Scleral reinforcement is one of the oldest ophthalmic surgical procedures, in which donor sclera allograft is used for structural reinforcement and repair in surgeries for traumatic perforations, scleral melts, wall thinning, and focal or diffuse defects of the scleral wall. Many of those clinical applications are related to underlying ocular inflammation, infection, trauma scleromalacia, pathologic myopia, or other conditions. Over the last couple of decades, more than 90% of scleral reinforcement surgery has been in the context of glaucoma aqueous drainage devices (eg, Ahmed, Baerveldt) where allograft reinforcement is used to reinforce and fixate the tube onto the scleral wall to prevent tube erosion and tissue damage. More recently, new advances in allograft tissue processing and shaping are facilitating even more precise additive reinforcement and graft placements with microtrephined scleral graft material.¹ This can expand the clinical utility and capabilities of scleral reinforcement with improved surgical access to the underlying eye anatomy.

Allograft Material Used in Scleral Reinforcement Surgery

Scleral allografts often come either sterilized or alcohol preserved. The packaged tissue is acellular and has a long shelf life often exceeding 1 year. Allograft material is mostly available in larger donor patch grafts of sizes from 5 cm x 5 cm and 10 cm x 10 cm from which the surgeon can trephine and shape smaller sizes as clinically needed (Figure 1). In scleral reinforcement surgery, the reinforcing material, usually scleral donor allograft, is used additively on or around the scleral wall to increase its structural stability, provide additional thickness, or repair defects of the native sclera.

Although other allograft materials (eg, cornea and pericardium) can be used for scleral reinforcement, donor sclera has the highest homologous-use correspondence to the native tissue. The key attributes of the scleral reinforcement procedure are

• Use of scleral allograft or other structural material for the reinforcement;
• A biomaterial (eg, homologous scleral allograft) that is durable, biocompatible, and preferably indicated for the intended use;
• Surgical deployment of the allograft and the additive scleral reinforcement at the scleral wall (suprascleral, endoscleral, transscleral).

Reimbursement for Scleral Reinforcement

Scleral reinforcement is billed under Category I CPT code 67255. In 2015, scleral reinforcement for aqueous drainage devices (Ahmed or Baerveldt shunts) was bundled under the primary CPT code for 66180, and it is no longer billed separately in addition to the primary CPT 66180. Although scleral reinforcement continues to be the standard of care for almost every glaucoma shunt implant, the use of CPT 67255 has declined significantly from a peak of 10,000 procedures annually. For surgeons, this translated into reduced reimbursement for their surgery.  

In all other cases where scleral reinforcement (CPT 67255) is not done in combination with CPT 66180, it is reimbursed either as a primary or secondary procedure under CPT code 67255. The Medicare Physician Fee Schedule (MPFS) 2024 national unadjusted payment rate for scleral reinforcement CPT code 67255 is $683, and the ambulatory surgical center payment rate is $2,045.

Advances in Allograft Reinforcement and Surgical Techniques 

Advances in allograft processing techniques have enabled microtrephined biotissue for focal, targeted placement and reinforcement of the sclera wall (Figure 2). Precision-shaped allografts allow submillimeter structural reinforcements for smaller anatomic defects, which can expand the clinical utility of one of the most biocompatible natural materials, readily available from eye banks — donor sclera. New biointerventional approaches include the occlusive stenting of optic disc pits where a posterior peripapillary defect of the scleral wall leads to the accumulation of fluid and serous retinal detachment. Such bioscaffolding can also be applied to traumatic or iatrogenic sclerostomies and fistulas. For glaucoma, biointerventional microscaffolding and scleral reinforcement of a cyclodialysis can prevent premature closure and increase the durability of internal filtration and IOP-lowering without the need for exogenous hardware. A recent publication on the evolving clinical paradigm of scleral reinforcement in ocular surgery highlights the latest surgical techniques and innovations in scleral reinforcement.¹  

These advances in allograft materials and processing can lead to better, more precise, and expanded clinical applications of scleral reinforcement surgery. In all such cases, the intervention of scleral reinforcement is billed under CPT code 67255 either as a primary or secondary procedure, applying the appropriate discount factors for multiple procedures — except in the case of CPT 66180, where the allograft tissue is bundled and cannot be billed separately.

Nathan M. Radcliffe, MD, is a clinical associate professor of ophthalmology at the New York Eye and Ear Infirmary of Mount Sinai and a surgeon at the New York Eye Surgery Center. He reports consultancy to Iantrek.

Cynthia Mattox, MD, is an ophthalmologist based in Boston. She reports consultancy to Iantrek.

Reference

1. De Francesco T, Ianchulev T, Rhee DJ, Gentile RC, Pasquale LR, Ahmed IIK. The evolving surgical paradigm of scleral allograft bio-tissue use in ophthalmic surgery: techniques and clinical indications for ab-externo and ab-interno scleral reinforcement. Clin Ophthalmol. 2024;18:1789-1795. https://doi.org/10.2147/OPTH.S462719