Part B Medicare utilization data for procedures to treat glaucoma from 1994 through 2023 (Figure 1) reveals several significant trends:
- a substantial decline in the number of trabeculectomy procedures;
- a modest decline in the number of tube shunt procedures since 2014;
- a substantial increase in the number of ab interno minimally invasive glaucoma surgeries (MIGS); and
- a wide fluctuation in the number of laser procedures, primarily laser trabeculoplasty.
During this period, the population of Part B Medicare beneficiaries has remained relatively constant. However, enrollment in Part C Medicare (Medicare Advantage) has increased significantly (Figure 2).1
Over a 30-year period (1994-2023), the annual number of all glaucoma procedures performed on Part B Medicare beneficiaries ranged between 208,848 (2001) and 361,358 (1994); the annual average was 307,878. If we look closer at the utilization data relative to the population of Part B Medicare beneficiaries served, we find that aggregate glaucoma surgery increased beginning in 2012 when Glaukos received FDA approval for iStent and the popularity of MIGS began to surge (Figure 3).2 The dip in 2020 is due to the COVID-19 pandemic.
The rapid growth in MIGS procedures began to attract the attention of Medicare Administrative Contractors (MACs) once the number exceeded 100,000 surgeries in 2019. Following a controversial and unwelcome 2023 proposed local coverage determination (LCD) policy of MIGS, a 2024 LCD3 was finalized by all the MACs except Novitas and First Coast Service Options, with support from the American Academy of Ophthalmology (AAO), the American Society of Cataract and Refractive Surgeons (ASCRS), The Outpatient Ophthamic Surgery Society (OOSS), and the American Glaucoma Society (AGS). The new coverage policy is discussed in the November 2024 edition of Glaucoma Physician.4 The likely impact is a reduction in the growth rate of MIGS procedures, although probably not much reduction in the appetite for them.
Because the bar to qualify as a medically necessary MIGS procedure has been raised, we anticipate a corresponding increase in laser trabeculoplasty, perimetry, and optic nerve imaging. Each of these services is supportive of a recommendation of MIGS.
There are several new technologies that potentiate growth in these services. One is the Voyager direct selective laser trabeculoplasty (DSLT) device (Alcon).5 In DSLT, laser energy is applied directly through the sclera, eliminating the need for gonioscopy. “DSLT is performed without physically touching the cornea, and preliminary studies have shown that it is a more rapid and simpler technique when compared with SLT.”6
Multifocal pupillographic objective perimetry (mfPOP) from Konan Medical is another emerging technology. It offers an alternative way to assess visual field (VF) function by measuring pupillary responses to multifocal stimuli. Standard automated perimetry is not fun for patients, technicians, or physicians; this induces anxiety, which can affect test performance.7 Not surprisingly, many people would like to avoid that experience, so adherence to VF testing protocols is poor and the interval between tests is longer than recommended. A recent study by Bhim Bahadur Rai, MD, and colleagues concluded, “An objective, non-contact, highly reproducible, and reliable diagnostic test that takes less than 90 seconds to test both eyes and with easy structure–function correlation will be a game changer in busy clinics for providing standard eye care services.”8
An increase in optic nerve imaging, particularly, optical coherence tomography angiography (OCTA), is also likely. “Studies have shown that vascular impairment plays an important role in the etiology and pathogenesis of various ocular diseases including glaucoma, age-related macular degeneration, diabetic retinopathy, and retinal venous occlusive disease,” notes Jyotsna Maram and colleagues at the Doheny Image Reading Center in Los Angeles. “Thus, qualitative and quantitative assessment of ocular blood flow (BF) is a topic of interest for early disease detection, diagnosis, and management.”9 OCTA devices are available from Heidelberg Engineering, Optos, Optovue, Topcon, and Zeiss, among others.
As the US population ages, and the number of glaucoma patients increases, MIGS will likely continue to grow, albeit a little slower than before due to payor constraints. Related procedures can improve care and buttress a decision to perform MIGS. GP
References
1. Xu L, Welch P, Ruhter J, et al. Medicare Advantage overview: a primer on enrollment and spending. Assistant Secretary for Planning and Evaluation, Office of Health Policy. March 7, 2020. Accessed January 31, 2025. https://aspe.hhs.gov/sites/default/files/documents/14a262cfc2979b8cc1a9dffaee06b022/medicare-advantage-enrollment-spending-overview.pdf
2. Ahmed IIK. A brief history of MIGS. The Ophthalmologist. August 2015. Accessed January 31, 2025. https://theophthalmologist.com/business-profession/a-brief-history-of-migs
3. Centers for Medicare and Medicaid Services. Palmetto LCD L37531 micro-invasive glaucoma surgery (MIGS). October 3, 2024. Accessed January 31, 2025. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=37531&ver=20
4. Corcoran KJ. Medicare’s MIGS LCD Finalized. Glaucoma Physician. November 1, 2024. Accessed January 31, 2025. https://www.glaucomaphysician.net/issues/2024/november/medicare-s-migs-lcd-finalized/
5. Alcon innovations on display at AAO 2024 demonstrate efficiency and performance. News release. October 15, 2024. Accessed January 31, 2025. https://investor.alcon.com/news-and-events/press-releases/news-details/2024/Alcon-Innovations-on-Display-at-AAO-2024-Demonstrate-Efficiency-and-Performance/default.aspx
6. Geffen N, Ofir S, Belkin A, et al. Transscleral Selective Laser Trabeculoplasty Without a Gonioscopy Lens. J Glaucoma. 2017;26(3):201-207. doi:10.1097/IJG.0000000000000464
7. Ali MS. Commentary: Visual field testing: a distressing or an unpleasant experience! Indian J Ophthalmol. 2022;70(8):2887-2888. doi:10.4103/ijo.IJO_1189_22
8. Rai BB, Sabeti F, Carle CF, Maddess T. Visual field tests: a narrative review of different perimetric methods. J Clin Med. 2024;13(9):2458. doi:10.3390/jcm13092458
9. Maram J, Srinivas S, Sadda SR. Evaluating ocular blood flow. Indian J Ophthalmol. 2017;65(5):337-346. doi:10.4103/ijo.IJO_330_17
