How to succeed in today's glaucoma brave new world

If clinicians understand the current state of affairs and what lies ahead, they will be able to better manage the odds of glaucoma in an era of changing health-care delivery. Andrew G. Iwach, MD, provided a snapshot of the current landscape and where the field is headed.

Understanding the current state of affairs and what lies ahead will help ophthalmologists manage the odds in an era of changing health-care delivery. Andrew G. Iwach, MD, provided a snapshot of where things stand and where they are headed during the Glaucoma Symposium CME at the Glaucoma 360 meeting.

“We have to take a look at the whole picture and realize that while we don’t have control over much of what is coming in the future, we have to at least become engaged and stay involved,” said Dr. Iwach, executive director, Glaucoma Center of San Francisco, and associate clinical professor of ophthalmology, University of California-San Francisco. “I certainly do not have all the answers, but I think we need to start thinking out of the box.”

Practice pattern trends

Reviewing recent data on diagnostic testing, Dr. Iwach reported during the Glaucoma Symposium CME at the Glaucoma 360 meeting that utilization of optical coherence tomography (OCT), pachymetry, and visual fields has been increasing, while fluorescein angiography has been on the decline.

For treatment, prostaglandin analogues remain the most prescribed class of medications for lowering intraocular pressure (IOP), followed by beta-blockers. The number of laser iridotomy procedures are stable, but trabeculectomy continues to decline. There also is an increase in utilization of the trabecular micro-bypass stent (iStent, Glaukos).

“According to all projections, microinvasive glaucoma surgery (MIGS) procedures are here to stay and their utilization will continue to grow over the next few years,” Dr. Iwach said.

Treatment developments


Treatment developments

Challenges with medication compliance continues to be an issue in glaucoma patient care and the industry is rising to address the need. The number of companies developing novel delivery systems for extended-medication release has grown over the past five years. Several products are in later stage clinical trial development, and a new code has been created for drug-eluting implants.

“These types of products will not only provide long-term medication delivery, but, avoiding the need for high-peak doses to maintain the local concentration of medication within a narrow window may allow the use of molecules that might otherwise be unsafe or poorly tolerated,” Dr. Iwach said.

He noted that rising utilization of MIGS may reflect the need to provide patients with safer surgical alternatives even with some trade-off of efficacy. Some new developments also show sensitivity to cost, such as a simple surgical instrument developed by Malik Kahook, MD, (Kahook Dual Blade, New World Medical) which removes trabecular meshwork tissue, resulting in increased outflow.

Encouraging safety and efficacy data are also being reported from early experience with transscleral cyclophotocoagulation using a micropulse diode laser system (MicroPulse P3 Glaucoma Device with the CYCLO G6 glaucoma laser system, Iridex). However, Dr. Iwach cautioned when adopting new technology because safety issues may emerge only when sufficient numbers of patients are treated.

Practice management

Practices are also being affected by coding changes. With ICD-10, the number of codes increased from about 18,000 to about 141,000. Explained in part by increased specificity, the increase in codes has increased coding complexity.

Ophthalmic practices also are affected by the changing compensation models and the narrow provider networks in third-party insurance plans. Fortunately, there are reports that CMS will end Meaningful Use in 2016, Dr. Iwach said.

Setting up a game plan


Setting up a game plan

Concluding his talk, Dr. Iwach described some basic defensive and offensive strategies that may help ophthalmologists as they navigate through the changing environment of health-care delivery. He encouraged colleagues to make sure their malpractice coverage is in place and to speak first to their risk manager quickly in the event of an unexpected outcome.

Dr. Iwach also highlighted informed consent documents that can be accessed on the Ophthalmic Mutual Insurance Company (OMIC) website, as well as patient education resources available from the Glaucoma Research Foundation and the American Academy Ophthalmology (AAO).

“The AAO recently released new glaucoma patient education videos to supplement informed consent,” Dr. Iwach said. “They provide a great way to relay information at a time when we are being pressed to see more patients.”

The encounters also should be documented in the patients’ chart, he added.

In building an offense, ophthalmologists need to be aware of the growing impact of patient perceptions as posted on social media. They should review websites and address negative reviews.

“While our focus is on how we are helping patients maintain their vision, patients may consider other issues as more important when they judge value-of-services delivered,” Dr. Iwach said. “Remember, that patients begin to form perceptions of you based on the first encounter they have with your office staff. Ask yourself whether you want your patients to think of your practice as the U.S. Postal Service or FedEx.”


Andrew G. Iwach, MD


Dr. Iwach is a consultant for Allergan, Alcon, and AcuMems.