Flavius Beca, MD
Wills Eye Hospital, Philadelphia, PA
The following talks at AAO 2025 gave us need-to-know updates for other ophthalmic subspecialties including neuro-ophthalmology, glaucoma, cataract/refractive, and office visit coding.
What Every Retina Doctor Needs to Know about NeuroOp – Andrew Lee, MD
Dr. Andrew Lee delivered a characteristically memorable reminder – in the words of Aretha Franklin – to “R.E.S.P.E.C.T. [neuro-ophthalmology]”. He emphasized that the exam should go beyond the retina alone. An abnormal optic nerve may still be due to a retinal problem, and therefore not require neuro-ophthalmology referral for which the average wait time is 6 months. He highlighted several core principles:
CRAO and BRAO are true strokes and therefore require an emergent stroke workup, preferably at a designated stroke center. However, the resultant optic atrophy from Wallerian degeneration does not require neuro-ophthalmology referral. Similarly, patients presenting with optic atrophy or sectoral atrophy should be examined for retinal pathology that explains the optic nerve defect, obviating the need for neuro-ophthalmology evaluation. In his characteristic humor, Dr. Lee recommends we treat ischemic transient vision loss with the same urgency as any other stroke symptom. “Do not D.I.Y. a T.I.A. or the patient will D.I.E.”
In contrast to a frank stroke, NAION, despite our classic teaching, is a small-vessel ischemic optic neuropathy, not a central nervous system stroke. Therefore, MRI and neuro-ophthalmology consultation are generally not required.
Finally, Dr. Lee encouraged us to obtain Humphrey visual fields for any unexplained vision loss. Our main goals are to detect bitemporal or homonymous field defects which should prompt immediate hospital evaluation. However, if we encounter an enlarged blind spot without optic nerve edema, we should reconsider a retinal exam or macular OCT which may reveal severe peripapillary atrophy. Finally, he reminded the audience that an enlarged blind spot with optic disc edema does indeed require a neuro-ophthalmology referral.
Anti-VEGF Injections and Glaucoma – Iqbal “Ike” Ahmed, MD
Dr. Ike Ahmed reminded us to not forget about the optic nerve. As a Canadian, he jokingly recommends we rename the disc the “Cup of Trump” to help us not forget to evaluate the nerve.
In his talk, he reviewed the literature on the effects of transient IOP spikes from injections on the health of the optic nerve. In patients with glaucoma, frequent injections are a known risk for requiring additional drops or even surgery. In patients without glaucoma, the data remains inconclusive but several studies suggest a signal towards increased rates of glaucoma and prolonged ocular hypertension in patients requiring frequent and long-term injections. The mechanisms are likely multifactorial, potentially related to silicone microdroplets, low-grade inflammation, transient volume overload and cumulative potentially toxic drug exposure. Dr. Ahmed stressed the importance of routine IOP checks and yearly optic nerve imaging, and advised involving glaucoma specialists early when managing high-risk or susceptible patients.
IOL Technology and Innovation – David Chang, MD
Dr. David Chang reviewed newly available intraocular lenses in the cataract refractive world. He discussed small-aperture optics such as the Aphthera lens which may make posterior viewing during surgery more complicated. He also reviewed light-adjustable lenses (LALs) which are often silicone-based lenses. The makeup of the IOL implant may need to be considered when selecting a tamponade agent. Dr. Chang also noted the rising rate of IOL exchanges mirroring the rising rate of cataract surgery. He used this opportunity to preview a promising new technology, the prosthetic capsular bag system entering clinical trials in the US next year. The device potentially allows fast, stable insertion of any single piece lens in its intended location following placement of the capsular system. Meanwhile, the capsular system is placed quickly and easily via 3 sclerotomes with subconjunctival anchors. Early 1-year results in 15 patients demonstrated no erosions and excellent stability. The new device will also entail creation of a new CPT code for more equitable billing compared to the current options for secondary lens fixation. Dr. Chang credited retina specialist Dr. Frank Brodie (UCSF) for his contributions to this device.
Coding Essentials for Retina Specialists – Michael Lai, MD
Dr. Michael Lai, the only retina specialist in this group of speakers, provided an overview of some important coding principles. He first reviewed differences between E/M codes and eye codes. E/M coding depends on visit complexity, often better suited for high-acuity visits such as retinal detachment. Eye codes reflect documentation completeness and may be more appropriate for stable chronic conditions like uncomplicated ERM.
Next, Dr. Lai reviewed key postoperative modifiers. Modifier 58 is a staged or more complex-than-planned procedure, modifier 78 is unplanned return to the OR for a related complication, and modifier 79 is return to the OR for an unrelated procedure. Dr. Lai also indicated the importance of checking on the CMS site for the quarterly updates on bundling guidance and offered some examples of appropriate bundling. Finally, the talk concluded with a note on the 25 modifier. Dr. Lai asked the audience to stay tuned while the AAO and ASRS seek clearer guidance from CMS.
