[*** I'm moving this to a new thread as this is now completely
off-topic from the original thread. ***

The original article to which this is being followed-up to can be
found here:
<http://groups.google.com/group/sci.med.vision/msg/11b99635aa2185db?dmode=source&hl=en>]

On Tue, 06 Jun 2006 20:37:48 GMT, William Stacy <wstacy@obase.net>
wrote:

[snip]

I already discussed this.  I don't (emphasis added):

<http://groups.google.com/group/sci.med.vision/msg/91c1a24071a3f030?dmode=source>

       [...]
       I have CCT measured on all my glaucoma patients/suspects at
       the same time I have optic nerve/retinal nerve fiber layer
       photographs, optic nerve and retinal nerve fiber layer
       imaging/analysis *done offsite*.
       [...]

[...]

Your "book" is not consistent with the consensus opinion of experts in
commonly accepted mainstream Ophthalmology and Optometry (hereafter
referred to as "COoEiCAMOaO").

IOW, "thin corneas", in and of themselves, do not make someone a
glaucoma suspect according to COoEiCAMOaO -- it is merely a risk
factor.

IOW still, a glaucoma workup is not indicated according to the
COoEiCAMOaO in 6/2006 on a 80 year old with a central corneal
thickness by ultrasound pachymetry (CCT) of 480 microns that has:

       o  Long-standing IOPs history <12mm Hg.
       o  Average or large optic nerves (e.g., >=1.8mm in diameter).
       o  Small, normal cupping (i.e., obeys the ISNT rule, thick/
           healthy neural rim tissue, C/Ds 0.20 round, etc.).
       o  No retinal nerve fiber layer dropout/defects.
       o  No optic nerve hemorrhages.
       o  No other risk factors/signs/symptoms of glaucoma.

If in 06/2006, you billed MediCare, Blue Cross, Blue Shield, other PPO
for pachymetry on such a patient, and they did a chart audit, a
glaucoma workup would be denied as inappropriate.

This is the same as if performed a Shirmer's test on every pateint and
you then instilled (and billed) for punctal plugs on every patient
<10mm.

That's the real difference between CCT and the other risk factors for
glaucoma that are included in the COoEiCAMOaO in a routine
comprehensive medical eye examination (hereafter referred to as
"RCMEE") in 6/2006.  Regardless of *your* opinion above, there is no
"magic number" where the CCT is thin enough that, no matter what the
rest of the exam results show, a glaucoma workup is considered the
standard of care (SOC).  And I submit that the COoEiCAMOaO is such
unless you have evidence to prove otherwise.

That's not true when it comes to tonometry.  The COoEiCAMOaO is that
there is a pressure that is so high that every patient that has one
that high deserves a glaucoma workup or is a glaucoma patient.  That
used to be <=21, now it's somewhere between 21-28 depending on other
risk factors, but the COoEiCAMOaO is that everyone with an IOP of 40
deserves a glaucoma workup.

Same thing goes for people with characteristic optic nerve appearance.
The COoEiCAMOaO is that everyone with an average sized optic nerve
(~1.5-1.8mm in diameter) with cup-to-disc ratio of 0.9 deserves a
glaucoma workup.  Ditto for visual field loss on confrontation that is
characteristic and consistent for glaucoma.

"Used to perform threshold perimetry on every patient"?

Things become clearer now.

But that doesn't make it the "SOC".

Regardless RCMEEs as defined by the COoEiCAMOaO are based on
attempting/performing certain tests while other tests are excluded
unless the history, findings or other exam results indicate otherwise.
And there are good reasons for including some tests and excluding
others.

Once again see
<http://www.aao.org/education/library/ppp/upload/Comprehensive_Adult_Medical_Eye_
Exam.pdf>

In 6/2006, things like:

       o  Best corrected visual acuities.
       o  Pupillary function.
       o  Tonometry

are (in general) indicated and part of a RCMEE.  Things like:

       o  CCT measurement.
       o  Perimetry.
       o  Optic nerve/retinal nerve fiber layer imaging/analysis

are not.

Ditto for what AAO considers part of a routine eye examination
<http://www.aoa.org/documents/CPG-1.pdf>.  Pachymetry is not there.

A similar story goes for what MediCare considers to be part of a RCMEE
(920x4).  Tonometry is there -- pachymetry is not.

Billing for routine pachymetry without an associated medical diagnosis
is going to result in your claim being rejected.

There is no "maybe".  It is clearly NOT the SOC for RCMEE.  Period.

Even doctors such as Dr. Woolridge who believe pachymeters are a
worthwhile addition to a practice don't go as far to state that CCT
measurement is a part of the RCMEE and that failure to do perform
pachmetry on non-glaucoma (suspects) and ocular hypertensive patients
is a failure to feel the SOC.

See <http://www.optometric.com/article.aspx?article=71466> (emphasis
mine)

       [...]
       This landmark study, the largest and perhaps best-designed
       investigation of risk factors for glaucoma in ocular
       hypertensives, advises that pachymetry be a standard part of
       the evaluation of *ocular hypertension patients*.
       [...]
       Clearly, pachymetry is rapidly becoming a standard of care in
       the evaluation of *ocular hypertension and glaucoma patients.*
       [...]
       So doctor, who needs pachymetry? You and your *glaucoma
       patients* do.
       [...]

My views NOW are even more stringent than Dr. Woolridge's were then.
Pachymetry IS NOW clearly the SOC in the evaluation or ocular HTN and
glaucoma patients.  I think it isn't even debatable anymore in
06/2006.

See:
    o  OHTS
    o  Medeiros FA, Sample PA, Zangwill LM, et al. Corneal
    thickness as a risk factor for visual field loss in patients
    with preperimetric glaucomatous optic neuropathy. Am J
    Ophthalmol 2003;136:805-13.
    o  AAO's PPP for PAOG suspect -- 09/2005 edition.
    o  Wills Eye Manual -- 4th Edition -- Chapters 9.1/9.2.

You may be right -- time will tell.

Attempting tonometry on all patients didn't used to be the SOC either
(see <http://www.4lawschool.com/torts/helling.shtml>) -- now it is.

But it "ain't now".

I personally think that it will be a lot harder to make the case for
pachymetry than it was for tonometry though.

You miss a corneal thickness of 480 on an otherwise normal patient
because you didn't measure CCT on everyone, nothing bad might happen
in a lot (most?  the vast majority?) of them over the course of time.

You miss a pressure of 45 on an otherwise normal patient, something
bad will happen to all of them over the course of time.

It is unfair to hold the profession of Optometry to a higher "SOC"
(everyone should be tacitly aware we are talking about the medicolegal
definition of malpractice here) than the COoEiCAMOaO.

I want to make it clear -- I have no problem with you performing
pachymetry as a part of your RCMEE.  And you know what?  You have some
valid points -- a pachymeter is *relatively* cheap, objective, safe
and it is a quick test.  It may one day be part of a RCMEE (but I'd
prefer baseline stereo optic nerve photographs over pachymetry as
being included as a part of a RCMEE).  But, *you* don't get to define
what is the SOC for the general eye care community.  And your stating
that the measurement of CCT is is passing along incorrect information.

FWIW, I perform tests on my RCMEE that are not the "SOC" for routine
adult comprehensive eye examinations (e.g., Hirschberg corneal
reflexes, Bruckner binocular red reflex) because I *personally* find
them useful.  However, I would and do not hold those doctors that do
not as failing to meet the SOC because the COoEiCAMOaO do not feel
that those tests are an integral and necessary part of a RCMEE.

But to tacitly state that those eye doctors who do not perform
pachymetry on RCMEE is failure to meet the "SOC" in performing a is
flat-out wrong.

The legal defintion "SOC" (i.e., failure to perfom can be tantamount
to malpractice) is based on more than the evidence you have presented
so far (which is basically just your opinion).  Unless you are
considered to be an "expert witness" -- if so, I would be interested
in seeing your qualifications as such.