eyecare myths

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  • 1. Common Wisdom in Eye Care Science or Myth? Dwight Thibodeaux, OD

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? 3. PISK Pressure-induced Intra-lamellar Stromal Keratitis Diamox +/-Compazine Combigan q2min Pilo 2% in 10 min, then qid until PI 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 5. Ocular Perfusion Pressure Diastolic Ocular Perfusion Pressure = DBP IOP BP 110/70 IOP 25 DOPP = 70-25 = 45 DOPP < 50 high risk of progression 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 IOPs, 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 IOPs, but better VFs 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 ( POAG? DDX -- PVD, diabetes, HT Myth All hemorrhages of the disc signify glaucoma progression 23. Disc Hemorrhage 24. Myth Timolol is old school Side effects/contraindications overblown- Melton and Thomas 15-20% IOP reduction at qd AM (Istalol) Great adjunct to PAs, few allergic rxns. .25% for whites, .5% for the the more pigmented Very inexpensive in generic form GFS not needed - no better, more expensive 25. 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% 26. 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 27. iStent Trabecular Micro-bypass Stent 28. MIGS Minimally Invasive Glaucoma Surgery -ab interno iStent, others 1 or more, w or w/o cat. sx. Eliminates one topical med CyPass, others supraciliary microstents - 3mm incision Trabectome RF surgical ablation of 2-4 clock hrs of trabecular meshwork and Schlemms canal 29. Supraciliary microstents increase uveoscleral outflow 30. Trabectome 31. MIGS ab externo Canaloplasty enlarges Schlemms 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 32. 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 33. Well known iris and periocular pigment changes, iris cysts and contraindications for iritis and CME -- but what is this? Prostaglandin Analogs 34. PAP Prostaglandin Associated Periorbitopathy Upper lid ptosis Fat atrophy Involution of dermatochalasis Deepening lid sulcus Mild enophthalmos Inferior scleral show Prominent lid vessels 35. 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 36. Cigna and Lovelace discrimination - status report ODs forced to use VSP PEC for Lovelace Salud medical visits ODs forced to be panel providers for vision plan to be on Cigna medical panel Meeting with Insurance Superintendent after legislative session 37. 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 38. 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 39. 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 40. Other Third Party Woes Medicare Zone Program Integrity Contractors (ZPICs) and Recovery Audit Contractors (RECs) 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 41. 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 42. 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