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Jennifer Li, MD, details a talk she gave alongside Melissa Barnett, OD, FAAO, FSLS, FBCLA, at CRU 2025 in Napa, California.

CRU 2025: Neurotrophic keratitis and multidisciplinary approaches to enhance patient outcomes

Deb Ristvedt, DO, details a handful of presentations on glaucoma she gave during CRU 2025 in Napa, California.

CRU 2025: Interventional glaucoma as a proactive approach to glaucoma management

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The decision to discontinue the trials comes shortly after the announcement that COAST missed its primary endpoint.

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Myopia- Management

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

Vision Expo East

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.

He says: “Drugs have different pH, some are suspensions…how do they live together in the same bottle? Little data supports efficacy, and pharmacies will not start making the compound until the patient pays for it.”

No one knows what the next new glaucoma drug will be, Gaddie says. Adherence improvement will be a big part of innovation in glaucoma treatment.

One potential treatment in phase 2 trials is a drug-eluting 

 for the treatment of glaucoma, dry eye, and ocular allergy. Patients wear the lens for 5 days, then remove. This product is made by MediPrint Ophthalmics, formerly Leo Lens Pharma.

“How many glaucoma patients will want to wear a contact lens unless they already do?” says Gaddie.

What’s new in glaucoma medications

 While online optical retailers have disrupted eyewear sales for many optometric practices, ODs can position their expertise and branded lenses in a way that hooks a large portion of interested consumers. Jackie O’Keefe, LDO, explored branded eyewear consumer markets and explained how to appeal to them at Vision Expo East 2021.

Three main motivations drive branded eyewear sales. They are:

· I know you—there is an intimate understanding of what the brand is

· I like you—the brand is held in a high regard

· I need you—the brand is appropriate for the consumer’s needs

Depending on how distinctive, unique, and appealing eyewear is, consumers may also be motivated to buy on impulse.

Branded eyewear buyers often enjoy accessorizing and may be status conscious, desiring the latest fashion, says O’Keefe. These individuals may justify spending more for popular products, which hold more value.

ODs who foster a trusting relationship with patients will have an easier time selling branded eyewear than those who do not take the time to nurture trust, she says.

According to O’Keefe, 2% of U.S. market consumers are innovators.

“These individuals would be willing to fly out to the house of Coco Chanel and purchase in European countries where trends are first emerging,” O’Keefe says.

Some 30% of U.S. consumers are early adapters. “These people enjoy buying their eyeglasses from places like small, hometown boutiques that are hidden from the masses,” O’Keefe says.

The majority (69%) of U.S. consumers buy glasses when they become comfortable to purchase.

“It takes fashion in the European market about 4 years to become comfortable to the average U.S. citizen,” O’Keefe says. “After 4 years, most folks have become familiar enough with a fashion trend to spend money on it.”

About 16% of U.S. consumers are laggers and want frames based on functionality instead of fashion. “These individuals want to feel value for the product itself,” O’Keefe says. “They much prefer spring hinges, titanium, stainless steel; they don't want a designer’s name on their temples.”

Branded eyewear offers advantages over generic options. Aside from looks, quality, and warranty coverage, branded eyewear can simplify purchasing, inspire confidence, imply additional benefits, create loyalty, and even evoke emotion.

“Branded eyewear makes a promise that distinctly defines the product in its market and against competition over time,” O’Keefe says. “Use this to create ongoing relationships with buyers.”

Selling eyewear is a visual process, and the first step to success is a hands-on approach. O’Keefe suggests every staff member in an optometric practice wear branded frames and change them often in front of patients. ODs can create a positive emotional experience with a specific brand by:

“Lead by example, and maintain the essence,” O’Keefe says.

How to position branded eyewear in your practice

The visual needs of elderly patients differ greatly from those of the general population. Because of this, ODs should have senior-friendly processes in place to accommodate the fastest-growing population. Jackie O’Keefe, LDO, discussed methods to proficiently dispense to elderly patients at Vision Expo East 2021.

Older is wiser, but sometimes seniors misunderstand or are reluctant to accept the visual changes they experience with age. When this happens, it is the job of the OD to exercise empathy while educating senior patients on the natural aging process.

ODs should be prepared to give seniors personal attention and answer questions in a way that speaks their language.

“Talk slower, not louder,” O’Keefe says, “and keep common fears and misunderstandings in mind.”

Common fears and misunderstandings that arise in elderly patients include:

· Questions the patient wanted to ask the doctor but forgot

To help patients with questions they might have had but forgot, keep a printout of common questions and answers handy to give elderly patients during their visit, O’Keefe suggests.

Certain lighting, furniture, procedures, and fonts in your practice might be inadequate to senior needs.

· Chairs without arms or cushions that sink in

Low vision aids like magnifiers, Early Treatment Diabetic Retinopathy Study (ETDRS) charts, contrast sensitivity charts, continuous text reading cards, and near vision materials can provide ODs with a better sense of elderly patients’ vision than visual acuity alone and grant seniors a sense of independence.

Aging can affect the eyes in a number of ways, from increased incidence ofpresbyopia, glaucoma, cataracts, and macular degeneration to weakened vision, smaller fixed pupils, slower visual reaction, cloudier lenses, less productive lacrimal systems, thin vitreous humor, increased floaters, and decreased night, near, and clear vision.

When it comes to driving, the American Optometric Association (AOA) recommends the following guidelines for elderly patients:

· Avoid tapered temples, which can block peripheral vision

ODs can make a big difference in the lives of senior patients by walking a mile in their shoes and practicing compassion and patience.

“Don’t patronize, make them feel comfortable and valued, and go easy on the jargon,” says O’Keefe.

Consider these suggestions for accommodating the fastest-growing patient population

Tips for dispensing to the elderly

Cecelia Koetting, OD, FAAO, outlines what ODs should watch for in determining urgent vs emergent situations.

Click here to read the associated transcript

Related: Tips for implementing and coding telehealth services

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

Melissa Barnett, OD, FAAO, FSLS, FBCLA, offers quick tips for ODs to ensure an optimal ocular surface for their patients wearing scleral contact lenses.

Related: Tools help to address multifocal contact lens fitting challenges

Scleral lens wear and ocular surface disease

Orasis Pharmaceuticals CEO Elad Kedar says the company is looking to achieve a balance of safety, efficacy, and comfort with its drop in development for treating presbyopia. He says Phase 3 studies should finish at the end of 2021.

Orasis Pharmaceuticals drop in development for treating presbyopia

Pipeline: Presbyopia treatment to finish Phase 3 late 2021

Look at risk factors for patients who are glaucoma suspects or who have ocular hypertension, says Michael Chaglasian, OD, FAAO, 

® Editorial Advisory Board member. They inform decisions on observation or treatment. Find out more!

Related: How diabetes and glaucoma intersect

 Hi, everybody. I am Gretchyn Bailey with 

®. And I have the pleasure of speaking now with Dr. Jake Lang from Minneapolis. Jake is talking to us about a lecture he is delivering at this year’s Twin Cities Ocular Surface Disease Symposium. Boy, that is a mouthful. And that meeting is all virtual this year. It is also combining with Dry Eye Boot Camp at the same time. Jake, first, thanks very much for talking with me. I really appreciate you taking the time.

 My pleasure. Thanks for having me here. And thanks to Everything Dry Eye, Dry Eye Boot Camp and Twin Cities OSD symposium for allowing me to speak to people about advanced technology, intraocular lenses (IOLs), and ocular surface disease.

We spoke a lot about advanced technology IOLs, where IOLS have come from, where they are going, new technology that is on the horizon, ways of correcting refractive error, ways of correcting presbyopia, and maybe ways of integrating technology into our IOLs in the future. We talked a lot about that and then how the ocular surface plays such a huge role in making these advanced technology lenses work. Without a healthy ocular surface, we just can’t get out of that technology what we want. I kind of did it a little analogy to having this great cell phone and having horrible service. You just can’t get out of your phone what you want. If you don’t have that, if you don’t have good WiFi, your Zoom meetings just don’t work that way.

Related: MGD: Identification and treatment

 And we have all experienced that lately, haven’t we?

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