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A Review of Medically Necessary Contact Lenses a Review

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A Review of Medically Necessary Contact Lenses a Review 3/23/2016 A Review of Medically Necessary Contact Lenses •When is a contact lens considered To Fit or Not to Fit: medically necessary A Review of Medically •Fitting approach Necessary Contact Lenses •Lens types Tara C Vaz, OD FAAO •Condition specific lens applications March 18, 2016 What Are Medically Necessary Medical Necessity Is…. Contact Lenses? “Services or supplies that are proper and needed for Medically and visually necessary contact lens the diagnosis or treatment of the patient’s medical services are for those patients whose visual conditions, are provided for the diagnosis, direct experience and function is significantly improved care and treatment of the patient’s medical through the use of contact lenses rather than condition, meet the standards of good medical spectacle lenses. practice in the local area and aren’t mainly for the convenience of the patient or the physician.” Source: www.Medicare.gov Benefits of Medically Necessary Conditions for Medically Necessary Contact Lenses Contact Lenses Improved visual acuity Examples, not limited to: Corneal dystrophies Keratoconus Corneal irregularities and ectasia Improved peripheral vision Irregular astigmatism Corneal disorder due to contact lens Corneal transplant Congenital anomalies of corneal size and shape Reduced asthenopia Corneal graft complication Acid and Alkaline chemical burn of cornea and conjunctiva Corneal opacities Reduced suppression Aphakia Keratitis Better option for face or head deformity i.e. can’t wear Dry Eye spectacles Corneal ulcers Corneal neovascularization Improved comfort Corneal edema Bullous keratopathy Support the ocular surface Corneal degenerations 1 3/23/2016 Visually Necessary Criteria First Thing Nystagmus What is the first thing that is to be Anisometropia of at least 3.00 D in any meridian documented? based on spectacle prescription A chief complaint! High ammetropia at least -10.00 D or +10.00 D in • Blurry Vision either eye in any meridian based on spectacle • Dry Eye • Pain prescription The patient specific information is necessary to support the services provided to each individual. The coverage of services given by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient’s condition. Approach Additional Testing Keratometry What do you do? Think Evidence Based treatment • Only measures middle ~3.0mm What does the patient want? Not always what you Corneal topography Horizontal Visible Iris Diameter would like to provide the patient Anterior Segment Photography What is in the patient’s best interest? • There are cases when photography may be necessary to communicate with a lab, capture the details of a fluorescein pattern or document preexisting conditions, such as corneal scarring, microcystic edema or neovascularization. Endothelial Cell Count • E.g. Corneal graft Advantages and Disadvantages of Various Types of Contact Lenses-Overview Lens Types Lens Types Advantages Disadvantages Soft Contact Lenses: Traditional hydrogel lenses and Silicone hydrogel lenses Excellent vision... short adaptation period... Require consistent wear to maintain Generally, hydrogel soft lenses are available in these categories, based on their water content: Rigid gas-permeable (RGP) comfortable to wear... correct most vision adaptation... can slip off center of eye more Made of slightly flexible plastics that problems... easy to put on and to care for... easily than other types... debris can easily • Low water content (less than 40 percent water) allow oxygen to pass through to the eyes. durable with a relatively long life... available get under the lenses... requires office visits • Medium water content (50 to 60 percent water) in tints (for handling purposes) and bifocals. for follow-up care. • High water content (more than 60 percent water) Do not correct all vision problems... vision Very short adaptation period... more Hydrogels are classified as either ionic or non-ionic. Ionic materials have a negatively charged Daily-wear soft lenses may not be as sharp as with RGP lenses... comfortable and more difficult to dislodge surface and therefore may attract positively charged proteins in the tear film. Non-ionic Made of soft, flexible plastic that allows require regular office visits for follow-up than RGP lenses... available in tints and oxygen to pass through to the eyes. care... lenses soil easily and must be hydrogels are treated to reduce this negative surface charge and therefore may be less prone to bifocals... great for active lifestyles. replaced. attract protein deposits. Do not correct all vision problems... require Extended-wear The FDA uses four categories to classify soft lens materials: Can usually be worn up to seven days regular office visits for follow-up care... Available for overnight wear in soft or without removal. increases risk of complication... requires RGP lenses. Category 1 = low water, non-ionic regular monitoring and professional care. Category 2 = high water, non-ionic Extended-wear disposable Require little or no cleaning... minimal risk of Vision may not be as sharp as RGP lenses... Soft lenses worn for an extended period eye infection if wearing instructions are do not correct all vision problems... handling Category 3 = low water, ionic of time, from one to six days and then followed... available in tints and bifocals... may be more difficult. discarded. spare lenses available. Category 4 = high water, ionic Planned replacement Silicone hydrogels have silicone within the hydrogel material to increase the oxygen Require simplified cleaning and disinfection... Vision may not be as sharp as RGP lenses... Soft daily wear lenses that are replaced good for eye health... available in most do not correct all vision problems... handling transmissibility of the lenses. on a planned schedule, most often either prescriptions. may be more difficult. every two weeks, monthly or quarterly. Source American Academy of Optometry Website 2 3/23/2016 Lens Types Lens Types Gas Permeable (Corneal) Gas Permeable (Corneal) Lenses Continued Lenses Large GP/Intra-limbal (10.5-12.0mm depending on HVID) • Rests entirely on cornea (8.0- 10.5mm) • Good for previous GP wearers with decentration • Custom, proprietary, aspheric • Less movement/better centration designs • Less lid interaction so better comfort • Multiple DK materials • Pros: Ease of application, • Larger area of cornea on which to bear, better for long-term great vision, low cost corneal health • Cons: If not ideal fit, possible staining and scarring, easier to dislodge, prone to foreign body und lens Lens Types • Spectacles: High astigmatism, poor vision Piggyback (Tandem) • Fit GP on top of SCL • Corneal gas permeable lenses: Potentially good • Often same GP lens already using as best-fit vision, can be uncomfortable and difficult to fit depending on degree of ectasia • Use high dk SCL (SiHy) using low plus +1.00 • Challenge to avoid SCL inferior edge fluting • The corneal lens moves to the steepest part of the • Use when want to keep the same GP fit but patient is symptomatic cornea Keratoconus-Custom Soft lenses Keratoconus-Custom Soft lenses Flexlens-Custom Parameters Advantages HydraKone-Custom Parameters • Good comfort • Good centration NovaKone • Many parameters • Variable Base Curve and “fitting curve” • Minimal corneal insult • Variable Thickness (0.22 to 0.65mm) to create rigidity of lens Disadvantages • Sphere or Toric • Worse VA than GP Kerasoft IC • Potential solution toxicity • Variable Base Curve and periphery • Fitting challenges • Diagnostic Fitting necessary (OR changes with change in BC) 3 3/23/2016 Lens Types Lens Types Hybrid Lenses Scleral Lenses GP center with soft skirt Made of GP materials e.g.. Boston XO, Boston XO2 • Central clearance-good comfort and corneal health-less scarring • Corneal scleral (rests partly on cornea and on sclera) • Peripheral bearing-stability, soft skirt aids in centration • Mini scleral (up to 6mm larger than HVID, rests entirely on sclera) • Scleral bearing-good comfort and minimal movement • Scleral (more than 6mm larger than HVD, rests entirely on sclera) • Soft lens like comfort • Less movement • Good VA associated with GP Disadvantage, learning fit and evaluation, some handling difficulty Lens Types Scleral Lenses Corneal Scleral Lens Gas permeable scleral lens may be considered medically necessary for patients who have not responded to topical medications or standard spectacle •Rests partly on the corneal and or contact lens fitting, for the following conditions: sclera so some corneal and • Corneal ectatic disorders (e.g., keratoconus, keratoglubus, pellucid marginal peripheral (limbal) bearing degeneration, Terrien’s marginal degeneration, post‐surgical ectasia); • Corneal scarring and/or vascularization; •For more “regular” cornea • Irregular corneal astigmatism (e.g., after keratoplasty or other corneal •~12-15mm diameter surgery); • Ocular surface disease (e.g., severe dry eye, persistent epithelial defects, neurotrophic keratopathy, exposure keratopathy, graft vs. host disease, sequelae of Stevens Johnson syndrome, mucus membrane pemphigoid, post‐ocular surface tumor excision, post-glaucoma filtering surgery) with pain and/or decreased visual acuity Scleral Lenses Scleral Lenses Scleral lenses are filled with Lenses fit under the eyelids and rest on the relatively insensitive white tissue of the eye, vaulting the sterile saline at insertion, damaged cornea and creating a new smooth optical creating a reservoir of fluid that surface that protects the eye
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