1

Andrew G. Iwach, M.D.Associate Clinical Professor

University of California, San FranciscoSan Francisco, California

Glaucoma Management:Changing Treatment Algorithms

• I have the following financial interests or relationships to disclose:

• Consultant– AcuMEMS– Alcon– Bausch & Lomb

Financial Disclosure

Flora Lum, M.D.AAO Policy Director, Quality of Care and Knowledge Base Development

William L. Rich III, MD, FACS

AAO Medical Director of Health Policy

Sue Vicchrilli, COT, OCSAAO Coding Executive

Cherie L. McNettAAO Director of Health Policy

Cathy CohenAAO Vice President, Governmental Affairs

Shan Lin, M.D.AAO Health Policy Committee

Patient Care Committee, American Glaucoma Society

Cynthia Mattox, M.D.AAO Health Policy Committee

Emmett Cunningham. Jr., M.D., PhD., MPHStanford University Faculty. Clarus Ventures

Industry Members

Acknowledgments

0.00

0.05

0.10

0.15

6 12 18 24 30 36 42 48 54 60 66 72 78 84

Primary POAG Endpoints*Log Rank P-value <0.001, Hazard Ratio 0.40, 95% CI (0.27, 0.59)

*through 8 Nov 2001

Pro

port

ion

PO

AG

Medication Observation

Months

2

Treatment vs. Observation

POAG = primary open-angle glaucoma; OHT = ocular hypertension.

1. Kass MA et al. Arch Ophthalmol. 2002;120:701-713.

0

10

20

30

40

50

60

70

OHT Over 5 Years1

Untreated Treated

Most Patients are Asymptomatic

Diagnostic Studies in Ophthalmology

Medicare data, courtesy of Dr. William L. Rich III

Managing the Odds

3

Glaucoma: Managing the Odds

Medical Trends

IOP Lowering Medications: Retail Market

Thank you to Rick Halprin at Alcon recent data from IMS

IOP Lowering Medications: Retail Market

Thank you to Rick Halprin at Alcon recent data from IMS

4

The Concept of PersistencyImpacting Factors

With economic issuesWith added side effects

With complicated dosing

IdealAfter human complacency/denial

0

10

2030

40

50

60

7080

90100

Per

sist

ent

Pat

ien

ts (

%)

3 mo 6 mo 9 mo 12 mo

Glaucoma & Ectropion

• 74 year old, Exfoliation Syndrome

• Meds: Simbrinza bid– Brinzolamide 1.0%

– Brimonidine Tartrate 0.2%

• Tearing, Lid Crusting, Discharge

• Lid Redness + Ectropion

• Diagnosis:

– ? Tear Duct Issue

– ? Drug Reaction

• Need for Surgery??

Glaucoma & Ectropion

Vijay Hegde, et al: Drug-Induced Ectropion: What Is Best Practice? Ophthalmology 2007;114:362–366

Sustained Release Travoprost (OTX-TP)

• Intended use:– Reduction of intraocular pressure in patients with

open-angle glaucoma or ocular hypertension

• Product design:– Non-invasive punctum plug formulation– Tailored drug release (2-3 months)– Visible for retention monitoring– Comfortable and absorbable

• Components:– Polyethylene glycol hydrogel– PLA microparticles– Travoprost ophthalmic solution– Fluorescein

16

Punctum plug size

Fluorescent plug observed under blue light

Ocular Therapeutix, Inc.

5

Sustained Release Travoprost (OTX-TP)

18

0

1

2

3

4

0 5 10 15 20 25 30

Hype

remi

a Sco

re (0

to 4)

Days

Hyperemian=24

Baseline

Error Bars = Standard deviation

0 = None 1 = Trace 2 = Mild 3 = Moderate 4 = Severe

*Data on file at Ocular Therapeutix

Surgical Trends

6

Success: PerspectivesSurgeon vs. Patient

SurgeonPatient

Surgical Trends: 1994-2014

Medicare data, courtesy of Dr. William L. Rich III

iStents: 2007: 200/month 2014: 4000/month Total: 40,000+ in US so far

7

Surgical Trends: Aqueous Shunts and Cyclophotocoagulation

Medicare data, courtesy of Dr. William L. Rich III

MicroPulse CP LaserAnterior Uveitis

• 72 y.o Vietnamese Male

• Pre-Op:

– 20/40

– IOP 27 mmHg, Max Meds

• Post-Op Day 1:

– IOP = 10, No Meds

– Light Perception

– Hyphema, Corneal Haze

• Meds: Durezol q 1 Hour

• Axial Length: 20.8 mm

Week 6: Hand Motion Vision

Non-Medical Trends Affecting Glaucoma Managment

8

Newer Health Plans: Impact on Continuity of Care

• Older PPO Provider Networks are Only Available with Older Insurance Plans

• Older Insurance Plans have been …a) Discontinuedb) Significant Increase Premium Increase

• Remaining Older Insurance PPO Plans Closed to New Patients

• Newer “PPO” Panels are cheaper but have very restricted Provider Panels

• e.g. Blue Cross Pathway PPO and Pathway X PPO

• Insurance Companies Use Cost and Quality Metrics to Invite Provider to New Plans

• Annual Reassessment, Poor/Inconsistent Communication• Disruption of Continuity of Care

Impact on Glaucoma ManagementBig Data: Impact on Medical Care

ACA: Impact on Glaucoma Care Prescribing Patterns

http://projects.propublica.org/checkup/providers/search

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Prescribing Patterns

http://projects.propublica.org/checkup/providers/search

Propublica Partners with Yelp

Corporations: Customer SatisfactionDo you have an opinion?

ICD-9 / ICD-10 ComparisonsICD-9 ICD-10

Diagnosis Usage Inpatient and Outpatient

Inpatient and Outpatient

Number of Characters

3-5 Numeric/alphanumeric

3-7 Alphanumeric

Number of Codes~17,000 ~141,000

Chapters 17 21

ICD-10 Fundamentals

Of the 21 chapters in ICD-10, 10 involve diagnosis pertaining to eyes

10

ICD-10 Fundamentals ICD-10 Fundamentals

ICD-10 Fundamentals Glaucoma Center of San Francisco

www.GlaucomaSF.com

11

January 28Annual Gala

January 29New Horizons Forum

January 30Glaucoma Symposium

January 28 – 30, 2016San Francisco, CA

Celebrate Innovate Educate

Glaucoma Center of San Francisco

www.GlaucomaSF.com