Boomers and Disease Detection with OCT: Catalyst for Optometric Practice Growth

Boomers and Disease Detection with OCT: Catalyst for Optometric Practice Growth COPE 38496-PD Michael Chaglasian, OD

Boomers and Disease Detection with OCT: Catalyst for Optometric Practice Growth Disclosure: Boomers and Disease Detection with OCT: Catalyst for Optometric Practice Growth Michael Chaglasian, OD, FAAO COPE # 38496-PD This course material and information was developed independently of any assistance. I do have the following financial arrangements to disclose: Michael Chaglasian, OD, FAAO Illinois Eye Institute Illinois College of Optometry mchaglas@ico.edu Alcon Honorarium/Advisory Board Allergan - Honorarium/Advisory Board Carl Zeiss Meditec - Honorarium/Advisory Board Objectives: 1. Understand the increasing prevalence of ophthalmic disease in the typical optometric practice. 2. Identify what the risk factors and clinical indicators are in patient examinations that suggest the need for OCT imaging. 3. Learn how to read and review OCT images of patients with diabetes, glaucoma, AMD. 4. Understand how latest generation spectral domain OCT instruments have improved their ability to detect and monitor disease. What is a Boomer A baby boomer is a person who was born during the demographic post- World War II baby boom, between the years 1946 and 1964, according to the U.S. Census Bureau. The Problem is an Opportunity America's 78 million baby boomers are turning 65 at a rate of one every 10 seconds (3 million to 4 million per year). Healthcare has become a big issue for baby boomers. Over 60% of adults ages 50 to 64 who are working (or have a working spouse) have been diagnosed with at least one chronic health condition, such as arthritis, cancer, diabetes, heart disease, high cholesterol, or high blood pressure, according to a report from The Commonwealth Fund. Michael Chaglasian, O.D. 1

Possible Indications for Performing OCT Where does optometry and OCT technology fit? Elevated IOP > 21mm Hg C/D >.5 or Asymm. > 0.2 Poor visual field test-takers Narrow anterior chamber angles High myopia Personal or family history of -diabetes -glaucoma -hypertension - field defects Suspicious Optic Nerves - Marcus Gunn pupil - Acquired color defect - poor confrontation fields - Disc pallor Unexplained decreased vision Drusen / AMD Numerous maculopathies and retinopathies And Many Others Requirements of OCT Technology Validation / Accuracy / Improved Outcomes Peer reviewed articles in the literature Not sales/marketing hype Cost Effectiveness Can be challenging. Survey your patients for three months Consider added value to your practice Ease of Use / Ease of Interpretation OCT out performs Photography Conclusions: For detection of a variety of retinal irregularities evaluated in the current study, volume OCT scanning was more sensitive than non-mydriatic retinal photography in our asymptomatic individuals. OCT detected clinically relevant disease features, such as subretinal fluid, that were missed by FP, and had a lower ungradable image rate. It is likely that OCT will be added to photography screening in the near future for chorioretinal disease. The Retinal Disease Screening Study: Prospective Comparison of Nonmydriatic Fundus Photography and Optical Coherence Tomography for Detection of Retinal Irregularities IOVS February 2013 54:1460-1468;published ahead of print January 15, 2013. Michael Chaglasian, O.D. 2

Growth of OCT (2009) OCT Coding / Billing 2013 92132- Used for cornea and narrow angle diagnoses Some carriers/insurances are not covering 92133- Used for ALL Glaucoma and optic neuropathy diagnoses 92134- Used for ALL (approved) Retinal diagnoses Mutually exclusive and cannot be billed on the same day as 92133. Can be billed with 92132. None can billed on same day as fundus photos, 92250 OCT Coding / Billing 2013 2013 Avg. Reimbursement: Must be based upon Medical Necessity and entering CC / reason for visit Reason for diagnostic test? Directly stated or easily implied Will it effect diagnosis or treatment? Always requires an Order and an Interpretation and Report $45-48 Each of these new codes is considered unilateral or bilateral Frequency varies with diagnosis Obtain List of covered ICD-9 codes (Medicare LCD) John Rumpakis, OD, MBA Here s the bottom line: Your patients medical insurance is not the same thing as your malpractice insurance. Optimize Revenue The OCT model can help you improve your billing and coding Help you build glaucoma and retina patients According to Dr. John Rumpakis, a new glaucoma patient can require procedures valued up to $985 the first year. 1 FIRST YEAR GLAUCOMA PATIENT REVENUE VISIT # TOTAL FEES PER VISIT RUNNING TOTAL FIRST $164 $164 SECOND $288 $452 THIRD $224 $676 FOURTH $ 55 $731 FIFTH $144 $875 SIXTH $ 55 $930 SEVENTH $ 55 $985 http://www.revoptom.com/content/d/coding and practice_management/c/36039/ 1 Rumpakis, Putting an Economic Spin on Glaucoma, Optometric Management, Marc Michael Chaglasian, O.D. 3

ADDITIONAL INCOME DUE TO IMPROVED CASE DETECTION It s definitely not getting easier. One ROI Example: OCT only 13.5 per month or 3.4 week for breakeven Procedures for each Glaucoma suspect and diagnosed, 2nd and 3rd visits 2 92014 Ophthalmological services, comprehensive medical examination $ 113 92250 Fundus Photography $ 47 92020 Gonioscopy $ 26 92083 Threshold Visual Fields $ 52 76514 Corneal Pachymetry $ 12 92012 Ophthalmological services, intermediate $ 77 92132 Dqiagnostic Anterior Digital Imaging, - Spectralis $ 38 92133 Diagnostic Posterior ONH Digital Imaging, -Spectralis $ 42 Income generated by two follow-up visits of each glaucoma suspect $ 407 2. Rumpakis, Putting an Economic Spin on Glaucoma, Optometric Management March 2004, pp 53-54. There is no guarantee that your Medicare carrier will pay for these procedures when performed on the same day. Please contact your local Medicare carrier to determine appropriate billing guidelines. http://www.revoptom.com/content/c/22520/ 3 Reasons your Optometry Practice is decreasing in value 1.Technology 2.New Patient Ratios - Boomers!! Chad Fleming, OD, FAAO 3.Resistance to the Medical Model CASE EXAMPLES http://www.optometryceo.com/2013/01/23/3-reasons-your-optometry-practice-is-decreasing-in-value/ Spectral Domain OCT Spectral Domain Comparison Time Domain OCT Stratus SPECTRALIS Typical SD OCT SD OCT w/tracking & Noise Reduction Michael Chaglasian, O.D. 4

Spectral Domain: Many Options Spectral Domain: Many Options Optical Coherence Tomography RS-3000 Advance NOT FDA Approved for US Sales Still Valuable: But Perhaps Limited Future (I am unaware of any timelines) SD-OCT - Heidelberg Engineering SD-OCT Spectralis 40,000 scans per sec. GDx Stratus Eye Tracking SPECTRALIS Reference scan Cross section scan EYE TRACKING Eye Movement The reference image tracks eye movement, and the cross section is moved to match Michael Chaglasian, O.D. 5

Eye-Tracker Controls Scan Location in Real Time Cirrus HD-OCT Eye tracker recognizes eye movement and repositions scan pattern Data acquired during eye movement is discarded Stored data is free of motion artifacts Cirrus HD-OCT Optovue: RTVue X 6.5 Optovue Family Optovue: icam and Normative DB 35 Michael Chaglasian, O.D. 6

OCT Gives You a Powerful New Perspective on These Most Common Ophthalmic Diseases Pre & Post- Cataract Complications 2 million patients diagnosed annually AMD 6 million patients diagnosed annually DME 5 million patients diagnosed annually GLAUCOMA 3 million patients diagnosed annually What are practitioners' most common misunderstandings of imaging technology? The thought that these devices can diagnose glaucoma in the absence of corroborating clinical evidence is, in my opinion, the most common (and potentially dangerous) misunderstanding. The limited normative databases against which scans are compared can never cover the remarkably varied appearance and structure of the optic nerve we encounter in normal individuals. James Brandt, MD Red Disease! Red Disease CASE AK 54 year old woman Recently moved from Poland VA = 20/40 and 20/50-14D myope Current Medications Dorzolamide TID Timolol BID Complaints of topical SE s with drops Michael Chaglasian, O.D. 7

CASE AK Glaucoma Madness Plethora of information Nothing Definitive in Early Stages Nothing Stable ONH IOP-C/D Ratio Pachymetry Gonio family history Ethnicity Stereo Photos Pallor Rim Area Asymmetry-Blood Flow Visual Fields FRUSTRATION Increasing Prevalence of Glaucoma Increasing Prevalence: African American IOVS, Special Issue 2012, Vol. 53, No. 5 IOVS, Special Issue 2012, Vol. 53, No. 5 Michael Chaglasian, O.D. 8

Increasing Prevalence: Hispanic Glaucoma At Risk Review African-Americans Glaucoma is the leading cause of blindness among African-Americans. It is six to eight times more common in African-Americans than in Caucasians. People Over 60 Glaucoma is much more common among older people. You are six times more likely to get glaucoma if you are over 60 years old. Family Members with Glaucoma Family history increases risk of glaucoma four to nine times. Hispanics in Older Age Groups IOVS, Special Issue 2012, Vol. 53, No. 5 Glaucoma At Risk Review Asians People of Asian descent appear are at higher risk for angle-closure glaucoma. Steroid Users 40% increase in the incidence of ocular hypertension and open-angle glaucoma in adults who require approximately 14 to 35 puffs of steroid inhaler to control asthma. Other Risk Factors Other possible risk factors include: high myopia (nearsightedness), diabetes, Hypertension, Central corneal thickness less than.5 mm OCT for Glaucoma RNFL Optic Nerve Head Ganglion Cell Thickness 65 yo with Hx of OHTN x 3 yrs 38 yo GAT= 22 OD 25 OS Michael Chaglasian, O.D. 9

Cirrus RNFL Optic Nerve Analysis Optic Nerve Cross Sections Visual Fields Combined Report Michael Chaglasian, O.D. 10

The Ganglion Cell Complex (GCC) RTVue: RNFL and GCC Inner retinal layers provide complete Ganglion cell assessment: Nerve fiber layer (g cell axons) Ganglion cell layer (g-cell body) Inner plexiform layer (g-cell dendrites) Images courtesy of Dr. Ou Tan, USC NEW for Glaucoma: Ganglion Cell Analysis Anatomy: Ganglion Cell Layer and IPL Measures thickness for the sum of the ganglion cell layer and inner plexiform layer (GCL + IPL layers) using data from the Macular 200 x 200 or 512 x 128 cube scan patterns. Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012 Cirrus: Ganglion Cell Analysis The analysis contains: Data for both eyes (OU) Thickness Map shows thickness measurements of the GCL + IPL in the 6mm by 6mm cube and contains an elliptical annulus centered about the fovea. Deviation Maps shows a comparison of GCL + IPL thickness to normative data. Thickness table shows average and minimum thickness within the elliptical annulus. Glaucoma Suspect Initial 3 years later Michael Chaglasian, O.D. 11

RTVue and Cirrus OCT Topography of Retinal Ganglion Cells Large variation in total ocular axonal count (0.5 to 1.2 mil) amongst normals and thus large variation in normative databases. However, the variation in ganglion cell numbers in the central macula is small. Curcio CA, Allen KA.. J Comp Neurol 1990;300(1):5-25 Posterior Pole Asymmetry Analysis A new SPECTRALIS software feature to help assess RNFL and GCL loss by mapping retinal thickness across the posterior pole Glaucoma Case Study 1: Asymmetry of Ganglion Cell Analysis Potential to detect earlier RNFL loss compared to RNFL thickness circle scans, fundus photos or visual fields Glaucoma Case Study 1: IOP 28 OD, Early VF Defect, Inferior RNFL defect Posterior Pole Case Study 2 Michael Chaglasian, O.D. 12

250 200 150 100 50 0 0 50 100 150 200 250 TSNIT Boomers and Disease Detection with OCT KOA 2014 New Reports RNFL & Post. Pole Posterior Pole Assessment RNFL & P. Pole Asymmetry Progression Analysis: Absolutely Essential Progression Analysis: Absolutely Essential Detecting Structural Progression of Glaucoma A Key Component of Glaucoma Management Cirrus HD-OCT Guided Progression Analysis Image Progression Map Two baseline exams are required GPA Analysis SS = 10 Baseline Registration SS = 10 Baseline Baseline Registration SS = 8 Registration SS = 9 Third exam is compared to the two baseline exams Sub pixel map demonstrates change from baseline Yellow pixels denote change from both baseline exams Third and fourth exams are compared to both baselines. Change identified in three of the four comparisons is indicated by red pixels; yellow pixels denote change from both baselines Change refers to statistically significant change, defined as change that exceeds the known variability of a given pixel based on population studies Cirrus HD-OCT GPA Analysis RNFLT (microns) TSNIT Progression Graph TSNIT values from each exam are shown Significant difference is colorized yellow or red Yellow denotes change from both baseline exams Red denotes change from 3 of 4 comparisons Trend Analysis: Summary Parameter A Regression Line is drawn to determine rate of change for all the data that has been collected over time. Less variability with Structural/OCT testing as compared to Functional/ Visual Field testing. Michael Chaglasian, O.D. 13

New Updates on Cirrus HD-OCT (Zeiss): Ganglion Cell Analysis Updated Guided Progression Analysis (GPA ) Optic Nerve Head information now included Average Cup-to-Disc Ratio plotted on graph with rate of change information. RNFL/ONH Summary includes item Average Cup-to- Disc Progression. Printout includes an optional second page with table of values, including Rim Area, Disc Area, Average & Vertical Cup-to-Disc Ratio and Cup Volume. Each cell of the table can be color coded if change is detected. Ver 6.0 Ver 6.0 Updated Guided Progression Analysis (GPA ) Page 1 Page 2 Provide the best possible glaucoma care to your patients Find more glaucoma suspects Diagnose glaucoma earlier Glaucoma is a leading cause of blindness in the US Over a million people in this country have glaucoma but don t know it. 1 Failure to diagnose open-angle glaucoma is a leading cause of liability claims involving eye care practitioners. 2 Ver 6.0 81 1 The Eye Diseases Prevalence Research Group. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122(4):477-485. 2 Classe JG. Glaucoma--a clinicolegal review. J Am Optom Assoc. 1997; 68:389-394. Retina Retina AMD 1.47% >40 age have Macular Degeneration Over 7 Million at risk for AMD Drusen >125um 1.75 million individuals in US w/significant AMD 15% of the white women older than 80 years AMD will increase by 50% to 2.95 million in 2020 Source National Eye Institute Citations and Abstracts from April 2004 Archives of Ophthalmology Prevalence of Age-Related Macular Degeneration in the United States The Eye Diseases Prevalence Research Group Michael Chaglasian, O.D. 14

AMD Risk Factors Smoking Obesity Race Smoking may increase the risk of AMD. Research studies suggest a link between obesity and the progression of early and intermediate stage AMD to advanced AMD. Whites are much more likely to lose vision from AMD than African Americans. Many faces of AMD Family History Those with immediate family members who have AMD are at a higher risk of developing the disease. Gender Women appear to be at greater risk than men. Dry AMD Dry AMD HD Raster with Enhanced Depth Imaging (Cirrus) HD 5 Line Raster Classic CNVM 20/40 CF@ 5 ft Michael Chaglasian, O.D. 15

Advanced RPE Analysis Gain new insights on your AMD patients RPE Elevations RPE Elevations. If the RPE is raised above a baseline plane, a new proprietary algorithm for Cirrus maps and measures the area and volume of the elevations. Sub-RPE Illumination Sub-RPE Illumination. If the RPE is absent or has lost integrity, the OCT beam penetrates into the choroid. A new proprietary algorithm for Cirrus can determine when this occurs and then map and measure the affected area. 92 PED Missed PED Idiopathic CNV Retina-Diabetes 1 in 17 Americans or 16 Million with Diabetes 10.2 million US adults 40 years and older known to have Diabetes Mellitus (Proliferative/Non or DME) 4.1 million US adults 40 years and older have diabetic retinopathy 3.4% or 4.1MM of Population w/vision threatening retinopathy Retina Source National Eye Institute Citations and Abstracts from April 2004 Archives of Ophthalmology The Prevalence of Diabetic Retinopathy Among Adults in the United States Michael Chaglasian, O.D. 16

DME CSME Full Thickness Macular Hole Macular Hole Vitreo Macular Traction: OCT Anterior Segment Imaging Anterior Segment Module provides a close up view of chamber angles Michael Chaglasian, O.D. 17

Lasik Flap Cornea, Angle & Sclera Mode Cirrus HD-OCT Anterior Segment Imaging Cirrus Anterior Segment Imaging Images courtesy of Martha Leen, M.D. & Paul Kremer M.D. Achieve Eye and Laser Specialists, Silverdale, WA Cirrus HD-OCT scan of normal cornea. Layers identified with colored arrows as follows: tear film (blue), epithelium (white), Bowman s layer (red), Descemet s/endothelium (green). Cirrus Anterior Segment Imaging RTVue Clinical Applications Cirrus HD-OCT image with a visible angle recess (blue arrow). Schlemm s canal is very well clearly seen (red arrow). Retina Glaucoma Anterior Chamber Michael Chaglasian, O.D. 18

MultiColor Technology MultiColor image composed of three selective colour laser images Infrared, green and blue reflectance MultiColor Automatic color balance to match fundus appearance on photographs Limitations: Optic disc colour does not match natural appearance Uveal pigment appears pale The Versatility of MultiColor Imaging View images of individual laser colors to gain better understanding of anatomic and pathologic detail at different depths within the retina ERM, RNFL, macular pigment blue reflectance blood vessels, blood, excudates green reflectance drusen, RPE, choroid infrared reflectance Image courtesy of S. Wolf, MD, PhD, Bern, Switzerland Online Education Widely Available How do you view all of this data and image imformation? http://www.elearning.zeiss.com/ Image Management System. Designed for EyeCare Michael Chaglasian, O.D. 19

Why would I need more than an Electronic Health Record (EHR) system for my ophthalmic practice? A Few Definitions Acronym Term IMS DICOM EHR EMR IMS PACS HIS PMS Digital Imaging and Communications in Medicine Electronic Health Record Electronic Medical Record Image Management System Picture Archiving and Communication System Health Information System Practice Management System The IT Landscape in an Ophthalmic Practice IT integration is key PMS or HIS Manages the practice business (administration, scheduling, accounting, billing) EHR / EMR Medical charts. Documentation of clinical decisions, treatments and prescriptions IMS Manages and archives diagnostic reports and images. Viewing, comparing and reviewing ophthalmic data Medical data standard protocols 117 What does an EHR alone offer? Clinical Management EHR/EMR IMS (PACS) Medical charting Treatment Plan Ophthalmology exam templates e -prescribing Report storage Raw data storage from instruments Central scheduling of patient tests Side-by-side report viewing Customizable viewer for images and reports Combined reports from instruments Full resolution images (Fundus Images) Practice Management Billing CCHT Certification AARA Certification What can EHR + an IMS offer? Clinical Management EMR/EH R IMS (PACS) Medical charting Treatment Plan Ophthalmology exam templates e -prescribing Report storage Raw data storage Central scheduling of patient tests* Side-by-side report viewing Customizable viewer for images & reports Combined reports from instruments Full resolution images (Fundus Images) Practice Management Billing An Image Management System helps: Reduce errors Save time Better appreciate patient s diagnostic data * A feature that helps reduce errors in formatting patient records What clinical needs can an IMS uniquely address? Clinical Need IMS Feature Store all test data & reports on a Broad device connectivity via DICOM & file server imports Perform change analysis (GPA) Centralized, raw data storage See your HFA data in your EHR Review reports in context A single FORUM - EHR interface with many EHRs supported Display VF, OCT, fundus photos, structurefunction GPA side by side Clean up legacy records Merge tool to find & merge multiple patient records using a variety of match criteria. Innovative analyses Combined Visual Field - OCT Reports Patient education Customizable viewer for images and reports Michael Chaglasian, O.D. 20

An IMS can integrate patient data in unique ways Example: VF-OCT combined report Zeiss Forum Viewer Software Zeiss Forum Viewer Software Zeiss Forum Viewer Software Zeiss Forum Viewer Software Zeiss Forum Viewer Michael Chaglasian, O.D. 21

Zeiss Forum: Combined Report Forum Glaucoma Workplace Forum Glaucoma Workplace FORUM 3.2 What s new? Clinical Displays Auto-selection rules Cataract 1. Display is set to 3 x 1 (fixed arrangement) 2. The following documents are selected automatically A. Left panel: Overview report from CZM Atlas B. Middle panel: Macular Thickness Analysis Report from CZM Cirrus or Stratus C. Right panel: IOLMaster report 3. The most recent visit date will be selected. All documents must be from the same date 4. Laterality (R/L) according to the user selection: IOLMaster report with laterality Both is selected in both cases (R/L) Clinical Displays Auto-selection rules Glaucoma (OCT-VF-FI) 1. Display is set to 3 x 1 (fixed arrangement) 2. The following documents are selected automatically A. Left panel: ONH and RNFL Analysis report or RNFL Thickness Analysis report from CZM Cirrus B. Middle panel: SFA report from Humphrey Field Analyzer C. Right panel: COLOR Fundus Image 3. The most recent visit date will be selected. All documents must be from the same date 4. Laterality (R/L) according to the user selection: ONH / RNFL report with laterality Both is selected in both cases (R/L) 131 132 Michael Chaglasian, O.D. 22

Clinical Displays Auto-selection rules Glaucoma OU (OCT-VF-FI) 1. Display is set to 3 x 1 (fixed arrangement) 2. The following documents are selected automatically A. Left panel: COLOR Fundus Image of the right eye B. Middle panel: HFA Visual Field and Cirrus ONH (/RNFL) Combined Report C. Right panel: COLOR Fundus Image of the left eye 3. The most recent visit date will be selected. All documents must be from the same date Clinical Displays Auto-selection rules Glaucoma Progression (FI) 1. Display is set to 2 x 2 (fixed arrangement) 2. The following documents are selected automatically A. Top left panel: COLOR Fundus Image from the patient s latest ( / current) visit B. Top right panel: COLOR Fundus Image from the patient s 2 nd latest ( / last) visit C. Bottom left panel: COLOR Fundus Image from the patient s 2 nd earliest visit D. Bottom right panel: COLOR Fundus Image from the patient s earliest ( = first) visit 3. Laterality (R/L) according to the user selection 133 134 Clinical Displays Auto-selection rules Glaucoma Progression (OCT-VF) 1. Display is set to 4 x 1 (fixed arrangement) 2. The following documents are selected automatically A. Left panel: GPA Optic Disc Cube report CZM Cirrus Right eye B. 2nd panel from left: GPA report from Humphrey Field Analyzer Right eye C. 3rd panel from left: GPA Optic Disc Cube report CZM Cirrus Left eye D. Right panel: GPA report from Humphrey Field Analyzer Left eye 3. The most recent GPA reports will be selected. Clinical Displays Auto-selection rules Retina Overview 1. Display is set to 3 x 2 (fixed arrangement) 2. The following documents are selected automatically A. Top left panel: COLOR Fundus Image B. Top middle panel: RED FREE / GREEN Image C. Top right panel and bottom panels (left to right): 4 phases of a FA or ICG series: i. Early phase (earliest image within 0 s and 25 s), ii. Earliest image within 25 s and 1 min, iii. Earliest image within 1 min and 2 min, iv. First image after 2 min 3. The most recent visit date will be selected. All documents must be from the same date 4. Laterality (R/L) according to the user selection 135 136 Clinical Displays Auto-selection rules AMD Progression (OCT) 1. Display is set to 4 x 1 (fixed arrangement) 2. The following documents are selected automatically A. Left panel: Macular Thickness Analysis report (Cirrus or Stratus) from the patient s earliest (= first) visit B. 2 nd panel from left: Macular Thickness Analysis report (Cirrus or Stratus) from the patient s 2 nd earliest visit C. 3 rd panel from left: Macular Thickness Analysis report (Cirrus or Stratus) from the patient s 2 nd latest ( / last) visit D. Right panel: Macular Thickness Analysis report (Cirrus or Stratus) from the patient s latest ( / current) visit 3. Laterality (R/L) according to the user selection Image Management Systems Topcon Synergy OIS Symphony Web Canon Retinal Imaging Control Software Kowa DigiVersal EHR Systems Generally don t offer as much functionality All should be DICOM compliant 137 Michael Chaglasian, O.D. 23

Retain the glaucoma/retina patients that you identify Increase patient retention rates by: Diagnosing patients early Educating them on glaucoma and retina pathology Managing them with state-of-the art technology YOU WILL MAXIMIZE YOUR RETURN ON INVESTMENT WHLE PROVIDING BETTER PATIENT CARE OCT in Optometric Practice: mchaglas@ico.edu Michael Chaglasian, O.D. 24