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Myopia- Management

® Editorial Advisory Board members Jeffry Gerson, OD, FAAO; and Steven Ferrucci, OD, FAAO, chat about what’s new in the retina space while at Vision Expo West 2021 in Las Vegas.

Vision Expo West

Podcast: Retina pipeline as discussed by Gerson and Ferrucci

Videos

Gerson and Ferrucci talk retina pipeline

ODs can help detect visual field defects earlier with population screening, says Mohamed Abou Shousha, MD, FRCS, PhD. He is founder and CEO of Heru, which is launching its wearable field testing platform re:Vive at Vision Expo West 2021 in Las Vegas, Nevada.

Podcast: How population screening detects early visual field defects

 There is a huge unmet need for the diagnosis and for the screening of diseases that affect the visual field, such as glaucoma, macular degeneration and a lot of diseases that actually affect more than 450 million patients worldwide.


A study that was published more than 10 years ago came out from Johns Hopkins University showed that more than 27% of the population has visual field defects that they don't know about. They were able to capture this using screening of the visual field. However, it is very difficult, as we know, with the status quo and with legacy devices to provide care for patients because the devices are bulky, they require a separate room, technicians, and it is a bottleneck.

Now the technology has changed. So, there is artificial intelligence (AI), there is cloud computing, there are wearable devices and those are game changers. So, optometrists now have the opportunity to serve as the first line by doing screening for visual field defects using this new technology to fill this gap.

Population screening needed for earlier detection of visual field defects

Heru founder and CEO Mohamed Abou Shousha, MD, FRCS, PhD, discusses the origins behind re:Vive. The company launched the wearable visual field testing platform at Vision Expo West 2021 in Las Vegas, Nevada.

Podcast: Heru's visual field testing platform launches at Vision Expo West

 My name is Mohamed Abou Shousha. I am the CEO and founder of Heru. I am also an associate professor at Bascom Palmer Eye Institute.


We are very proud to say that we are launching our first product here at Vision Expo West—re:Vive. We have been working on this for the last 10 years and we realized at Bascom Palmer that visual field testing is a bottleneck. So, it is done using medical grade furniture, it requires a room, a technician. And it is very difficult to do for the patient. And it is the most hated test in ophthalmology and optometry, I would say.


So, what we did is we launched this new app that actually is in a wearable device. We converted the test from being delivered by a 50 pound device to 13.7 ounce wearable device. And we also improved the accuracy by using active pupil tracking. So you know how it is when patients sit on a visual field tests and just keep clicking and looking everywhere. Now we have a pupil tracking that is tracking the eye of the patient, and only delivering the test when the patient is looking where they should be looking. That leads to better accuracy for the test.


We also have an automatic workflow. So we are able to provide the patient with a screening test that takes only 30 seconds. And when there is a visual field effect, it moves the patient automatically to a full threshold test.


Moreover, the test is smart, and it talks to you. So it is a gamified experience and a smart experience it talks to the patient tells the patient what to do. We also ran a clinical trial, comparing the accuracy of hero to the standard of care. And this is in process we have great news to share very soon.

Heru launches re:Vive wearable visual field platform

Scott G. Hauswirth, OD, FAAO, discusses identifying and treating pain-related diseases that affect the eye

Podcast: How to identify and treat pain-related diseases

I am Scott Hauswirth and we are here at Vision Expo West in Las Vegas, Nevada. I am going to be talking about pain photophobia and how to help your patients that have this. 

Really, the class is about how to recognize neurosensory abnormalities, be it dry eye and other types of pain related diseases that affect the eyes. And really the first, the first place you want to start off with is recognizing that there are a lot of symptomatic cues your patients can give you, or tell you that will help you sort of keep this in your differential as you go through your examination with patients. 

Second piece of information is really how to do a very thorough examination because we do have to rule out a lot of other causes for ocular pain. 

And the third aspect of it is how to treat these patients. And, you know, by and large, we are doing a lot of the same things we do in dry eye. 

There are a lot of other regenerative types of therapies and collaboration that you can do with pain management specialists and other providers that will help you take care of these patients better. That will keep them in your chair.

How to recognize neurosensory abnormalities

Ken DauSchmidt, founder and CEO of Tear Restore, Inc., shares information about TearResore Mask, the first open-eye warm compress treatment.

Podcast: TearRestore CEO, Ken DauSchmidt, reviews new open-eye warm compress treatment

 Hello, my name is Ken DauSchmidt. I am the co-founder and CEO of TearRestore. We are here at Vision Expo West talking to thought leaders about everything new dry eye. We have got the first open open-eye warm compress available on the market today. It improves the efficacy of the treatment because the patient's blinking and naturally expressing the meibomian glands throughout. It also improves the compliance of the treatment because they can maintain their activity while they are doing their daily treatment. We have got a clinical study underway and we hope to share those results with you soon.

Open-eye warm compress helps with efficacy, compliance

Marc Bloomenstein, OD, FAAO, and Editorial Advisory Board member for 

 outlines what attendees can anticipate from the greatest anterior segment disease and medical management of contact lens complications course ever at 

Podcast: The greatest anterior segment course ever at Vision Expo West, with Dr. Bloomenstein

outlines what attendees can anticipate from the greatest anterior segment disease and medical management of contact lens complications course ever at 

 and I am joined today by Dr. Marc Bloomenstein, Optometry Times editorial advisory board member in Scottsdale, Arizona. He is lecturing on anterior segment disease and medical management of contact lens complications at Vision Expo West (VEW). Dr. Bloomenstein, thank you so much for talking with me today.

 Thanks, Brooke. I am excited to be here, virtually at least.

So, what are some key points from your talk?

I have to admit that the title of the talk is the greatest anterior segment lecture ever. And I am one of 4 panelists, myself, Dr. Paul Karpecki, Dr. Jack L. Schaeffer and Dr. Laura Periman. And I think the key kind of takeaway that I would love for people who are coming, or if they haven't come, they are thinking about coming, to leave with is that we all kind of have differing opinions about how to resolve common problems that we as optometrists see. I think the common thread within this talk is really is looking at, you know, anterior segment challenges, whether it be with contacts, without contacts, and then getting differing opinions on what is—not necessarily the best course of action—but what might be a course of action that you might want to be able to take away from that.

The nice thing about it, too, is that everybody kind of plays off of each other and having Dr. Periman there, who is a brilliant, brilliant ophthalmologist, and she is also quite the singer.

 Yeah! She drops few little diddies here a there, a little raps.

That sounds like a really fun course! What would you say is your take home message for ODs of this course, you kind of touched on it.

Well, to be honest with you, Brooke, it is the greatest course. Okay.

 A take home message, honestly, would be the practicality of it. To me, our take home messages is that anterior segment is almost kind of like you know, breathing. Every single patient has it. We have to manage it so that our patients get best quality of vision, whether it be somebody who's a pediatrics, or whether it be somebody who is in their teens or there with contacts or pre or post-surgery. The bottom line is, is that there are a lot of different scenarios which could affect the quality of the vision and we have so many new opportunities to look at each patient and say, "What can I do to help this patient get the best quality of vision?" I think the real the biggest take home messages is try to get people excited about the fact that we have new diagnostics, we have new treatments, and it reallyallows us to be able to manage our patients in a much different way. It is really cool. And also, you know, it is the greatest course ever.

Well, nobody should miss the greatest course at VEW this year. Thank you so much for speaking with me today. Dr. Bloomenstein. It was a pleasure.

Dr. Bloomenstein discusses the greatest anterior segment course ever at Vision Expo West

Lumenis launched its OptiLight intense pulsed light (IPL) device at Vision Expo West 2021 in Las Vegas, Nevada.

The FDA granted the company authorization for OptiLight, which is designed to improve 

A multicenter, double-blinded, randomized controlled trial revealed that the Lumenis IPL system with Optimal Pulse Technology (OPT) significantly improved tear break-up time, meibum quality, and meibomian gland expressibility.

Related: Optimizing management of dry eye disease

“Unless we address the underlying inflammation, it’s difficult to meaningfully impact dry eye disease,” said Steven J. Dell, lead investigator in the clinical trial, in a statement.1 “OptiLight helps us to address the inflammation, and improves signs of dry eye disease due to MGD, positioning it as a valuable tool in our dry eye toolkit.”

In related news, private equity firm Baring Private Equity Asia and Lumenis have partnered to accelerate the investment in vision and aesthetics vertical markets following the sale of Lumenis Surgical for $1.07B.

Lumenis recently completed the sale of its surgical division to Boston Scientific Corporation, a global medical device manufacturer.

The company plans to increase its vision and aesthetic businesses through its research, development, and marketing efforts.

Related: How to implement IPL into an optometry practice

1. Britton G. Lumenis receives FDA approval for Its IPL device to manage dry eye disease and launches OptiLight. Lumenis news release. April 29, 2021. Accessed September 22, 2021. 

https://lumenis.com/medical/news/lumenis-receives-fda-approval-for-its-ipl-device-to-manage-dry-eye-disease-and-launches-optilight/

2. Lumenis and Baring Private Equity Asia to accelerate investment in aesthetics and vision verticals following the strategic sale of Lumenis Surgical for $1.07B. Lumenis news release. September 1, 2021. Accessed September 22, 2021. https://lumenis.com/medical/news/lumenis-and-baring-private-equity-asia-to-accelerate-investment-in-aesthetics-and-vision-verticals-following-the-strategic-sale-of-lumenis-surgical-for-1-07b/

Articles

The new intense pulsed light technology targets meibomian gland dysfunction

Lumenis introduces OptiLight at Vision Expo West

Hey everyone, I am Dr. Michael Chaglasian. We are here in Orlando, and I just finished my lecture on the glaucoma suspect, key tips for optimal management. We focused on several key things for ODs to take home to their practices for their glaucoma patients. One of the things that I like to focus on is always looking at risk factors for your glaucoma suspects and patients with ocular hypertension.

Risk factors are the key things that make a decision on whether or not someone needs to be treated or to be observed. And things that go into the risk factors, of course, are things like the pachymetry, the family history, all the typical risk factors that people know about from glaucoma over time. But it is integrating them into the diagnostic side of things where the whole picture comes together. 

So, look at your risk factors, use your optical coherence tomography (OCT), use your visual fields, and put the whole picture together. With OCTs, it is always key to know that you have a good quality OCT scan. Do not misinterpret artifact or bad scans, and look at your report and drill down to the areas that really show glaucoma change and match it up to the visual field.

You have been doing perimetry for years, but you really want to match up the OCT for the visual field and make a clinical correlation. And then that cycles back to the risk factors. What is the age of your patient? What is the background? What is the family history?

When people take the time to assimilate all that data together, then they make the best decisions for their patients.

Related: How diabetes and glaucoma intersect

Vision Expo East

Transcript: Tips for optimal management of glaucoma suspects

 Hi, I’m Cecilia Koetting, and I am giving a lecture on urgency versus emergency. The idea behind the lecture is helping us to determine what is important when triaging a patient, whether it be our staff, over the phone, at the front desk, our technicians working the patients up, or ourselves within the exam lane.

What are the important things to ask our patients to really get a good story of what happened, why are they there? And how can we best treat them? My favorite is the five Ws: who, what, when, where, and why. I learned them when I was young, a little tot, and I think it still applies now, especially with medicine when we are trying to figure out how to address these problems with patients.

We will be going through case examples such as somebody calling in and saying, “I have a red eye.” Well, we know that there are a lot of different variances of red eye and what could cause a red eye. Subconjunctival bleeding, viral conjunctivitis, did they get hit in the eye and is this actually a laceration and just a sequela of something else that is going on?

We will be talking about double vision. We know there is a long list of what can cause double vision and just go through different scenarios and walk through a decision tree on how best to treat these patients within office.

Related: Tips for implementing and coding telehealth services

Transcript: Know when it’s emergent and when it’s not

Telehealth expanded rapidly for many ODs after the start of the pandemic. According to the Centers for Disease Control (CDC), the number of telehealth visits increased by 50% during the first quarter of 2020, compared with the same period in 2019.

 This led to a marked shift in practice patterns that still affect ODs. Christopher Wolfe, OD, FAAO, Dipl ABO, discussed best practices of telehealth implementation during a lecture at Vision Expo East 2021.

“I don’t think there is going to be a reversal on implementing telehealth services,” Wolfe says. “If anything, I think there will be ongoing payments and expansion from here on out.”

The first thing ODs should do when implementing telehealth services is consider all the clinical situations that can be used. Things like contact lens checks, eyelid checks, and conjunctivitis screenings are good places to start. Next, make sure medical insurance carriers cover all services. Coverage information can usually be found online or call carriers to ask, Wolfe suggests.

With assurance that services are covered, it is time to move patients to a new telehealth system.

Several free applications are available to make implementing telehealth easy. Doxy.me, Zoom, and Facetime allow for simultaneous, back-and-forth communication with video and audio, so all will work. However, Wolfe suggests ODs use doxy.me over Zoom and Facetime because of its simplicity and ease of use.

Says Wolfe: “The reason I like doxy.me, in addition to being simple, is that if a patient texts me or calls me and I immediately take the call, I can very quickly say, ‘Hey, this sounds like something that I want to be able to see face to face. Let's jump on. Here is the link.’ Boom. I can send him a link that takes him directly to the portal. I log in, he logs in. It is that easy.”

The majority of services ODs provide can be appropriately coded with 99 codes, Wolfe says. Follow documentation guidelines and consider the following:
· Don’t use 920XX codes

· Don’t get bogged down with other codes if you are just starting out

· When billed, use 11 (Medicare) or 02, depending on payer

· Use -95 modifier on your 99-code to identify telehealth services

“I recommend using 99 codes most frequently because they have a longer time limit, and they are the most clearly defined. If I saw a patient yesterday in my practice and I want to see him today, online, remotely, I can do that. All I have to do is satisfy medical necessity and any 99-specific code requirement.”

When it comes to modifiers, check with your carrier before billing.

“Most carriers want a 95 modifier on your 99 codes, some Medicaids will want GT modifiers, but most of them now have consolidated to match content management system,” says Wolfe.

Virtual check ins are short meetings that occur via video, telephone, or other telecommunications to decide whether an office visit or other services are needed. Wolfe says to use these rarely because nuances make them more challenging to code. 

One nuance related to virtual check-ins is that the service must not originate from a related service provided within the previous 7 days, nor leading to a service or procedure within the next 24 hours or soonest available appointment.

 A virtual check-in must also include 5 to 10 minutes of medical discussion.

“If captured images or video files are sent to the patient, you would also need to build a G-2010 form,” Wolfe says.

An e-visit is a communication with an established patient through an online portal. Wolfe says to use these sparingly and only with a non-face-to-face patient-initiated communication. Codes for e-visits are:

A telehealth service visit occurs when a patient uses real-time audio and video telecommunication systems to meet with a provider. Wolfe recommends using these most frequently because they are reimbursed at the same rate as in-person visits and are all ODs need to quickly and easily provide care.

Codes for telehealth services are 99201 to 99215. They do not include 92-codes. Additionally, they have -95 modifiers. When signifying a place of service, use 11 for office and 02 for telehealth.

1. Koonin LM, Hoots B, Tsang CA, et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic — United States, January–March 2020. 

2. Medicare’s virtual check-in codes. American Optometric Association. Published July 31, 2019. Accessed June 17, 2021. https://www.aoa.org/news/practice-management/billing-and-coding/medicares-virtual-check-in-codes?sso=y

For a majority of ODs, 99 codes work best

Tips for implementing and coding telehealth services 

Benjamin Gaddie, OD, FAAO, kicked off his lecture on new 

 drugs by stating that eye care providers haven’t seen a new mechanistic class of glaucoma medications introduced to the market since 1996. The lecture took place at Vision Expo East 2021 in Orlando, Florida.

“We have had combination drugs such as Simbrinza (brinzolamide/brimonidine tartrate, Alcon) and Vyzulta (latanoprostene bunod, Bausch + Lomb),” he says. “The first new class is Rho kinase inhibitors.”

Following are highlights from his lecture.

Tips for optimal management of glaucoma suspects

Prostaglandins such as latanoprost are lipid family receptors. About 70% of the market is generic latanoprost, says Gaddie. Note that the teal bottle top denotes the drug inside is a prostaglandin.

“My goal today is not to put anybody on eye drops,” Gaddie says. “They look like hell, and we have to deal with prior authorizations. I would love to keep people off drops. Injectables and lasers are options to look at.”

Latanoprostene bunod is considered a prostaglandin because the FDA did not designate it as a new class, Gaddie says. The drug releases nitric oxide is released, and it is used to treat heart disease and erectile dysfunction (Viagra, sildenafil citrate; Pfizer).

“It relaxes smooth muscle contraction like the heart or trabecular meshwork,” Gaddie says.

About 90% of all glaucoma patients presents with an intraocular pressure (IOP) under 15 mm Hg.

“Instead of adding something,” he says, “switch within that class to obtain lower pressure. A 25 to 30% reduction is the goal for most patients because that is what prostaglandins give you.”

He says that the lower the IOP when treatment starts, the harder it is to lower IOP. Plus, Vyzulta is the first drug to be approved to lower IOP, not reduce elevated IOP.

Gaddie says the retinal nerve fiber layer (RNFL) plays a role in glaucoma.

“If the RNFL is lower than 70 µm, somebody needs to convince me it’s not glaucoma,” he says. “I used to diagnose glaucoma based on ganglion cell complex (GCC). Today, I do the direct opposite. I want to see some type of matching pattern between the GCC and the RNFL. Loss on the temporal side of the macula is telling you that even if the patient doesn’t have glaucoma now, they will.”

OCT in glaucoma management: Green isn’t always clean

Rho kinase inhibitors, or ROCKs, target the trabecular meshwork. Two drugs in this category are Rhopressa (netarsudil, Aerie Pharmaceuticals) and Rocklatan (netarsudil and latanoprost, Aerie Pharmaceuticals).

Netarsudil is not as effective as latanoprost, Gaddie says.

“When it is tolerated, it’s a great drug. I get at least 4 mm Hg of IOP reduction.”

The challenge with ROCKs is adverse events, he says. About 54% of patients experience conjunctival hyperemia. Another event is corneal verticillata, caused by an increase in phospholipids, which is reversible upon drug discontinuation.

“A big one for me is blurred vision,” says Gaddie. “I think 10% of patients have blurry vision, and their visual acuity is affected by at least 1 line, maybe 2.”

Rocklatan offers 4 mechanisms of action with once-daily dosing.

“If you haven’t experienced this agent, I suggest you give it a look,” he says.

Eye care providers understand that patient adherence to medication may depend on cost. Some patients’ medical plans require that patients meet the full deductible prior to prescription benefit coverage.

A cash pay option from manufacturers may help, says Gaddie.

“The first glaucoma option for cash pay is Xelpros (latanoprost) from Sun Pharma,” he says. “It’s a branded drug without benzalkonium chloride (BAK) preservative—it uses potassium sorbate, which burns on instillation. It costs $55 for 1 month or $110 for 3 months, and patients are happy with it.”

A similar option is available for Travatan Z (travoprost) from Novartis. Pricing is $55 for 1 month or $135 for 3 months.

“These options work for Medicare patients because it’s all cash,” says Gaddie.

Compounding pharmacies are another option to help patients with glaucoma save costs on medications.

“Before dropless surgery came into vogue, I used compounding pharmacies to put all 3 medications—nonsteroidal anti-inflammatory (NSAID), antibiotic, and glaucoma—into the same bottle,” he says. “Anything you can think of, pharmacies can compound it into a drop. But the insurance coverage can get messy.”

However, he cautions practitioners on the use of compounded drugs for chronic diseases.

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