Capital Eye Consultants
Winter 2015 Newsletter


Capital Eye Consultants


We hope you find this newsletter interesting and informative of new developments at our center and in the field of eye care

 

Sincerely,

 

Clinical Staff
Capital Eye Consultants
Capital Eye Consultants
In This Issue
From The Center Directors Desk


 

This article will review clinical, business and legal aspects of cataract co-management...doctors who have had experience in this field may still gain a few pearls.

 

Thanks to AOA advocacy, CMS allows optometrists to bill for cataract post-operative services using a modifier system.  In the next two years, CMS is doing away with the concept of post-op periods for all surgeries.  Procedures with 10-day post-op periods will be discontinued in 2017 and procedures such as cataract with 90-day periods will be discontinued the following year.  Post-operative care will become a separate billable event but the actual replacement system has not yet been published. We will keep you informed as these changes occur.

 

Post-op care is a patient-directed choice.  Optometrists should discuss the option with the patient and indicate the patient's choice for care on the referral form.  CEC's referring optometrists range in care dates from the last 60 days to a few who provide all 90 days of care.  Patients sign an agreement as part of the scheduling process expressing their choice.  Our consult reports include dates of surgery and a recognition of the length of post-operative care;  any other arrangement between the surgeon and the referring doctor is fraudulent and can result in fines and loss of Medicare participation.  If you are billing Medicare and do not receive Medicare payment for post-operative care, it is imperative that you contact our office so that we can help rectify the problem.

 

Our recommended standard post-operative visits are as follows:

 

24-hour visit:
  • Obtain uncorrected and pinhole vision
  • Slit lamp examination and intraocular pressure using a fluorescein strip and anesthetic bottle that is not used for other patient contact
  • Review of post-operative instructions including: 
    • Topical medications of Ofloxacin q.i.d. x one week

    • Pred Forte q.i.d x four weeks

 

Post-op instruction sheets are available from CEC to put on your letterhead.

 

One-Week Post-Op Visit

  • Visual acuity and refraction, if vision is below what is expected.
  • Slit lamp examination and IOP.

If the second eye is already tentatively scheduled, confirmation to move forward with surgery, as well as patient's lens choice, are documented.

 

Final Post-Op Visit 3 weeks or later

  • Vision refraction, if necessary
  • Slit lamp exam
  • Pressure
  • Dilated fundus exam.

 

Because many patients choose consecutive surgery with the eyes booked 2-3 weeks apart, we now see the one-week visit for such patients at CEC.  That way, there is no time lost in communication about choices for the second eye.  The days billed by our office and your office are given on our final notes which usually arrive in your office by fax in the form of a copy of our post-op notes from CEC.

 

Because of the pre-operative educational time and the post-operative hand-holding, CEC offers a separate co-management program for ReSTOR multifocal lenses.  Because this is not a Medicare-covered service, a global fee is collected from the patient and an optometric co-management fee check is issued directly from Capital Eye Consultants for this portion of care.  Medicare patients are also billed for medical post-operative care, as discussed above.  Optometric co-management centers around the country do not provide extra co-management payment for toric lenses because no extra services are provided by the optometrist.  Pre-operative measurements are very exacting and must be performed in the surgeon's office.  Some surgeons do cut checks to referring doctors for toric patients.  This is very likely inducement to refer, punishable by Federal Statutes.

 

If you are not actively co-managing cataract patients, you are not taking advantage of hard-won services allowed under Medicare.  Optometrists are uniquely qualified to provide these services, given our clinical training and recognized expertise in patient communication skills.  Patient care is also enhanced by easily accessible care closer to home provided efficiently by someone who knows the patient.  Inter-communication between the surgeon's office and the co-managing doctor is of paramount importance.  Our system has been honed over the years to make that communication as seamless as possible.  We welcome your participation and feed-back.  Remember, this system is in place throughout the U.S. and is probably the best way to deliver cataract surgery.  It utilizes the expertise of the best surgeons in the country, coupled with trained and caring primary care optometrists to provide the clearest choices and the best results for cataract patients.

 

James E. Powers, O.D.

 

.

CEC  To Start Performing Implantable Miniature Telescope (IMT) Surgery

  

            

 

 

 

Dr John Baldinger will shortly be performing IMT surgery on patients with advanced macular degeneration with macular scars.  This novel intraocular lens has been available since 2010 (FDA approved), however was only allowed to be performed in a hospital operating room . CMS (Medicare) this year is allowing the implant to be placed in the eye at the time of cataract surgery in a free standing ambulatory surgery center setting, where most cataract surgery in the US  is currently performed. 

 

Only patients who meet strict criteria, pass pre-surgery tests with an external eye telescope and agree to vision training afterward are eligible. 

 

The procedure will be performed at the Fairfax Surgical Center in Fairfax Va where Dr. Baldinger has performed over 25,000 procedures since 1986.  We are proud to be the first practice in Northern Virginia to offer this technology

 

John C Baldinger MD

 

 

 

 


    Eyelea Is Best For Diabetic Macular    Edema (DME), Right?

                       

                   

Do you know which anti-VEGF injection is best for DME (diabetic macular edema)? Until recently, I didn't have a clue. I, too, thought they were basically equal. I am a huge fan of Avastin. Presently, Eylea, Lucentis and Avastin are all standard of care for the treatment of DME whereas only Eylea and Lucentis are FDA approved for this most common complication of diabetic retinopathy. This means it's not malpractice for a doctor to administer any of the 3 drugs - all are acceptable. anti-VEGF Compared Head to Head 

 

For the first time, a head to head study has been published comparing the 3 anti-VEGF medications. As published in the New England Journal of Medicine, February 19, 2015, Eylea, Lucentis and Avastin were compared in a one year study. For certain patients, Eylea was found to be superior to the other 2 anti-VEGF injections. 

 

"Protocol T" Found Eylea Superior The NIH funded study, called Protocol T, involved over 600 patients. Patients were examined and treated for diabetic macular edema receiving anywhere from 9-10 injections depending upon the anti-VEGF agent used. Those receiving Avastin and Lucentis received 10 injections whereas Eylea patients received an average of 9 injections. Eylea was found to be superior in those patients with moderate or worse vision loss at the start of the study. Vision improved by almost four lines whereas Lucentis improved almost 3 lines and Avastin patients improved 2.5 lines. Moderate or worse vision was defined as 20/50 or worse. Patients with Better Vision Protocol T found that patients with initial vision better than 20/50 did equally well regardless of the anti-VEGF medication used. The average improvement with all 3 medications was almost 2 lines

 

What Does This Mean? The average cost for the anti-VEGF injections: ● Eylea $1950, ● Lucentis $1200 ● Avastin $50. Protocol T clearly helps me decide to whom I should offer certain anti-VEGF injections. According to this study, those with 20/50 or worse should be treated with Eylea. If your patient has 20/40 vision or better - any of the 3 anti-VEGFs are appropriate and effective treatments. Considering the price; however, Avastin clearly should be offered as, according to this study, all other factors appear to be equal. I've long used Avastin for my patients with DME whereas others in the area favor Lucentis. Now I have a strong evidence to continue my preference for Avastin. Reasons for using Lucentis have become, uh, "blurrier." 

 

Randall Wong, M.D.

Retina Specialist Capital Eye Consultants Fairfax, VA 



Denver Academy 2014

                               

I recently attended the Academy meeting in Denver.  Cold was the theme with temperatures as low as -2 degrees.  There were many fine speakers and lectures, but of course I gravitated towards the ocular disease track.


 

I really wanted to gain a better understanding of OCT interpretation in glaucoma.  What I found is that nobody has a great way to interpret these tests.  But, there are several opinions out there that can be helpful.  I did garner a few nuggets(Denver - get it) that did apply to the Humphrey Cirrus.


 

Asymmetry between the eyes appears to be a key finding  according to Dr. Micheael Sullivan-Mee.  He looked extensively at asymmetry of greater than 5 microns of macular thickness, especially in the inferior temperal region, as a good indicator of disease.  Macular thickness also may be a better indicator in moderate to advanced glaucoma

 

As far as RNFL loss, more than 1 clock hour at <5% level (yellow) has a 90.5-96.6% sensitivity. Global RNFL asymmetry of greater than 9um can be indicative of early glaucoma. Change over time can be monitored with the Glaucoma Progression Analysis or a change of more than 5um/year is considered a significant negative trend. 

 

Remember that we lose RNFL at a rate of 1.5-2.0 microns per decade.  You also have thinning associated with high myopia( 1.2um/diopter)and being a male.

 

You want a quality score of 7 or higher on your scans or they are unreliable.

 

Larger optic nerve heads give a thicker rNFL measurement because the circle of measurement is always placed from the center of the disc, therefore measuring closer to the rim.

 

These instruments give us lots of information - we just aren't sure of the relevance or how to interpret some of it yet.  Expect more information in the interpretation of all of this data to continue to evolve. 


 

James Mattern OD


 


 

About Us

Founded in 1986 by doctors of optometry in Northern Virginia, Capital Eye Consultants has provided 28 years of quality and comprehensive consultative / surgical co-management services for the optometrists and their patients in the Northern Virginia area. 

Find us online at CECEyes.com!

 

Capital Eye Consultants
3025 Hamaker Court
Fairfax, Virginia 22031
(703) 876-9630