Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months

Copyright 2017 PCPI(R) Foundation and American Medical Association. All Rights Reserved.

The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. 

The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. 

Commercial uses of the Measures require a license agreement between the user and the PCPI(R) Foundation (PCPI[R]) or the American Medical Association (AMA). Neither the American Medical Association (AMA), nor the AMA-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI), nor PCPI, nor their members shall be responsible for any use of the Measures.

The National Committee for Quality Assurance's significant past efforts and contributions to the development and updating of the Measures is acknowledged. 

AMA and PCPI encourage use of the Measures by other health care professionals, where appropriate.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
 
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, PCPI, and its members and former members of the AMA-PCPI disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications. 

CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) is copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2016 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R].

None

None

None

Changes in the optic nerve are one of two characteristics which currently define progression and thus worsening of glaucoma disease status (the other characteristic is visual field). There is a significant gap in documentation patterns of the optic nerve for both initial and follow-up care (Fremont, 2003), even among specialists (Lee, 2006). Examination of the optic nerve head and retinal nerve fiber layer provides valuable structural information about glaucomatous optic nerve damage. Visible structural alterations of the optic nerve head or retinal nerve fiber layer and development of peripapillary choroidal atrophy frequently occur before visual field defects can be detected. Careful study of the optic disc neural rim for small hemorrhages is important, since these hemorrhages can precede visual field loss and further optic nerve damage.

When initiating therapy, the clinician sets a target range of controlled IOP based on the pretreatment pressure and the presence of optic nerve damage. According to the AAO Glaucoma Preferred Practice Pattern, lowering the pretreatment IOP by 25% or more has been shown to inhibit progression of POAG to preserve visual function (AAO, 2010)

Ophthalmic Evaluation
The ophthalmic evaluation specifically focuses on the following elements in the comprehensive adult medical eye evaluation:

Visual acuity measurement
Pupil examination
Anterior segment examination
Intraocular pressure (IOP) measurement
Gonioscopy
Optic nerve head (ONH) and retinal nerve fiber layer (RNFL) examination
Fundus examination
(AAO, 2015)

Higher score indicates better quality

American Academy of Ophthalmology Glaucoma Panel. Preferred Practice Pattern Guidelines. Primary Open-Angle Glaucoma. San Francisco, CA: American Academy of Ophthalmology; 2015. Available at: www.aao.org/ppp

Fremont AM, et al. Patterns of Care for Open-angle Glaucoma in Managed Care. Arch Ophthalmol. 2003;121:777-783.

Lee PP, et al. A Multicenter, Retrospective Pilot Study of Resource Use and Costs Associated With Severity of Disease in Glaucoma. Arch Ophthalmol. 2006;124:12-19.

None

Optic nerve head evaluation includes examination of the cup to disc ratio and identification of optic disc or retinal nerve abnormalities.  Both of these components of the optic nerve head evaluation are examined using ophthalmoscopy.

The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but ICD-9-CM and SNOMED-CT do not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible professional or eligible clinician will record laterality in the patient medical record, as quality care and clinical documentation should include laterality.

TBD

All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma

Equals Initial Population

None

Patients who have an optic nerve head evaluation during one or more office visits within 12 months

Not Applicable

Documentation of medical reason(s) for not performing an optic nerve head evaluation

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

None