Laser therapies for Narrow or Closed Angles Flashcards by Sarah W

What is H40.003?

Anatomical Narrow Angle, Bilateral

An anatomical disorder in which the peripheral iris and the trabecular meshwork are in close apposition.

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What is the major cause of anatomical narrow angle?

Pupillary block: primary or secondary

Flow of aqueous from posterior to anterior chamber is restricted.

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What happens during a posterior synechiae?

Absolute pupillary block: posterior synechiae 360 = iris bombe; less common than relative pupillary block

This occurs when the posterior surface of the iris adheres to the lens.

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What is the result of increased IOP in the posterior chamber?

Iris is pushed forward into apposition with the trabecular meshwork, obstructing the outflow of aqueous

This can lead to angle-closure glaucoma.

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What percentage of angle-closure cases are due to relative pupillary block?

90%

The remaining cases are due to absolute pupillary block.

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Define Primary Angle Closure Suspect (PACS).

≥180 degrees iridotrabecular contact (ITC) and normal IOP

No optic neuropathy is present.

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What distinguishes Primary Angle Closure (PAC) from PACS?

PAC has ≥180 degrees iridotrabecular contact (ITC) with peripheral anterior synechiae (PAS) OR elevated IOP

PAC also has no optic neuropathy.

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What is Primary angle-closure glaucoma (PACG)?

≥180 degrees iridotrabecular contact (ITC) with peripheral anterior synechiae (PAS) AND elevated IOP

PACG includes optic neuropathy.

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What characterizes an Acute angle-closure crisis (AACC)?

Occluded angle with symptomatically high IOP

This condition requires immediate attention.

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What is Phacomorphic Glaucoma?

Narrowing of angle due to growth of lens with age (lens intumescence)

It can physically push the iris and narrow the angle.

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What is Plateau iris configuration?

Anatomical configuration of the iris causing narrowing of the angle

Caused by anterior insertion of the iris on the ciliary body or displacement of the CB anteriorly. The peripheral iris ends up in apposition with the TM.

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What are the indications for Laser Peripheral Iridotomy?

Primary angle-closure glaucoma (PACG), subacute/intermittent, chronic, acute angle-closure crisis (AACC)

Also for prophylaxis in fellow eye or chronic angle-closure glaucoma.

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What does the term ‘irido-trabecular contact’ refer to?

Contact over posterior trabecular meshwork of greater than or equal to 180 degrees

This is a key measurement in diagnosing angle closure.

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What is the purpose of gonioscopy?

Direct visualization of angle anatomy and associated structures (PAS, pigmentation, recession, neovascularization, etc)

It helps assess angle depth.

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What are the goals of a PI procedure?

Deepening of the anterior chamber and improved IOP control

A successful PI will re-establish aqueous outflow.

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What is the laser type commonly used for PI?

Argon (green) Laser (532 nm)

It uses a photocoagulative mechanism.

What are the settings for Argon laser during PI?

Spot size 50 microns; duration 0.1 seconds; Power 300-1200 mW

This varies based on patient and iris characteristics.

What should be administered pre-operatively for PI?

1 drop Pilocarpine 1% or 2%; 1 drop alphagan/iopidine

Proparacaine in both eyes is also given.

What are the absolute contraindications for PI?

NVI/NVA
Iridocorneal epithelial syndrome (ICE)
Contracture of inflammatory precipitates
Axenfeld-Rieger syndrome
Epithelial or fibrous ingrowth

These conditions can complicate the procedure.

When is surgical iridectomy a good option?

When concurrent surgery is already happening.

same result as laser PI, but more invasive with increased trauma and risk of infection

What is the purpose of Argon Laser Peripheral Iridoplasty (ALPI)?

To deepen the anterior chamber angle and make angle structures more visible or when iridotomy cannot be performed

It creates contraction burns in the peripheral iris.

What are the common complications following a PI procedure?

IOP Spike/Elevation
Inflammation
Non-perforation
Floaters
Blur
Hyphema
Peaked Pupil (avoid iris sphincter)
Synechiae
Monocular diplopia/ dysphotopsia
Retinal detachment/ damage
Vision loss (CME)
lenticular damage
malignant glaucoma

listed from most to least common

What is the CPT Code for laser iridotomy?

66761

This code is used for iridotomy/iridecomty by laser surgery (e.g. for glaucoma).

What factors influence the duration of treatment effect in angle closure?

Duration of treatment effect depends on level of block and its resolution

The effectiveness of treatment may vary based on the specific type of angle closure and the resolution of the underlying issue.

Do eyes with plateau iris typically require re-treatment?

Eyes with plateau iris rarely need re-treatment ## Footnote Plateau iris configuration is less likely to result in recurrent angle closure.

What can cause angle closure to recur?

Angle closure can recur with lens enlargement ## Footnote An increase in lens size can lead to a renewed blockage of the angle.

When is re-treatment most necessary in angle closure cases?

Re-treatment most needed when mechanism was forward lens movement ## Footnote Re-treatment is particularly important when the lens has moved forward, obstructing the angle.

What are the contraindications for ALPI?

Contraindications include: * Severe corneal edema or opacification * Moderate edema acceptable, higher power necessary ## Footnote These conditions can compromise surgical outcomes and patient safety.

What should be considered to temporarily clear the cornea before cataract surgery?

Glycerin ## Footnote Glycerin can help reduce corneal edema and improve visibility for surgery.

What risk occurs in shallow anterior chambers during cataract surgery?

Damage to corneal endothelium occurs in shallow AC’s as aqueous humor is heated ## Footnote Shallow anterior chambers can be particularly vulnerable to thermal damage during procedures.

Is synechial angle closure effective for treatment?

Synechial angle closure: ineffective ## Footnote This type of angle closure does not respond well to standard treatments.

What is the CPT code for iridoplasty by photocoagulation? | ALPI

CPT Code: 66762 ## Footnote This code is used for billing purposes for one or more sessions of iridoplasty.

What modifiers are required for CPT code 66762?

Requires RT, LT, or 50 modifiers ## Footnote These modifiers indicate whether the procedure is performed on the right eye, left eye, or both.

What modifier is used if ALPI is performed on the second eye during the global period of the first eye?

79 modifier ## Footnote This modifier indicates that the second procedure is unrelated to the first one within the global period.

What is the global period for procedures related to angle closure treatment?

Global period: 90 days ## Footnote This is the time frame during which follow-up services are included in the initial procedure payment.

Can an office visit fee be billed on the same day as a procedure?

Cannot bill office visit fee same day ## Footnote This is an important billing rule to follow in practice management.

What is the approximate Medicare reimbursement for CPT code 66762?

Approximate Medicare reimbursement: $500 ## Footnote This amount can vary based on location and specific insurance agreements.