Medical Management of Glaucoma: It's a New Era
Advances in disease detection, treatment and monitoring present opportunities for your practice.
BY ANDREW RABINOWITZ, M.D.

The medical management of glaucoma is considered a staple in the diet of the general ophthalmologist. But from the mid-1980s to early 1990s, ophthalmic practices were seeing a growing number of cataract and refractive patients, and busy surgeons began to believe that glaucoma patients were "clogging" their waiting rooms. Indeed, many surgically oriented practices recruited subspecialists to handle the growing number of glaucoma patients, and established practices had difficulty accepting new patients because a majority of their office hours were spent with existing glaucoma cases.

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A perception grew within the ophthalmic community that caring for glaucoma patients was intellectually challenging, time consuming, and financially unrewarding. Typically, glaucoma patients then accounted for 15 to 25% of a general ophthalmology practice. Caring for these patients consumed valuable time, which otherwise could have been spent in the operating room, where reimbursement was significantly greater. Thus, ambitious surgeons struggled to manage their office hours so that they could spend more time performing cataract and refractive surgeries.

Dedicated ophthalmologists continued to provide care for their glaucoma patients. In an effort to expedite the chair time needed to follow glaucoma patients, ophthalmologists routinely checked IOPs, but sometimes neglected to maintain standard of care when it came to ancillary testing. Visual fields, which should have been performed annually, were done every few years. Disc photographs were obtained at the initial examination, but rarely thereafter. Gonioscopy was underutilized both at the initial examination and over the course of follow-up visits.

Reimbursement per office visit was minimal. The perception among ophthalmologists was that glaucoma patient visits were of nominal financial gain. The financial impact of medically managing glaucoma reached its nadir in the early to mid 1990s.

1995 was a Turning Point

But beginning in 1995, the tide began to turn. Major forces served to usher in a new era of glaucoma management and its financial rewards. In this, the first of a series of five articles designed to serve as an overall guide to providing standard of care medical management for glaucoma patients, I'll explain how two important developments created the current opportunities in glaucoma management.

The first development that altered the landscape of glaucoma management was the introduction of several novel drugs for the treatment of elevated IOP. In 1995, Pharmacia's blockbuster drug Xalatan gained FDA approval. Shortly thereafter, Allergan introduced Alphagan. Concurrently, Alcon designed several competitive ophthalmic drugs.

From 1995 to today, Pfizer/Pharmacia, Allergan and Alcon have invested millions of dollars in educating physicians and promoting their drugs. The infusion of funds and information regarding these medications has profoundly changed the course of glaucoma management. The efficacy of these drugs, as well as more recently introduced prostaglandin analogs, has dramatically reduced the need for glaucoma surgery. This trend was eloquently documented in a study by David Paikal, M.D., and Anne Coleman, M.D., published in the July 2002 issue of Ophthalmology and titled Trends in Glaucoma Surgery Incidence and Reimbursement for Physician Services in the Medicare Population from 1995 to 1998.

General ophthalmologists currently play a more active role in the treatment of glaucoma at all stages. Continuing medical education programs sponsored by the major pharmaceutical companies keep general ophthalmologists well educated by providing regularly updated information in a clinically relevant fashion. Prior to 1995, patients who were uncontrolled on a medical regimen consisting of beta-blockers and miotics were often referred to glaucoma specialists for surgical management once laser trabeculoplasty was completed. Today, these same patients remain under the care of the general ophthalmologist because the potency of newer, topical medications helps keep IOP controlled at levels in the mid to low teens. Providing care for these patients can be intellectually challenging, professionally stimulating and financially rewarding.

The second event responsible for ushering in the new era of glaucoma management also occurred in 1995. This event was the introduction of the Heidelberg Retina Tomograph (HRT). Prior to the introduction of the HRT, the only ancillary testing in glaucoma management were visual fields and fundus photography. Scanning laser ophthalmoscopy was given a unique billing code (92135) shortly after HRT's introduction. From 1995 to today, the use of the 92135 codes by ophthalmologists has steadily increased. Alternative devices such as the GDx also employ laser polarimetry. Unlike HRT, which focuses on optic disc morphology, GDx studies the nerve fiber layer.

Although the roles of the HRT, GDx and somewhat similar diagnostic instruments such as the Zeiss Stratus OCT and Talia's RTA haven't been clearly defined in terms of their exact role in glaucoma evaluation and management, their use has become commonplace among practicing ophthalmologists. These instruments have been at the forefront of the movement to incorporate as much ancillary data as possible in treating glaucoma suspects and beyond.

More Data for Decision-Making

Judicious yet appropriate use of emerging technologies such as scanning laser ophthalmoscopy, frequency doubling technology, and corneal pachymetry are now the rule rather than the exception. The emerging technologies are highly useful if the practitioner understands their value and respects their limitations.

But these tests shouldn't be overused. Rough standards for appropriate testing currently exist. These standards continue to evolve as new technologies are introduced.

Ophthalmologists who practice standard of care glaucoma management are eager to incorporate emerging technologies into their clinical practices. The information garnered from these technologies helps them make critical decisions regarding patient care.

The new financial realities of practicing standard of care glaucoma management are only beginning to be fully appreciated. Third-party payers have continually increased the emphasis on early screening and preventive medicine. Reimbursement for office visits as well as ancillary testing of glaucoma patients has gradually increased. In fact, a properly managed glaucoma patient has great financial value to an ophthalmic practice.

Glaucoma Care is Continual

If managed properly, a glaucoma patient may be seen from two to six times annually. Many of the visits include ancillary testing in addition to the office visit reimbursement. Examples of ancillary testing include visual fields, contrast sensitivity testing, scanning laser ophthalmoscopy, corneal pachymetry, fundus photography, gonioscopy, and serial tonometry. Each of these ancillary tests carries with it a unique billing code.

In order to maintain standard of care, these visits and ancillary tests must be performed over subsequent years with varying frequencies. Additionally, if the patient is managed and controlled medically, he or she doesn't present the potential medical-legal risks to the practice as an analogous cataract or refractive patient.

Another important financial consideration is that building a thriving glaucoma practice doesn't require major advertising dollars. Surgically oriented practices -- especially those with a high percentage of refractive patients -- must advertise to attract new candidates. The investment required to build a glaucoma practice primarily consists of quality time spent communicating with and educating each patient. The best form of advertising in building a glaucoma practice are happy, well-informed, and actively compliant patients.

Practice patterns that offer patients the most appropriate, technologically advanced, and thorough standard of care medicine also offer the physician a predictable, relatively low risk, yet financially rewarding patient base.

Dr. Andrew Rabinowitz is a board-certified ophthalmologist specializing in glaucoma management. He's currently in private practice at the Barnet Dulany Perkins Eye Center in Phoenix, Ariz., and can be reached at Barnet Dulany Perkins Eye Center, 4800 North 22nd St., Phoenix, AZ 85016.