The Ocular Hypertension Treatment Study published in the June 2002 Archives of Ophthalmology brings new insight to the treatment and management of our patients with ocular hypertension. One of the study’s primary findings was that reduced corneal thickness is a powerful predictor for glaucoma development.

So the question is—should pachymetry measurements be considered the standard of care for all glaucoma patients and glaucoma suspects?

At Pacific Cataract and Laser Institute, we believe pachymetry will benefit some glaucoma and glaucoma suspect patients. In certain instances, corneal thickness measurements will help us determine how to manage their care.

Pachymetry holds less value for patients with obvious diagnosis of glaucoma:

• High pressure measurements
• Optic nerve head damage
• Corresponding visual field loss

In instances of clearly diagnosed glaucoma, knowing the absolute and most accurate intraocular pressure may not be as important because it is simply too high and needs to be lowered 25% or more. Published studies also support the notion that patients with glaucoma are much less likely to have thicker than average corneas than glaucoma suspects. So, when the diagnosis is obvious, there is probably little need to obtain pachymetry measurements as they will not provide added value.

Pachymetry can be very helpful and provide added value when:

• A diagnosis is not clear
• Goldman tonometry readings don’t make sense
• Tonopen readings are much lower than Goldman readings

Examples of cases where findings don’t seem to make sense may include:

Clinical Observations

• High intraocular pressure
• Normal ocular nerve head
• Normal visual field
• No response to glaucoma medications

Diagnosis: ocular hypertension/glaucoma suspect

If the cornea measures thicker than normal, you can be more relaxed about the possibility of glaucoma. However, if corneal thickness is average or thinner than average, intraocular pressure readings may appear lower than they actually are. You and the patient must remain very alert for the development of glaucoma. Pachymetry measurements in this case could help you determine that treatment is necessary.

Clinical Observations

• Low to normal intraocular pressure
• Glaucomatous optic nerve head changes
• Progressive visual field loss

Is the intraocular pressure really normal? If corneal measurements are thinner than normal, the true intraocular pressure is probably elevated. Additional attempts to lower pressure (including surgery) are more likely to be helpful. If corneal thickness measures normal or above normal, the low tension glaucoma is probably caused by poor circulation or other factors. This information can be shared with the patient and used to estimate the value of additional attempts to lower the pressure.

Although many parts of an eye examination are considered the standard of care, some cannot be billed separately. Unfortunately, pachymetry for glaucoma patients currently falls into this category. Even when an appropriate CPT code is provided to support this service, third-party payers are not likely to provide reimbursement at this time.

Pachymetry for glaucoma patients is not currently accepted by most insurance carriers as a billable standard of care. Patients that may benefit from this measurement are faced with paying for it themselves, unless we perform it as a value-added service without charge. But keep in mind that we are not allowed to provide services free to some individuals and not to others. We must be consistent with everyone—with the exception of true financial hardship.

Whether or not to perform pachymetry boils down to making a clinical decision. As eye care practitioners, our job is to be familiar with the research that may help us decide what tests are needed to provide appropriate care. Pachymetry is a very useful tool but may not be needed on every glaucoma patient or glaucoma suspect. As we learn more about glaucoma, we will continue to be faced with new tests and procedures that can be added to our toolbox. But the question will always be the same…to do or not to do.

As of July 1, 2003 Noridian Administrative Services has determined that pachymetry will be covered as a once in a lifetime service. Payment will be based on the accompanying diagnosis of glaucoma suspect, ICD-9-CM codes 365.00-365.04. You may be aware of this as the information regarding pachymetry was distributed to the provider community via the NAS medicare part B Latest Updates section of the website (www.noridianmedicare.com) on May 16^th, 2003.

Several weeks ago, Dr. Ford surprised Pacific Cataract and Laser Institute staff by purchasing a beautiful 50^th anniversary Corvette—for all of us with his personal funds. Each one gets to take it home to enjoy with family and friends for 100 miles. Dr. Ford’s only warning sticker is not to take the gift as an encouragement of materialistic values. “Don’t set your affections on things that rust!”

For the next year or so this mean little machine will roam the Northwest, circulating between our offices and 275 staff. I can tell you from personal experience that depressing the right foot results in a throaty roar and forward motion that’ll peel your lips back in a permanent grin.

After 10 years with Pacific Cataract and Laser Institute, I can truly say I love my job—and I’m not alone. Almost everyone in this unique organization enjoys what they do. Part of our enjoyment comes from having a focused and meaningful mission. But a large part is the corporate values and wonderful work environment Dr. Ford has created. Long ago he discovered it is more fun to give than to get and we are the lucky recipients of his thoughtful generosity.

Thanks Dr. Ford!