Eyeworld

SPRING 2024 | EYEWORLD | 103 G by Ellen Stodola Editorial Co-Director About the physicians Leon Herndon Jr., MD President, American Glaucoma Society Past Chair, ASCRS Glaucoma Clinical Committee Professor of Ophthalmology Duke University Durham, North Carolina Parag Parekh, MD, MPA ASCRS Government Relations Committee Chair Dubois, Pennsylvania Nathan Radcliffe, MD Chair, ASCRS Glaucoma Clinical Committee New York Ophthalmology New York Eye Surgery Center New York, New York I n 2023 into early 2024, glaucoma surgeons were facing a potentially disastrous reim- bursement situation when five Medicare Ad- ministrative Contractors (MACs) proposed and finalized limiting coverage of several MIGS procedures in their Local Coverage Deter- minations (LCDs). These LCDs would have gone into effect at the end of January, but because of extensive advocacy efforts from ASCRS, the American Glaucoma Society (AGS), and the American Academy of Ophthalmology (AAO), the LCDs were retired, and it was announced that there would be no change in the coverage at this time. This issue started in early 2023. Through- out the year, ASCRS worked collectively with AAO and AGS to meet with the MACs (National Government Services (NGS), Palmetto, CGS, Wisconsin Physician Services (WPS), and Norid- ian) about these LCDs. This advocacy included numerous letters and individual meetings with the MACs, as well as attending and speaking at every single open meeting and public listening session held by the five MACs. When a MAC releases a proposed LCD, one of the requirements is to hold an open meeting. ASCRS, AAO, and AGS had a physician representing the three organizations at every meeting, from each service area covered by the MAC, speaking up against these changes and how that specific policy would affect their patients. After the draft LCDs were finalized towards the end of 2023, ASCRS and the other orga- nizations participated in "grasstops" advocacy by asking physician members who had close, personal relationships with key members of Congress to reach out and ask them to advocate on their behalf to CMS to put pressure on the MACs to retire the policies. The MACs ultimately made the decision to retire their LCDs for MIGS, scoring a huge win for our doctors and patients. Importance of advocacy—ASCRS helps score big win for glaucoma surgery continued from page 102 continued on page 104 If he does perform a trabeculectomy on patients with low pressures, Dr. Ramulu said he modifies his technique. "The best results I've gotten with these patients are when I've left the flap tighter than I normally would," he said. Dr. Moster also engages primary care doctors for systemic conditions that can affect patients with NTG. She asks whether hyperten- sive medications they might be taking at night could be switched to during the day. She also asks for sleep apnea tests because if left untreat- ed, obstructive sleep apnea can be associated with progression. In addition to traditional glaucoma thera- pies—drops, laser, and surgical procedures— and looking at how systemic conditions could affect progression, Dr. Moster asks her patients to take antioxidants, such as gingko, resveratrol, turmeric, and enzyme CoQ10. She said that there is evidence in the literature that these may help but acknowledged that it isn't very well established. There are also behavioral elements that she discusses with patients to reduce the risk of progression. These include avoiding headstands if they do yoga and always keeping their head above their heart in general during exercise. She also said wearing tight neckties, playing wind instruments that require forceful blowing, or lifting heavy weights with Valsalva maneu- vers are discouraged. While she's treating and monitoring these patients, Dr. Moster said she regularly doc- uments the optic nerves, especially looking for optic disc hemorrhages and treating them more aggressively. "It's been shown that these patients progress faster when hemorrhages are occurring," Dr. Moster said. Dr. Moster said that there is a new mindset for treatment of NTG, which is to test more frequently, treat earlier, treat more aggressive- ly, and change therapy often. Also, you should choose a therapy that works for the patient's lifestyle. "That's very important because medi- cines don't work in the bottle," she said.

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