Article

Develop Partnerships for Glaucoma Care

To best manage patients who have glaucoma, maintain contact with their other health care providers

The world’s highest bridge opened a few years ago in Southwest China. At an impressive length of nearly a mile long, this bridge is 1,854 feet above the valley below and took over three years to complete. It now overcomes the natural landscape barriers of mountains and rivers and, as a result, significantly reduces “travel time” by several hours.

Dr. Lifferth sharing patient information with a collaborating M.D.
Photo courtesy of Dr. Austin Lifferth.

As front-line eye care providers, and when it comes to inter-professional patient care, are we active “bridge-builders” through continual correspondence with other health care providers or are we, by default, “barrier-builders” with only casual correspondence? Do we cooperate and collaborate — and willingly work as one with other health care providers — on behalf of the patient’s best interest? Just as intra-professional collaboration significantly benefits our profession, inter-professional collaboration significantly benefits our patients as well, especially glaucoma patients, whose disease process can be tied to systemic findings.

In this article, I will review how we can start collaborating with other health care professionals regarding our glaucoma patients and what, specifically, we should communicate to ensure we are providing the best management.

HOW TO START

I have found that it is helpful to mention to the patient, while in the exam room, that we will be sending his primary care physician (PCP) or other health care provider (endocrinologist, internists, physical and occupational therapists, etc.) a letter about that day’s findings. This communication may go something like this:

“Mrs. Jones, it looks like your early stages of glaucoma appear to be well controlled at this time with your current eye drops. As we continue to help care for your glaucoma, we have found it helpful to work as a team with your primary care doctor, Dr. Smith, so that she can continue to help you with your diabetes and high blood pressure — both conditions that may also somewhat affect your glaucoma. We will send her a note right now about our visit today and give her our phone number to call if she has any questions. . .”

Sending a letter at the time of the exam has at least the following three compounding benefits:

  1. The patient quickly recognizes the optometrist’s integral role in his overall health care.
  2. The PCP, or other health care provider who receives the letter in a timely manner, quickly recognizes the O.D.’s integral role in the overall health care of the patient.
  3. The optometrist gets in the self-perpetuating habit of sending a letter with timely, up-to-date clinical findings. Habitual collaboration can lead to continual collaboration.

To facilitate the above inter-professional process even more, I recommend O.D.s add a “physician’s only” number, or a sort of “back-door” into the phone room system for quicker access. It may sound simple, but if a busy health care provider (or the office) must continually wait on the phone for several minutes at a time, we may miss that important, timely information. Even more, if we feel comfortable, we can share our personal cell number with doctors, so that they can also conveniently call to communicate any concerns with us, such as changes in medication, that may precipitate angle closure glaucoma in patients who have anatomically narrow angles. This personalized “quick access” line helps limit health care provider waiting time, while promoting professional partnerships and collaboration.

Projections for Glaucoma in 2010-2030-2050 (in millions)

Codes for Co-Managing with an Ophthalmologist

66984 – Pseudoexfoliation syndrome with IOL

66982 – Complex pseudoexfoliation syndrome with IOL

66987 – Complex pseudoexfoliation syndrome with IOL and endoscopic cyclophotocoagulation

66988 – Pseudoexfoliation syndrome with IOL and endoscopic cyclophotocoagulation

66821 – Yag capsulotomy

All billing and coding should follow the guidelines of CMS and the patient’s insurance plan, when that is being utilized.

WHAT TO COMMUNICATE

All parties involved should both provide and request information pertinent to the care of the glaucoma patient. When it comes to the O.D. providing such information, other health care providers are typically interested in:

  • A change/update in diagnosis/prognosis.
  • A change in the treatment plan with associated update on medications and any potential ocular or systemic adverse effects.
  • An update on adherence to current ocular medications or systemic medications that the health care provider may find helpful.
  • An update on physical limitations.

Fortunately, for convenience and completeness, many EHR systems can send the complete exam “as is” or can be customized to include pertinent data.

With regard to requesting information, the glaucoma doctor should ask the patient’s other health care providers for information regarding:

  • Hypertension, hypotension and vasospastic disorders1,2
  • Diabetes mellitus3,4
  • Obstructive sleep apnea5,6
  • Smoking cessation7,8
  • Medications, such as steroids (oral or topical), that may elevate IOP or adrenergic agents and sulfa-based medications that may precipitate angle closure in high-risk anatomically narrow angle patients.9

We must remember that although elevated IOP is the main modifiable risk factor for the development and progression of glaucoma, there are several other systemic conditions, which, if better controlled, may also slow the progression of glaucoma.10-12 O.D.s should consider communicating their concerns and perspectives continually with, at least, the patient’s PCP, on these top systemic conditions.

BRIDGING A GAP

That bridge in Southwest China now continuously brings together two previously relatively remote areas, helping to connect and integrate people. Similarly, professional partnerships with comprehensive and continual collaboration literally bring together health care providers from different professions, significantly reducing information “travel time” and, as a result, maximizing patient care. OM

REFERENCES

  1. Zhao D, Cho J., Kim MH, Guallar E. The association of blood pressure and primary open-angle glaucoma: a meta-analysis. Am J Ophthalmol. 2014; 158: 615-627.
  2. Costar V.P., Harris. A, Anderson D, et al. Ocular perfusion pressure in glaucoma. Acta Ophthalmol. 2014; 92: 252-266.
  3. Song BJ, Aiello LP, Pasquale LR. Presence and risk factors for glaucoma in patients with diabetes. Curr Diab Rep. 2016; 16: 124.
  4. McMonnies CW. Glaucoma history and risk factors. J Optom. 2017; 10: 71-78.
  5. Lin CC., Hu. CC, Ho JD, Chiu HW, Lin HC. Obstructive sleep apnea and increased risk of glaucoma: a population-based matched co-hort study. Ophthalmology. 2013; 120:1559-1564.
  6. Perez-Rico C., Gutiérrez-Díaz E, Mencía-Gutiérrez E, Díaz-de-Atauri MJ, Blanco R. Obstructive sleep apnea-hypopnea syndrome (OSAHS) and glaucomatous optic neuropathy. Graefes Arch Clin Exp Ophthalmol. 2014; 252: 1345-1357.
  7. Law SM1, Lu X2, Yu F2, Tseng V1, Law SK1, Coleman AL1. Cigarette smoking and glaucoma in the United States population. Eye. 2018; 32: 716-725.
  8. Pérez-de-Arcelus M, Toledo E, Martínez-González MÁ, Martín-Calvo N, Fernández-Montero A, Moreno-Montañés J. Smoking and incidence of glaucoma: The SUN Cohort. Medicine (Baltimore). 2017; 96: e5761.
  9. Gottfredsdottir MS, Allingham RR, Shields MB. Physicians’ guide to interactions between glaucoma and systemic medications. J Glauc. 1997; 6: 377-383.
  10. Miglior S, P. N. European Glaucoma Prevention Study (EGPS) Group1, Miglior S, Pfeiffer N, Torri V, Zeyen T, Cunha-Vaz J, Adamsons I. Predictive factors for open-angle glaucoma among patients with ocular hypertension in the European Glaucoma Prevention Study. Ophthalmology. 2007; 114: 3-9.
  11. Early Manifest Glaucoma Trial Group: Leske MC, Heijl A, Hussein M, et al. Factors for glaucoma progression and the effect of treatment: the early manifest glaucoma Trial. Arch Ophthalmol. 2003; 121: 48-56.
  12. Gordon MO1, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002; 120: 714-20.