Use BP and supine IOP as guides in LTG
• No easy way to measure nocturnal IOP
Common practice: A target IOP
20. IOP, pach, gonio, VF and
S/D photos are still the
standard of care in glaucoma
SD-OCT is now becoming the standard for
early glaucoma diagnosis. VF alone will
under-diagnose
Ophthalmology 2012 - disc margin and C/D
estimates wrong in clinical exams and
photos compared to OCT
21. Evolving Standard of Care
Weinreb, UCSD
OCT-measured ganglion cell loss is first optic
nerve-related glaucoma finding
Sullivan-Mee, Aug. 2012 Optometry Times
OCT GCC best measure of RNFL in high
myopes and tilted discs. More repeatable,
better in assessing GC health than PP NFL
Is cost of instrumentation limiting scope?
25. Myth – Timolol is “old school”
• Side effects/contraindications overblown-
Melton and Thomas
• 15-20% IOP reduction at qd AM (Istalol)
• Great adjunct to PA’s, few allergic rxns.
• .25% for whites, .5% for the the more pigmented
• Very inexpensive in generic form
• GFS not needed - no better, more expensive
26. Myth: Alternative tx for
glaucoma are bogus
Mirtogenol - Clinical Ophthalmology, 2010
wild bilberry + pine bark extract
80 mg cap po 1/day = Lumigan qhs,
Takes 24 wks for full effect, also additive to topicals
Exercise – Johns Hopkins, 20% IOP reduction after 4 mo.
Punctal Occlusion w/plugs 2011 study - 2 mm Hg red.
Statins reduce incidence of glaucoma by 7%
27. Myth: Every new glaucoma
patient should be put on drops
• Consider age, health status, quality of life,
compliance and cost
• European standard of care is different - SLT first?
• Cataract sx. red. IOP by 20% in 40% of pts - OHTS
• W/iStent 68%
• Ab interno
• No bleb
• FDA approved
32. MIGS – ab externo
• Canaloplasty – enlarges Schlemm’s canal
by catheter dilation and suture placement
• Ex-PRESS glaucoma filtration device
(Alcon) Placed under lamellar scleral flap
and into ant. chamber – bleb drainage,
standardizes outflow level compared to
standard trabeculectomy
33. Emerging alternate drug
delivery system in glaucoma
• Punctal plug - latanoprost time release
• At 4 wks 6 mmHg reduction, lasts 2 mo.
• Mean IOP decrease of 24.3%
• Adverse effect – epiphora
• Stage 2 FDA trials
34. • Well known iris and periocular pigment
changes, iris cysts and contraindications
for iritis and CME -- but what is this?
Prostaglandin Analogs
35. PAP – Prostaglandin Associated
Periorbitopathy
• Upper lid ptosis
• Fat atrophy
• Involution of
dermatochalasis
• Deepening lid sulcus
• Mild enophthalmos
• Inferior scleral show
• Prominent lid vessels
36. 2013 CPT changes
• No additional codes for optometry in CPT, but NM
added new surgical codes:
68040 expression conj. follicles
68530 removal FB from lacrimal passages
68810 probing naso-lacrimal duct
• Two deleted codes- tonography
w/ and w/o water provocation
No ICD-9 changes, 10/1/14 ICD-10
37. Cigna and Lovelace
discrimination - status report
• OD’s forced to use VSP PEC for Lovelace
Salud medical visits
• OD’s forced to be panel providers for
vision plan to be on Cigna medical panel
• Meeting with Insurance Superintendent
after legislative session
38. 2014
• NM to have Health Insurance Exchange
ready for enrollment by October 2013
• 25% of NM population on Medicaid
• 340,000 children, funded 70% of births
• 170,000 more adults expected to be on
Medicaid by 1st Qtr. 2014 - ACA
• Pediatric benefit includes annual
comprehensive eye exam vs screening
• Embedded vision plans likely primary
39. SGR and IPAB
No fix for SGR soon, last cut of 5.4% in 2002
Independent Payment Advisory Board
(IPAB) established by ACA begins in 2014
Will recommend cuts, concentrating on
practitioners, based on variation from
targeted growth rate
Rulings can only be reversed by 2/3rds vote
of Congress
40. Medicare – Multiple
Procedure Payment
Reductions
• Started this January 1 this year for TC of VF, OCT,
photos, ultrasound, topography
• Reduced payments when multiple services are
furnished on the same day
• Most expensive service paid in full (PC and TC)
• TC of all other listed procedures paid at 50% of
fee schedule
• Claim adjustment code 59 on remittance advice
41. Other Third
Party Woes
• Medicare Zone Program Integrity
Contractors (ZPIC’s) and Recovery Audit
Contractors (REC’s) paid on % of amount
recovered. Using statistical sampling,
patient leads, etc.
• Unannounced visits, ruthless, $6 billon
recovered in 2012. Expanding to our zone
and moving to docs vs hospitals/facilities
42. EMR audit risk
• Auto-fill history for repeat patient visits vs
information entered at time of service
• Interpretation and Report poorly designed
in some software – not separate enough
from rest of chart - need orders for tests
• Complete I/R on day of service
43. Major Medical
Embedded
Vision Plans
• Typically low paying
• Monitor for discrimination - OD vs OMD
• Watch chair costs vs reimbursement
• Especially bad payments in optical goods
• AOA interactive calculator aoa.org/x9619
