Goals. Glaucoma PARA PEARL TO DO. Vision Loss with Glaucoma
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1 Glaucoma Janet R. Fett, OD Drs. Kincaid, Fett and Tharp So Sioux City, NE Goals Understand Glaucoma Disease process Understand how your data (objective and subjective) assists in diagnosis and management Understand Treatment Types and Goals Apply your knowledge to assist in patient education and compliance Understand good billing and coding policies Develop and maintain policies to ensure quality patient care PARA PEARL TO DO GLAUCOMA is a group of eye conditions that cause characteristic damage to the optic nerve nerve fiber layer and eventually causes visual field loss. The damage is PERMANENT & NOT RECOVERED Total loss of vision (NLP) can occur This damage is OFTEN caused by an abnormally high pressure in your eye. It cannot be cured, but many causes can be CONTROLLED Vision Loss with Glaucoma conditions/glaucoma/basics/definition/con Glaucoma is one of the leading cause of BLINDNESS in the United States and the world It can occur at any age but is more common in OLDER adults. The most common form of glaucoma has NO warning signs. The effect is so gradual that you may not notice a change in vision until the condition is at an advanced stage. Vision loss due to glaucoma can't be recovered. So it's important to have regular eye exams that include measurements of your eye pressure. If glaucoma is recognized EARLY,, vision loss can be slowed or prevented. If you have the condition, you'll generally need treatment for the t rest of your LIFE. 1
2 History Glaucoma and Cataract associated together from 400 BC to the 1700 s In the 1800 s s defined glaucoma a separate from cataract and that the eyes were hard (elevated eye pressure) 1851 Ophthalmoscope invented (von Helmholtz) 1973 Dr. Drance defined glaucoma as an optic nerve disease with multiple RISK FACTORS Age Risk Factors Age. People over age 60 are at increased risk for the disease. African n Americans, however, are at increased risk after age 40. The risk of developing glaucoma increases slightly with each year of age. Race Race. African Americans are significantly more likely to get glaucoma than Caucasians, and they are much more likely to suffer permanent vision loss. People of Asian descent and Native Alaskans are at higher risk of angle-closure glaucoma. People of Japanese descent are more likely to develop low-tension glaucoma. Family history Having a family history of glaucoma increases the risk of developing glaucoma. FIRST DEGREE RELATIVE Medical conditions. Some studies indicate that diabetes, high blood pressure and heart disease may increase the risk of developing glaucoma. g Injury. Risk Factors b Injury. Severe trauma, such as being hit in the eye, can result in immediate increased eye pressure. Internal damage from such a trauma can also cause future increases in pressure. Injury can also dislocate the lens, closing the drainage angle and increasing pressure. Other eye-related risk factors. Certain features of eye anatomy, namely thinner corneas and optic nerve sensitivity, indicate icate an increased risk for developing glaucoma. Conditions such as retinal detachment, eye tumors and eye inflammations may also trigger glaucoma. Some studies suggest that high amounts of nearsightedness may also be a risk factor for glaucoma. Corticosteroid use. Using corticosteroids (topical, oral, inhaled) for prolonged periods of time appears to put some people at risk of getting secondary glaucoma. PARA PEARL Take a good History, especially Demographics Age, Race Individuals of African American, Asian, & Native Alaskan decent have a higher incident of glaucoma -- would that include you? Eye injury, surgery, other conditions Medical Diabetes, Pulmonary, Cardiovascular Family History 1-2nd 1 degree relative Risk Factors ELEVATED IOP IntraOcular Pressure Eye Pressure Ta 2
3 Digital Reading Tonometry Goldmann Tonometry NE OD Practice Law allows Para s use these digital readouts WITH SUPERVISION of your doctor Standard of Care for Glaucoma Dx and Tx Requires DIRECT SUPERVISION Para Pearl Tonometry Script This test measures the pressure in your eye. It is an KEY/IMPORTANT test for the health of your eyes. Glaucoma is the eye disease this measurement helps detect. Glaucoma can cause permanent loss to your vision without pain or noticeable vision loss. Billing Tonometry Standard tonometry is considered part of your standard exam Exam element for & codes If unable perform/document reason G 0117 Glaucoma Screening Z13.5 Serial Tonometry When performed 3 or more times in a day. Includes I&R - Interpretation and Report Ocular Hypertension - H40.05x 1. IOP > 21 mmhg 2. No detectable visual field loss 3. No detectable optic disc or nerve fiber layer damage 4. Open angles 5. No ocular or systemic cause of increased IOP ICD 10 H40.05x x= 1R, 3L, or 3OU CPT
4 Aqueous Humor Formation at Ciliary Body (part of uvea) Aqueous flow around iris/through pupil Nourishes the posterior cornea/endothelium Leaves the eye: Trabecular meshwork at the angle (primarily) Iris root (Uveal/Scleral( Uveal/Scleral) Types of Glaucoma Open Angle Primary Normal Tension Closed-Narrow Angle Secondary Congenital 4
5 Gonioscopy & Slit Lamp PUPIL BLOCK Evaluation of the angle Open narrow - close Pigmentations Neovascularitization Scars and Recession Gonioscopy Lenses & View CPT Special Tests Medical Necessity Physician s s order When/Why is the test needed? Date performed When was it performed? Technician s s ID Reliability of the test? Patient cooperation? Test findings What are the results of the test? Assessment, diagnosis What do the results mean? Impact on treatment, prognosis What s s next? Physician s s signature Who is the physician? Threshold Field Testing 5
6 Fields Script This test measures your peripheral or side vision The earliest vision loss in Glaucoma is usually to your side vision. This test will help monitor the doctor/dr. monitor your eye health. Nerve Fiber arrangement Para Pearls Use proper test lens blur will cause a loss of sensitivity and make test less reliable to useless Educate patient on test procedure Proper and comfortable occlusion Keep head, eye, & trial lens alignment Watch for fixation losses Encourage &/or rest during test Results to doctor/into chart Coding SEVERITY Threshold Fields (92082, 92081) I&R Humphrey 30-2; 24-2; 2; Humphrey for significant field loss Unspecified H x 0 Mild H x 1 Moderate H x 2 Severe H x 3 Indeterminate H x 4 6
7 The Ocular Hypertension Treatment Study (OHTS) Decrease progression by reducing IOP risk factor early treat Early tx for High risk patients benefit greatly Early Tx no benefit for low risk CCT Central Corneal Thickness was a predictive risk factor for who would progress Risk Factors IOP ONLY RISK FACTOR THAT CAN BE MODIFIED Beta Blockers Prostoglandin CAI Inhibitors Alpha Agonist BID TiD Dosing Ciliary Body production Combinations BID Dosing 7
8 PARA PEARL PARA PEARL Most Ophthalmic meds have Color Coded Caps Talk CAP COLORS with patients. Discuss eye drops use/compliance every visit Check Blood Pressure each visit Testing Tradition Patient history to determine any symptoms the patient is experiencing and if there are any general health problems and family history that may be contributing to the problem. Visual acuity measurements measurements to determine if central vision is being affected. Tonometry to measure the pressure inside the eye to detect increased risk factors for glaucoma. Tonometry Visual fields perimetry perimetry,, to check if the field of vision has been affected by glaucoma. This test measures your side (peripheral) vision and central vision by either determining the dimmest amount of light that can be detected in various locations of vision, or by determining sensitivity to targets other than light. Gonioscopy to evaluate the condition of the angle Gonioscopy Testing Tradition Optic Nerve/Retina, which looking for chararteristic damage Ophthalmoscopy Stereo Photographs NFL analysis (OCT/HRT/GDx GDx) Monitor any changes over time. Drance Hemorrhage 8
9 ISNT Rule Nerve Fiber Analysis OCT Optical coherence tomography uses light waves to take cross-sectional sectional images, optic nerve and retina, anterior segment GDx Similar information as OCT nerve HRT Similar information as OCT nerve OCT Script OCT Anterior Segment This test measures the density of your optic nerve fibers. Damage to these fibers are some of the earliest sign of damaged in glaucoma. The Dr. Seewell will use this information to monitor your ocular health. CPT OCT Optic Nerve Signal Strength Normative Data 2 and 3 dimensional images RIM Thickness NFL TSNIT Guided Progression Analysis CPT
10 CHALLENGES/Fixes Eye movement/patient cooperation Reassure/Encourage/Educate Poor quality visual pathway Dry Eye/Poor Tear Film Artificial Tears Cornea irregularity/scars Cataracts Vitreous opacities Pupil size-- --Dilate Other Factors HYSTERISIS Low hysterisis increase risk Hysterisis varies w/ IOP GENETIC MARKERS GANGLION CELL/NFL Regeneration IOP/BP/CSF DYNAMICS Case Study Case Study Case Study Case Study 10
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