glaucoma

How to Build a Glaucoma Practice

By following these five steps, your practice will bloom and grow.

Chuck Aldridge, O.D., Burnsville, N.C.

Are you interested in taking a more comprehensive approach to managing glaucoma patients in your practice? If so, you'll need to consider a number of factors, from patient demographics to billing and coding. You'll also need to plan carefully, and focus on your goals. As Mark Twain noted, “If you don't know where you are going, how do you know when you get there?”

Here are the steps your practice needs to take to “get there,” that is, build a glaucoma practice.

1 Understand your practice's patient demographics.

The first step in building a glaucoma practice is to thoroughly review the epidemiology of glaucoma in your area and then determine how the glaucoma population aligns with your current patient demographics. As the noted Scottish ophthalmologist Sir William Stewart Duke-Elder once said: “Glaucoma is a sick eye in a sick body.” Although this statement may not be totally accurate, there is a large degree of truth to it. We find very few glaucoma patients in a healthy, young patient population.

Therefore, an O.D. who cares for few elderly patients will have a difficult time building a glaucoma practice regardless of their internal marketing efforts. In other words, it's difficult to catch fish in a bathtub. The bottom line: If you now see few geriatric patients, you can grow your glaucoma patient population by initiating a deliberate external marketing program, which includes measures, such as giving educational presentations at senior citizen centers.

2 Develop clinical acumen.

Assuming you have (or create) a patient base that consists of those likely to have glaucoma, a thorough understanding of glaucoma is mandatory. This is because the literature through the years has created confusion about how to diagnose, treat and monitor glaucoma. At the center of this misunderstanding is the question: “What is open-angle glaucoma?”

A study that reviewed 120 articles that defined open-angle glaucoma found no consistency among the definitions. Some articles defined open-angle glaucoma through optic disc and vision field changes; others claimed it was optic disc or vision field change. In other articles, only vision field changes defined glaucoma. And of course, some researchers said intraocular pressure (IOP) was the basis for open-angle glaucoma, and even a few claimed the diagnosis was exclusively through the optic disc evaluation.¹

Many clinicians feel the definition presented by Felipe A. Medeiros, M.D., Ph.D. and Robert N. Weinreb, M.D., a distinguished professor of Ophthalmology at Shiley Eye Center at the University of California, San Diego, should guide us in our diagnosis and management of glaucoma. They declared open-angle glaucoma is “a progressive neuropathy with characteristic structural damage that is frequently accompanied by a specific type of vision field defect.”^2,3 If we use this statement as the basis for our diagnosis, treatment and management of the disease, then many areas of ambiguity and controversy are removed.

This description perhaps runs counter to the traditional theory that glaucoma is a disease resulting from elevated IOP. This is not to diminish the importance of accurately measuring IOP, since this is the only factor current treatment affects, but a clinician interested in becoming more involved in diagnosing and managing open-angle glaucoma must realize IOP is a risk factor, and not necessarily the cause of this disease. Harry A. Quigley, M.D., director of glaucoma services for The Wilmer Eye Institute at Johns Hopkins, even proclaimed, “Screening by intraocular pressure measurement fails to detect half of those with glaucoma.”⁴

The essence of developing a glaucoma practice is the clinical acumen to recognize abnormal structural changes of the optic nerve and the instrumentation to monitor any progressive structural or functional changes that may occur. Then once you initiate IOP-lowering treatment, you must perform reliable and consistent tonometry to determine the efficacy of the treatment.

In putting this into practice, the first question we must ask is, “Does the optic nerve appear abnormal?” If the answer is “yes,” we must then follow with, “Is the change progressive?” For it to be truly glaucoma, a change to the optic nerve must exist, and and it must be progressive.

The ability to properly ascertain these structural and functional changes and then monitor any progression will require a major commitment by you, the doctor. This commitment will involve significant financial expense (e.g., education, diagnostic equipment acquisition, etc.) plus the time required to learn the new technology and the current philosophies involved in diagnosis and management.

3 Use the proper diagnostic tools.

A checklist of the tools recommended for a glaucoma practice include:

► Diagnostic lens. You may want to evaluate and purchase several lenses, as each lens has its own advantages. Some of the more common are 60D, 78D, and 90D.

► Tonometer. Goldmann tonometry is still considered the “gold standard.” Regardless of the method chosen, tonometry must be reliable and consistent.

► Vision fields. As clinicians debate whether frequency doubling technology will diagnose glaucoma earlier, vision field assessment is the “standard of care” in glaucoma care, so you must possess this instrument.⁵

► Optic nerve documentation. Even though this can be done in a narrative format or via sketch, perhaps the best method is with digital photography. It was initially felt stereoscopic photos were required, but more recent studies have shown traditional retinal photography can be as reliable.⁶

► Nerve fiber layer evaluation (ganglion cell complex). Optical coherence tomography (OCT) has become a major diagnostic instrument in glaucoma and retinal disease. Consider the new spectral domain (Fourier) OCT devices, which offer many advantages in image acquisition, speed and image detail vs. time domain OCT.

► Pachymetry. The National Eye Institute's Ocular Hypertension Treatment Study, or OHTS, first drew a correlation with corneal thickness and glaucoma severity. Although several proposed algorithms based on this finding didn't achieve their desired goal, the ability to detect an unusually “thick” or “thin” cornea has significant implications in treating and monitoring a glaucoma patient.

► Case history. Glaucoma is now being correlated with more underlying general health problems, such as high blood pressure. This and the fact of a higher incidence with a positive family history means we must be diligent and deliberate with our case histories.

4 Educate staff and patients.

You, the doctor, must be updated on the latest in glaucoma diagnosis and treatment. Your staff must also understand the basics of glaucoma. However, just as critical, you must “be the educator” to the patient, and be sure the patient thoroughly understands the morbidity of the disease and the necessity for compliance in their treatment and monitoring protocol.

Do not ignore the role of education. The patient who doesn't understand the disease will not appreciate the value of treatment and monitoring. When not given time for questions and discussion, the patient many times will “go into denial” and not comply with your recommendations.

We must recognize we all learn differently. Some want studies and statistics to convince them. Others want brochures and videos to educate them. But they all want the doctor to guide, recommend and treat.

5 Understand how glaucoma care will impact your practice.

While there's not enough space to cover the subject of practice management in detail here, you must understand how managing glaucoma patients will impact your practice. Key issues include:

► Finance/ROI. When forecasting your practice's finances, compare your expected volume of glaucoma patients (and the associated fees) with the cost of acquiring new diagnostic equipment. This will help you understand how long it will take your practice to realize a return on this investment as well as the overall profitability of glaucoma-related services.

► Office space utilization. Determine how you'll set up your exam lanes to accommodate new equipment.

► Patient flow. Assess how much time the additional testing will add to patient visits and corresponding follow-up visits. For instance, would it be more efficient to schedule all glaucoma patients and suspects during a specific block of time, say a Thursday morning, so that staff can focus on the unique testing and educational needs of this patient population?

► Staff utilization. Determine how much of the pre-test and testing you will delegate to staff. Can your current staffing levels accommodate additional testing and patient care for those patients who have glaucoma?

► Billing and coding. In addition to managing glaucoma patients, you must properly bill and code their visits. Otherwise, your practice could leave money on the table or risk penalties as the result of a CMS audit.

While the subject of billing and coding for glaucoma testing and visits would require another article, there are many sources of information available for your practice, including professional associations and journals, practice management consultants, trade publications, optometric meetings and online education.

The bottom line

Increasing your glaucoma practice has the same basic principle as increasing your general practice: Patients must appreciate what you've provided. If you've developed a clinical acumen regarding the disease, integrated the latest technology, thoroughly explained glaucoma and showed genuine care and concern, your glaucoma practice will bloom and grow. OM

1. Bathija R, Bupta N, Zangwill L, Weinreb RN. Changing Definition of Glaucoma. J Glaucoma.1998 Jun; 7:165-9.
2. Medeiros FA, Weinreb RN. Medical backgrounders; glaucoma. Drugs Today (Barc).2002;38:53-70.
3. Weinreb RN, Khaw PT. Primary open-angle glaucoma. Lancet 2004; 363:1711-20.
4. Quigley Harry A MD. “Diagnosing Early Glaucoma with Nerve Fiber Layer Examination.” New York: Igaku-Shoi Medical Pub; Spiral Edition;1996.
5. Brusini P, Salvetat ML, Zeppieri M, Parisi L. Frequency doubling technology perimetry with the Humphrey matrix 30-2 test. J Glaucoma 2006 Apr;15(2) 77-83.
6. Ewen A, Lee KE, Klein BEK, et al. Comparability of cup and disc diameters measured from nonstereoscopic digital and stereoscopic film images. Am J Ophthalmol 2006 Jun;141(6):1126-8.e2.

Dr. Aldridge is a member of the Optometric Glaucoma Society. He is in private practice in Burnsville, N.C., where he sees a great deal of glaucoma patients. E-mail him at ccaldridge@yahoo.com, or e-mail comments to optometricmanagement@gmail.com.