Eyeworld

80 | EYEWORLD | WINTER 2026 G UCOMA About the physicians Nathan Radcliffe, MD New York Ophthalmology New York Eye Surgery Center New York, New York Thomas Samuelson, MD Minnesota Eye Consultants Bloomington, Minnesota Manjool Shah, MD Clinical Associate Professor Kellogg Eye Center University of Michigan Ann Arbor, Michigan TO THE MOON AND BACK A progressive disease like glaucoma is a challenge for both physicians and patients alike. Though there have been many advances in treatments and procedures in recent years, the reimbursement landscape has continued to be an obstacle to getting patients the care they need. Three ophthalmologists discussed some of the recent issues and how they've impacted innovation in glaucoma, while also noting the importance of remaining proactive. Glaucoma has always been a difficult disease to treat, said Nathan Radcliffe, MD. It is progressive, irreversible, and potentially blinding. Historically, the treatment options for glaucoma have been relatively limited. "That is finally changing. MIGS, sustained drug delivery, and other interventional approaches are allow- ing us to treat glaucoma earlier and more safely, often before patients reach the point at which traditional incisional surgery becomes necessary. This should be an extraordinary moment for our field and for our patients," he said. "Unfor- tunately, innovation in glaucoma is increasingly colliding with reimbursement." Dr. Radcliffe pointed to the "inherent contradiction." "We have spent decades trying to develop safer ways to preserve vision in a disease in which lost vision cannot be restored. Now that those technologies are arriving, physicians are increasingly being told not sim- ply which treatments will be reimbursed, but indirectly which treatments they can realistically offer," he said. He noted that Medicare and commercial in- surers have to consider cost, and coding systems need to accurately describe the work physicians perform. "But when those systems cannot keep pace with innovation, the consequences are not confined to spreadsheets, claims departments, or coding manuals. They reach our patients." In previous commentary, 1 Thomas Samu- elson, MD, addressed the benefits of advanc- es in sustained-release options for glaucoma patients, but he also noted proposed policies from Medicare to limit or control how these are used. Earlier this year, proposed local coverage determinations (LCDs) would have limited how these drugs were implanted in combination with MIGS, potentially requiring multiple trips to the OR, and would have impacted patients' ability to receive the drugs alongside cataract surgery. Dr. Samuelson pointed out that while cost is a legitimate concern, it is most important for physicians to be able to determine the best stan- dard of care for their patients, rather than the coverage policy. Sometimes it makes sense to choose options for patients that may be expen- sive in the short term but can have cost savings in the long run. They also lessen the treatment burden for patients and reduce the likelihood that more invasive options become necessary in the future. Such invasive procedures often add considerably more cost to the healthcare system than less invasive procedures performed at an earlier stage of the disease. The LCD limitations faced significant opposition from physicians and the medical community when proposed. In July, the ASCRS Glaucoma Clinical Committee issued a statement on cyclodialysis with scleral reinforcement. Dr. Radcliffe spe- cifically touched on this controversy. Surgeons had been performing the procedure using CPT 66740 for creation of a cyclodialysis cleft and CPT 67255 for scleral reinforcement with graft, he said. While the codes were not created with this modern procedure in mind, they described important elements of the surgery, and reim- bursement using this approach had occurred for some time. However, he noted that the AMA subse- quently determined that the existing codes did not adequately describe the complete proce- dure. "There is a reasonable argument behind that conclusion," Dr. Radcliffe said. "These codes predated the development of the proce- dure, and the terminology is not a perfect fit. Iantrek pursued a new Category III CPT code specifically addressing this type of procedure, and that code is expected to become effective January 1, 2027." On paper, Dr. Radcliffe said this might look like the coding system is working exactly as intended: An innovative procedure emerges, ex- isting codes prove inadequate, and a new code is created. But what happens to patients in the meantime? "That is where a seemingly tech- nical coding issue becomes a clinical one," he said. "Once the previously used coding pathway was no longer supported, some ASCs became Brought back to earth: reimbursement barriers weigh on glaucoma advances

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