Modern Clinical Optometry Volume II

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Modern Clinical Optometry
AllDocs 2007

• Craig Thomas, O.D.
• 3900 West Wheatland Road
• Dallas, Texas 75237
• 972-780-7199
• thpckc_at_yahoo.com

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Medical Eye Care

• Professional Services
• Diagnostic Tests
• Minor Surgical Procedures
• Ophthalmic Ultrasound
• Laboratory Services

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Diagnostic Tests

• Group 1
• (1) Refraction
• (2) Sensorimotor Examination
• Group 2
• (1) Computerized Corneal Topography
• (2) Specular Endothelial Microscopy
• (3) External Ocular Photography

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Diagnostic Tests

• Group 3
• (1) Retinal Photography
• (2) Retinal Scanning Laser
• Group 4
• (1) Visual Field Examination
• (2) Color Vision Examination

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Ophthalmic Ultrasound

• A-Scan Ophthalmic Ultrasound
• B-Scan Ophthalmic Ultrasound
• Corneal Pachymetry
• High Resolution Biomicroscopy

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Corneal Topography Primer

• The clinical application of Computerized
• Corneal Topography is to determine the
• physical features and shape of the
• anterior surface of the cornea.
• The test is indicated in the identification
• of deep or superficial corneal disorders
• causing (1) irregular astigmatism
• (2) visual impairment.

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Examination Technique

• Determine test result reliability
• (1) Acquisition of high quality image of
• the air/pre-corneal tear film interface
• (2) Image quality is affected by corneal
• disease, the quality of the tear film,
• or any corneal deformity secondary
  
• to contact lens wear.

Note To improve image quality, instill one drop
of unpreserved artificial tears into each eye
prior to the image capture process.
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Interpreting the Maps

• Determination of Corneal Shape
• Assessment is accomplished by interpreting
• the color patterns and numeric values
• on the topographic map. Cool colors such
• as green and blue represent lower corneal
• curvatures - while warmer colors such as
• yellow and red suggest higher corneal
• curvatures.

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Interpreting the Maps

• Axial Map
• The standard topographic map of corneal
• curvature using an axial radius of curvature.
• The map is created by combining colors and
• patterns to represent corneal curvature.
• It shows corneal curvature in diopters, and
• is used to describe the overall corneal shape.

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Interpreting the Maps

• Tangential Map
• This topographic map also assesses corneal
• shape but, it is more sensitive at
• detecting the precise location of a specific
• defect. Because it is not axis dependent,
• this type of evaluation is better for patients
• with keratoconus, contact lens wearers, and
• patients with irregular astigmatism.

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Interpreting the Maps

• Determination of Corneal Shape
• (1) Round Corneal Shape
• (2) Oval Corneal Shape
• (3) Astigmatic Corneal Shape
• - regular astigmatism
• - irregular astigmatism

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Interpreting the Maps

• Round Corneas
• The color patterns on round corneas can
• present as concentric rings. These rings,
• radiating from the center of the cornea
• to the limbus, characterize the normal
• flattening that occurs in the corneal
• periphery. Round corneas are present
• in 23 of the general population.

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Round Cornea
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Interpreting the Maps

• Oval Corneas
• The color patterns form ellipsoid
• waves that radiate from the center
• of the cornea to the limbus.
• These oval corneas are present in
• 21 of the general population.

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Oval Cornea
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Interpreting the Maps

• Astigmatic Corneas
• Corneal astigmatism is expressed in two forms
  
• (1) Regular Astigmatism
• (2) Irregular Astigmatism
• In corneal astigmatism, the color patterns
• of a topography map form a bowtie
• configuration that can be used to determine
• the regularity of the astigmatism.

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Regular Limbal Astigmatism
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Interpreting the Maps

• Regular Astigmatism
• Patients with regular astigmatism can have
• limbal astigmatism or central astigmatism.
• In limbal astigmatism, the bowtie-
• shaped color pattern extends across the
• cornea. This type of corneal astigmatism is
• likely to be responsible for a corresponding
• amount of refractive astigmatism.

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Regular Central Astigmatism
Also known as Axial Astigmatism
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Interpreting the Maps

• Regular Astigmatism
• In central astigmatism, most of the
• bowtie-shaped color pattern occurs within
• the pupillary region. This type of corneal
• astigmatism can be underestimated by
• traditional keratometry readings and may
• not match the refractive astigmatism.

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Interpreting the Maps

• Irregular Astigmatism
• Irregular astigmatism can be
• expressed in three forms
• (1) Asymmetric
• (2) Non-Orthogonal
• (3) Unspecified

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Asymmetric Irregular Astigmatism
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Interpreting the Maps

• Irregular Astigmatism
• In asymmetric irregular astigmatism,
• the two ends of the bowtie-shaped color
• pattern are of a different size and color.
• This can be clinically significant if there
• is more than a one diopter difference in
• the amount of astigmatism on each end
• of the bowtie.

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Keratoconus
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Pellucid Marginal Degeneration
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Non-Orthogonal Irregular Astigmatism
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Interpreting the Maps

• Irregular Astigmatism
• In non-orthogonal irregular astigmatism,
• the bowtie-shaped color pattern is bent
• instead of being straight.
• Corneal dystrophies and other corneal
• diseases can produce non-orthogonal
• astigmatism.

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Interpreting the Maps

• Unspecified Irregular Astigmatism
• In unspecified astigmatism, there may be
• no bowtie-shaped color pattern displayed
• by the corneal topographer. The corneal
• irregularities may have a random distribution
• with no specific pattern. With this clinical
• presentation, focal changes of more than
• 1.5 diopters could be clinically significant.

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Unspecified Irregular
Astigmatism
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Interpreting the Maps

• Corneal Shape Anomalies
• (1) Abnormal Shape Symmetry
• (2) Areas of Significant Relative Steepness
• (3) Areas of Significant Relative Flattening
• (4) Abnormal Corneal Eccentricity

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Interpreting the Maps

• Corneal Shape Symmetry
• The shape of the superior cornea should be
• compared to the shape of the inferior cornea,
• just as the shape of the nasal cornea should
• be compared to the temporal cornea.
• Any asymmetry above 1.5 diopters
• could be clinically significant.

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Abnormal Shape Symmetry
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Specular Microscopy Primer

• The clinical application of specular
• endothelial microscopy is to enable the
• status of the corneal endothelium
• to be obtained by visual observation.
• The test is indicated in the diagnosis
• and treatment of any eye disease, eye
• injury, or ocular condition that can result
• in corneal endothelial cell damage.

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Modern Specular Microscope
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Clinical Indications

• Many eye diseases affect the corneal
• endothelium. Significant alterations
• in endothelial function (endotheliopathy)
• can result in any or all of the following
• (1) Blurred Vision
• (2) Fluctuating Vision
• (3) Permanent Visual Impairment

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Risk Factors for Corneal
Endotheliopathy

• Advancing Age
• Corneal Disease
• Ocular Disease
• Systemic Disease
• Ocular Surgery
• Ocular Injury
• Contact Lens Wear

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Specular Microscopy

• Endothelial cell damage is represented by the
  following
• (1) Reductions in endothelial cell density
• (2) Morphological changes such as
• polymegathism and pleomorphism
• (3) The appearance, enlargement, or
• coalescence of corneal guttata

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Specular Microscopy
Photomicrographs
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Specular Endothelial Microscopy Corneal
Endothelial Dystrophies

• Corneal guttata consists of abnormal
• outgrowths of Descemets membrane that
• squeeze between the endothelial cells.
• They are apparently formed as endothelial
• cell density decreases and the barrier
• function of the endothelium is compromised.
  
• Guttata appear as dark spots in the normal
• hexagonal mosaic pattern of the cells.

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Specular Endothelial Microscopy
Corneal Guttata
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Specular Endothelial Microscopy Corneal
Endothelial Dystrophies

• Guttata represent a generalized endothelial
• dysfunction. If they are present in large
• numbers, guttata may lead to stromal
• edema and an accompanying decrease in
• vision. Visual acuity can also be affected if
• the guttata are concentrated heavily in the
• axial region of the cornea.

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Corneal Physiology

• Deturgescence is the state of relative
• dehydration maintained by the normal
• intact cornea which enables it to remain
• transparent. The endothelium is the layer
• of the cornea responsible for this function.
• The functional limit for maintaining
• deturgescence is a cell count of 7001000.

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B-Scan Ophthalmic Ultrasound Clinical
Applications

• Ultrasound is the term for sound waves
• projected at a very high frequency.
• (over 20,00 kHz)
• B-Scan Ophthalmic Ultrasound uses
• transducer scanning and electronic
• processing to image the internal
• structures of the eye and orbit.

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Modern Transducer
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transducer scanning and electronic prossesing,
images the internal structures of the body.
When used in this manner, the examination
technique is known as diagnostic ultrasound.
B-Scan Ophthalmic Ultrasound is used to image
the internal structures of the eye and orbit.

Clinical Indications

• B-Scan ophthalmic ultrasound is used
• when clouding of the ocular tissues
• prevents proper visualization and
• examination of the structures of the eye.
• B-Scan ophthalmic ultrasound is used to
• determine the composition and contours
• of ocular and orbital structures.

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Clinical Indications

• Patients with dense cataracts or corneal
• opacities that prevent good visualization
• of the retina.
• Patients with vitreous floaters, deposits,
• hemorrhages, and/or degenerations.
• Patients with signs and/or symptoms of
• retinal detachment.

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Interpreting the B-Scans
Dense Cataract
Retina Grossly Normal
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Interpreting the B-Scans


Asteroid Hyalosis
Asteroid Hyalosis
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Interpreting the B-Scans
Retinal Detachment
Retinal Detachment
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VF defect from retinal detachment
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Case Report 1

• A 62-year old Black woman presented for an
• eye examination with a chief complaint of
• elevated intraocular pressure. The patient
• was referred by another optometrist that
• same day by telephone. The referring
• optometrist had measured the elevated
• intraocular pressures and was requesting
• an emergency appointment with me.

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Medical Eye Examination Service
Components

• IOP OD 36 OS 24 Tonopen
• _at_ 415
  pm
• Biomicroscopy All structures normal
• Ophthalmoscopy
• (1) Asymmetric cupping
• (2) Vertical elongation of right optic cup
• OD 0.4 h OS 0.2 h
• 0.6 v 0.2
  v

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Case 1 Open Angle Glaucoma
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Medical Eye Examination
Clinical Diagnosis

• Determining a clinical diagnosis of
  
• glaucoma only leads to other questions.
• Question 1 What type of glaucoma?
• Question 2 How bad is the glaucoma?
• Question 3 How are you going to treat?
• The answers require a Physical Diagnosis.

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Initiation of Diagnostic
Treatment Program

• Refraction OD 1.50 sphere 20/25
  
• OS 1.50 sphere
  20/20
• Scanning Laser Polarimetry
• (1) Severe fallout of retinal nerve fiber
  
• layer Right Eye
• (2) Abnormal inter-eye symmetry
• NFI 62 on the Right Eye
• NFI 27 on the Left Eye

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Initiation of Diagnostic
Treatment Program

• Visual Field Examination
• (1) Moderate reduction in retinal sensitivity
  
• Right Eye Mean Deviation 7.58 DB
• (2) Mild reduction in retinal sensitivity
• Left Eye Mean Deviation 3.54 DB
• (3) Paracentral scotomas Right Eye
• (4) Poor reliability Both Eyes

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Initiation ofDiagnosis Treatment
Program

• High Resolution Biomicroscopy
• (1) Normal iris configuration Both Eyes
• (2) Open angles Both Eyes
• (3) Thin corneal thickness Both Eyes

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Initiation of Diagnostic
Treatment Program

• Specular Endothelial Microscopy

• (1) Mild corneal endothelial dystrophy
• Both Eyes
• (2) No severe morphological changes to
• the endothelial cells or corneal edema
• from long-term exposure to elevated
• intraocular pressure.

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Iniatition of Diagnostic
Treatment Program
Specular Photomicrographs
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Initiation of Diagnostic
Treatment Program

• Serial Tonometry
• Medical treatment of acute elevation
  
• of intraocular pressure.
• OD OS Treatment
• 36 24 _at_ 415 pm 1 gt Timolol 0.5 _at_ 420
  pm
• 27 15 _at_ 558 pm 250 mg Diamox _at_ 440
  pm
• 19 15 _at_ 730 am 1 gt Pilocarpine 1 _at_ 440
  pm
• Next Day

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Initiation of Diagnostic
Treatment Program

• Physical Diagnosis Open-Angle Glaucoma
• Category of Glaucomatous Damage
  
• Right Eye Moderate
  
• Left Eye Mild
• Initial Target Pressure
  
• Right Eye 20 mmHg
• Left Eye 16 mmHg
• Initial Treatment Timolol and Pilocarpine

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Case Report 1Coding for 1st Visit (Blue
Cross Ins)

• CPT code 92004 126.28 Medical
  Eye Examination
• CPT code 92135 (RT) 44.50 Retinal
  Scanning Laser
• CPT code 92135 ( LT) 44.50
  Retinal Scanning Laser
• CPT code 92083 76.87 Visual
  Field Examination
• CPT code 92286 138.26
  Specular Microscopy
• CPT code 92100 86.16
  Serial Tonometry
• CPT code 76513 (RT) 97.87 High Resolution
  Biomicroscopy
• CPT code 76513 (LT) 97.87 High Resolution
  Biomicroscopy
• Total for initial visit 712.31

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Case Report 2

• A 62-year old White man returned to the office
  for an
• eye examination with a chief complaint of blurred
  vision.
• The History of Present Illness described a
  subjective
• decrease in vision over the past one month. The
  quality
• of the blurred vision was described as, like
  seeing a film
• over my eyes. The blurred vision was present in
  both
• eyes, moderate in severity, and seemed to be
  getting
• worse. Other than re-wetting eyedrops for
  contact lens
• wear, the patient reported using no modifiers for
  his
• condition. Previous eye exam was 15 months
  earlier.

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Patient History Case 2

• MEDICATIONS Insulin, Glucophage, Zestril,
  Plavix, and Lipitor
• PAST MEDICAL HISTORY Diabetes, hypertension,
  hyperlipidemia, sleep apnea
• PAST OCULAR HISTORY Significant for full-time
  soft contact lens wear for 25 years and mild
  nonproliferative diabetic retinopathy for 2 years
• REVIEW OF SYSTEMS Significant for chronic
  numbness of the feet

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Medical Eye Examination Service Components

• Acuity w/CLs OD 20/20 OS 20/50
• IOP Non-Contact Tonometer _at_ 945 am
• OD - 11 OS - 16
• Biomicroscopy All structures normal
• Ophthalmoscopy
• (1) Retinal hemorrhage Left Eye
• (2) Exudative maculopathy Left Eye
• (3) Peripapillary atrophy Both Eyes
  

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Medical Eye Examination Clinical Diagnosis

• Determining a clinical diagnosis of glaucoma
• suspect only leads to other questions.
• Question 1 Does the patient have glaucoma?
• Question 2 How bad is the macular edema
• in the left eye?
• Question 3 Is there anything else wrong
• with the patient?

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Initiation of Diagnostic Treatment
Program

• Determination of Differential Diagnoses
• These diseases, which share symptoms or
• signs with the clinical diagnosis, must be
  
• identified and excluded
  
• for the diagnostic process to continue.
• Differential Diagnosis 1 Glaucoma
• Differential Diagnosis 2 Visual Field
  Defect
• Differential Diagnosis 3 Corneal
  Disorder

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Initiation of Diagnostic
Treatment Program

• Refraction
• O.D. 5.50 0.50 x 090 20/20
• O.S. 3.75 0.50 x 090 20/25
• Contact Lenses
• (1) Proclear Multifocals by Cooper Vision
• (2) Modified monovision for past 5 years
• (3) Daily wear 1 month discard cycle

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Initiation of Diagnostic Treatment
Program

• Fundus Photography
• (1) Comparative retinal photographs from
• 15 months earlier reveal a worsening
• of the exudative maculopathy Left Eye
• (2) Flame hemorrhage in the left eye is in
• the peripapillary region, not on the
• optic disc therefore, hemorrhage is
• secondary to diabetic retinopathy.

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Initiaton ofDiagnostic Treatment
Program

• Visual Field Examination
• No clinically significant visual field
• defects exist - (poor test reliability)
• Scanning Laser Polarimetry
  
• 1. Moderate fallout of retinal nerve fiber
• layer Both Eyes - (atypical scans)
• Specular Endothelial Microscopy
• 1. Severe corneal dystrophy Both Eyes
• 2. Reduced cell density Both Eyes

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Initiation of Diagnostic
Treatment Program
Specular Photomicrographs
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Initiation of Diagnostic Treatment
Program

• Physical Diagnosis Corneal Dystrophy
• Secondary Diagnosis Mild Macular Edema
• Secondary Diagnosis Glaucoma Suspect
• Initial Treatment (1) Hypertonic Solution
• (2) Discontinue CL
  Wear

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Case Report 2 Coding for 1st
Visit (United Health Ins)

• CPT code 92014 95.09 Medical Eye
  Examination
• CPT code 92250 75.76 Fundus
  Photography
• CPT code 92083 76.87 Visual Field
  Examination
• CPT code 92286 138.26 Specular
  Microscopy
• Total for initial visit in this series 385.98

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Continuation of Diagnostic
Treatment Program

• Retinal Laser Scan
• Normal macular thickness Both Eyes
• Gonioscopy
• (1) Normal angle structures Both Eyes
• (2) Normal iris configuration Both Eyes
• Corneal Pachymetry
• Normal corneal thickness Both Eyes

2nd visit 14 days later
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Right Eye
Left Eye
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Continuation of Diagnosis
Treatment Program

• Primary Physical Diagnosis
• Mild nonproliferative diabetic retinopathy
  
• Both Eyes (Level 2 Low Risk)
• Secondary Physical Diagnoses
• (1) Mild diabetic macular edema Left Eye
• (2) Corneal endothelial dystrophy Both Eyes
• Excluded Differential Diagnoses
• (1) Glaucoma suspect
• (2) Visual field defect

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Case Report 2 Coding for 2nd Visit
(United Health Ins)

• CPT code 92012 64.46 Medical
  Eye Exam
• CPT code 92020 25.92
  Gonioscopy
• CPT code 92135 (RT) 44.50 Retinal Scanning
  Laser
• CPT code 92135 (LT) 44.50 Retinal
  Scanning Laser
• CPT code 76514 12.58 Corneal
  Pachymetry

Total fees for two visits 577.94
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Case Report 3

• A 43-year old Black woman presented for an eye
• examination with a chief complaint of blurred
  vision.
• The History of Present Illness described a
  subjective
• decrease in vision over the past few months. The
  
• patient also complained of the associated
  symptoms
• of burning, itching, and watery eyes. The
  primary
• symptom of decreased vision was present in each
• eye, moderate in severity, and seemed to be
  getting
• worse over time. Other than over the counter
• reading glasses, the patient reported that she
  used
• no eyedrops or other modifiers for her condition.

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Patient History

• MEDICATIONS Insulin, gabapentin
• PAST MEDICAL HISTORY Diabetes,
• epilepsy
• PAST SURGICAL HISTORY Hysterectomy
• REVIEW of SYSTEMS Significant for
• constipation

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Patient History

• PAST OCULAR HISTORY
• Significant for episodes of blurred vision,
• double vision, dry eyes, mucus discharge,
• red eyes, burning eyes, itchy eyes, gritty
• sensations, problems with glare, problems
• with light sensitivity, and chronic eye
• infections.

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Medical Eye Examination Service Components

• Unaided Visual Acuity
• OD 20/60 OS 20/60
• Biomicroscopy
• Moderately-severe keratoconjunctivitis
• Both Eyes
• IOP OD 23 OS 20
• Goldmann Tonometry _at_ 1000 am

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Case Report 4 Glaucoma Suspect
Medical Eye Examination

• Patient History
• Visual Acuity
• Intraocular Pressure
• Adnexal Examination
• Biomicroscopy
• Ophthalmoscopy
• Clinical Diagnosis

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Medical Eye Examination Service
Components

• Ophthalmoscopy
• (1) Microaneurysms Both Eyes
• (2) Dot hemorrhages Both Eyes
• (3) Cotton wool infarcts Left Eye
• (4) Intraretinal microvascular
• abnormalities Both Eyes

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Medical Eye Examination Clinical Diagnoses

• Primary Diagnosis Diabetic Retinopathy
• Secondary Diagnoses Glaucoma Suspect
• Dry Eye
  Syndrome
• Determining multiple clinical diagnoses
• only leads to other questions.
• Question 1 How bad is the retinopathy?
• Question 2 Does this patient have glaucoma?
• Question 3 What type of dry eye is present?

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Initiation of Diagnostic
Treatment Program

• Refraction
• O.D. 1.25 20/20
• O.S. 1.25 20/20
• External Ocular Photography
• Medically necessary to document the
• progress or deterioration of the keratitis
• and its response to treatment.

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Initiation of Diagnostic Treatment
Program

• Scanning Laser Polarimetry
• (1) Normal TSNIT curve analysis Both Eyes
• (2) Normal NFI values O.D. 23 O.S. 24
• (3) Normal inter-eye symmetry
• Corneal Pachymetry
• Thick corneas Both Eyes
• O.D. 610 um O.S. 590 um

This Patient Does Not Have Glaucoma
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Tear Film Analyzer
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Initiation of Diagnostic Treatment
Program

• Tear Film Chemistry Analysis
• (1) Lactofferin levels were low, suggesting
• an aqueous deficiency dry eye syndrome
• OD 2.13 mg/mL OS 0.78 mg/mL
• (2) Immunoglobulin E levels were normal,
• suggesting the absence of active ocular
• allergic response.
• OD 7 ng/mL OS 65 ng/mL

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Initiation of Diagnosis
Treatment Program

• Primary Physical Diagnosis
• Moderate Nonproliferative Diabetic Retinopathy
  
• Both Eyes (Level 3 Low Risk)
• Secondary Physical Diagnosis
• Dry Eye Syndrome
• (Moderately-severe aqueous deficiency)
• Excluded Differential Diagnosis
• Glaucoma Suspect

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Initiation of Diagnostic
Treatment Program

• Bandage Contact Lenses
• Some soft contact lenses can be used
  
• as corneal bandages in the treatment
  
• of corneal pathology such as keratitis.
• Closure of the Lacrimal Punctum
• Punctal occlusion with collagen plugs
• can be performed to diagnose and
• treat dry eye syndrome.

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Case Report 3 Coding for 1st
Visit (Medicare Insurance)

• CPT code 92004 126.28
  Medical Eye Exam
• CPT code 92135 (50) 89.00
  Retinal Laser Scan
• CPT code 92285 45.98
  External Photography
• CPT code 82350 (RT) 18.08 Tear
  Film Chemistry
• CPT code 82350 (LT) 18.08 Tear
  Film Chemistry
• CPT code 92070 (RT) 66.82 Bandage
  Contact Lens
• CPT code 92070 (LT) 66.82
  Bandage Contact Lens
• CPT code 68761 (E2) 137.29
  Collagen Plug Implant
• CPT code 68761 (E4, 51) 68.64 Collagen
  Plug Implant
• CPT code 76514 (TC) 3.22
  Corneal Pachymetry
• CPT code 76514 (26) 9.36
  Corneal Pachymetry

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Case Report 3Coding for 2nd Visit 3 days

• CPT code 99213 (24) - 61.55
• Purpose Medical eye examination to remove
  
• the bandage contact lenses and re-evaluate the
  
• status of the keratitis (ICD-9 code 370.33).
• Coding This exam is performed during the
  
• 10-day global period of the punctal occlusion
  
• (CPT code 68761) that was performed 3 days
• earlier for dry eye syndrome (ICD-9 code
  375.15)
• and therefore must be coded with the -24
  modifier.

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Continuation of Diagnostic Treatment
Program

• Specular Endothelial Microscopy
• Normal corneal endothelium Both Eyes
• Closure of the Lacrimal Punctum
• Punctal occlusion with silicone plugs
• may be used to treat dry eye syndrome.

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Case Report 3 Coding for 3rd Visit 2
weeks

• CPT code 92012 (25) 64.46
  Medical Eye Exam
• CPT code 92286 138.26
  Specular Microscopy
• CPT code 68761 (E2) 137.29 Silicone
  Plug Implant
• CPT code 68761 (E4, 51) 68.64 Silicone
  Plug Implant
• Total for 3 visits 1,119.77