Rates of Laser Trabeculoplasty by Ophthalmologists and Optometrists: A Comparative Analysis of the CMS Medicare Public Use File.

Purpose: To provide a comparative analysis of rates of laser trabeculoplasty (LTP) among eye care providers in the USA. Methods: This retrospective cohort analysis utilized the Centers for Medicare and Medicaid Services (CMS) Public Use File (PUF), 2015-2018. We used CPT code 65855 to select eye care providers who performed LTP in three key US states (KY, LA, and OK). Primary outcomes were eye provider differences in provider count, service count, unique beneficiary count, and Medicare-allowed payments. Asymptotic two-sided chi-squared tests were executed. Statistical significance was achieved at p<0.05. Results: The sum of Medicare-allowed payments for LTP in all three states in 2018 was roughly 26% lower than in 2015. The proportion of Medicare-allowed payments furnished by optometrists increased from 11.3% to 17.9% between 2015 and 2018 (p<0.001). Relative to ophthalmologists, we observed significant increases in optometric Medicare-allowed payments in KY, LA, OK, and the all-inclusive tri-state cohort (all p<0.001). Furthermore, significant optometric increases in number of providers performing LTP (p=0.007), number of unique Medicare beneficiaries seen (p<0.001), and number of LTP services billed (p<0.001) were observed relative to ophthalmologists. Conclusion: The recent expansion of surgical authority by optometrists in key US states is creating a tangible impact on ophthalmologic and optometric practice patterns. The findings of this study may act as provision for policymakers in the context of continually evolving guidelines for optometric surgical expansion.

Treatment of uncontrolled intraocular pressure secondary to uveal melanoma status post plaque radiotherapy with ab interno XEN gel stent implantation.

Purpose: To report treatment of uncontrolled intraocular pressure in a patient with uveal melanoma status post plaque radiotherapy with ab interno XEN gel stent implantation. Observations: A 21-year-old female with a history of iris and ciliary body melanoma underwent treatment with plaque radiotherapy with subsequent elevation of intraocular pressure refractory to maximum medical therapy. In order to control the pressure, ab interno XEN gel stent implantation with mitomycin C was recommended. Preoperatively, the patient was on four topical medications and oral acetazolamide with intraocular pressure of 39 mmHg by Goldmann applanation tonometry. The patient's intraocular pressure was reduced to 10 mmHg at her final postoperative visit on no medications. Visual acuity showed minimal degradation measuring 20/100 preoperatively and 20/150 eleven months after XEN gel stent implantation with VA improvement to 20/60 with refraction after cataract extraction at eighteen months. There were no postoperative complications and no recurrence or seeding of the uveal melanoma at follow up 18 months after her XEN gel stent implantation. Conclusions and Importance: Ab interno XEN gel stent implantation with mitomycin C may offer an effective method to control intraocular pressure in patients with refractory intraoperative pressure control following plaque radiotherapy treatment for uveal melanoma.

Metastatic lung adenocarcinoma to the iris mimicking Cogan-Reese syndrome.

PURPOSE: Case report of metastatic lung cancer to the iris mimicking Cogan-Reese syndrome. METHODS: A 61-year-old female with a history of non-small cell lung cancer presented with unilateral elevated intraocular pressure (IOP) and multiple hyperpigmented iris nodules associated with an anterior iris membrane. The patient's IOP could not be controlled medically, so she underwent trabeculectomy with simultaneous iris biopsy. RESULTS: Histopathology revealed proliferation of glandular epithelium on the iris surface consistent with metastatic lung adenocarcinoma. CONCLUSIONS: Iris metastases have varied presentations, and one must consider metastatic disease in any patient with a history of cancer presenting with iris lesions. The formation of an iris membrane and nodules by metastatic adenocarcinoma to the iris may mimic Cogan-Reese syndrome.

A review of canaloplasty.

Canaloplasty is a method of lowering intraocular pressure (IOP) by which a flexible, beacon-tipped microcatheter equipped with an ophthalmic viscosurgical device (OVD) delivery system is used to catheterize and introduce a suture into Schlemm's canal. Ligation of this suture provides tension on the canal and facilitates aqueous outflow. Canaloplasty is designed to be a blebless procedure that requires no antifibrotic agents and has been shown to safely and effectively lower IOP in patients with open-angle glaucoma (OAG) with minimal complications. Most importantly, no bleb-related adverse events are associated with this procedure. When contemplating surgical management of OAG, canaloplasty may be considered.