Eyeworld

EW GLAUCOMA 98 October 2015 by Michelle Dalton EyeWorld Contributing Writer when these procedures are used, especially those that are growing in frequency." Study specifics The group analyzed data in two time frames—1994–2003 and 2003–2012. To tabulate the number of times that different procedures were performed, the use of the CPT code for each pro- cedure, along with its modifiers, was assessed. Data analyzed comprised CPT codes 65800–66770, along with some temporary codes. The authors note that the set of codes might include some procedures not unique to glaucoma surgery. According to the study, 1 total conventional trabs decreased 42% from 63,278 in 1994 to 36,776 in 2003, and decreased an additional 51% to 18,007 between 2003 and 2012. Conventional trabeculectomy volumes in eyes with scarring has decreased 48% from 11,018 to 5,728 between 2004 and 2012, respective- ly. The number of laser trabeculec- tomy peaked in 2005, and has been in steady decline since, Dr. Ramulu said, but the number of laser iridoto- mies has remained relatively stable. Since 2009 when they were first introduced, external mini-shunt procedures have increased 131%, from 2,718 in 2009 to 6,273 in 2011. Aqueous shunts to the extraocular reservoir increased 231% from 1994 to 2003, and continued to increase another 54% to 12,021 procedures from 2003–2012. Total cyclophotocoagulation procedures increased 253% from 2,582 in 1994 to 9,106 in 2003, and another 54% to 13,996 between 2003–2012. It is important to note here, however, that until 2004 there were no separate codes for ECP and transscleral cyclophotocoagulation. group was that endoscopic cy- clophotocoagulation (ECP) was performed almost as frequently as trabeculectomy in the latter half of the time frame studied. ECP, howev- er, is often performed in more mild to moderate cases of glaucoma than trabeculectomy. "A lot of these new procedures are likely being done early in people who are undergoing cataract surgery and who wouldn't otherwise have glaucoma surgery," Dr. Ramulu said. "It will be interesting as we gather more data and drill down into the details to understand where and number of Medicare beneficiaries has increased. In 1994, there were 54,224 trabeculectomies performed in eyes without previous scarring; that number plummeted to fewer than 6,000 procedures in 2012. "There was a lot of homogene- ity in terms of how glaucoma was treated in the past," said Pradeep Y. Ramulu, MD, Wilmer Eye Insti- tute, Baltimore. "There was a small number of surgeries, and trab was basically all we did. Now the num- ber of trabeculectomy procedures is declining to the point where it's barely the most common glaucoma surgery." Over the time frame of the analysis (1994–2012), "there was a 9% increase in Medicare Part B enrollees, with 5% of this increase occurring between 1994 and 2003 and the remaining 4% between 2003 and 2012. Despite this increase, between 1994 and 2003, there was a 14% decline in the total number of glaucoma procedures and a 28% decline in the number of incisional glaucoma procedures," the study authors wrote. 1 In fact, what Dr. Ramulu said was a "surprise" finding for the G laucoma traditionally af- fects an older population, so as the number of people eligible for Medicare cover- age in the United States (65+ years) increases, so does the likelihood more recipients will have glaucoma. Since the introduction of the prostaglandin class of drugs in the earlier part of the century, no new class of intraocular pressure (IOP)-lowering medications has been introduced. What has changed is the availability of numerous surgical techniques and devices, all aimed at decreasing the number of trabe- culectomies performed. Couple the potentially detrimental side effects of conventional trab with the intro- duction of non-bleb-forming pro- cedures and other alternatives (i.e., tube shunts and EX-PRESS [Alcon, Fort Worth, Texas] procedures), and it's understandable that the number of conventional trabeculectomy surgeries is decreasing. New research 1 confirms the number of trabeculectomies—con- sidered the gold standard glaucoma procedure—has declined between 1994 and 2012, even though the Decrease in trab procedures over past 2 decades Incisional surgery, such as trabeculectomy, has been on the decline even though the number of Medicare beneficiaries has increased. Source: Pradeep Y. Ramulu, MD " People are being diagnosed earlier, and they're being medically managed earlier, so there may be other confounding factors to explain the decline in surgery. It seems somewhat of a paradox. " –Pradeep Y. Ramulu, MD While the number of Medicare beneficiaries continues to rise, the number of surgical procedures has fallen

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