By Thomas P. Arnold, OD, FSLS
Dec. 9, 2020
Your practice is built by providing high-quality care to patients. That care can be greatly enhanced by the right technologies. Here are a few key instruments I have added to my practice that have propelled our care to greater heights, while differentiating us from competitors.
A good quality fundus camera is a must-have for a progressive optometric practice. In addition to creating documentation of retinal findings over many years, it is a notable patient-pleaser. They are sure to be impressed by a technology that peers into that black hole within the iris to reveal the retina. Optic nerve, macula, choroidal nevi, toxoplasmosis scars, histoplasmosis spots, asteroid hyalosis, as well as early, pre-proliferative diabetic retinopathy, are all easily documented and reviewed.
Patients appreciate being able to see what the doctor is describing instead of trying to assimilate complicated medical terminology. Fundus photography brings the exam to life and sets one’s practice apart from the competition.
We were an early adopter of the Optos Optomap Ultra-Wide Field imaging system in 2001. In fact, we were just the 19th practice in the world to implement it, according to Optos founder Douglas Anderson. About five years ago we upgraded to the Daytona Optos.
Adding this technology to our practice helped to streamline our examination protocol, as images were captured during the preliminary evaluation and were ready for review during the examination with the doctor. In 2001, this created a “wow” factor that most patients had never experienced.
Patient care has been greatly improved because we have detailed photo images for up to 19 years for some patients. When patients move away and request their records, these images are a welcome part of the patient record. Pathology like cup-disc ratios, benign choroidal nevi, mild drusen, and even background diabetic retinopathy, can be seen over time, with any progression noted.
ROI: The full purchase price of the Optos Daytona is $85,000. Initially, we paid per image saved with a monthly minimum. When the opportunity to purchase the equipment came, we obtained a 36-month loan through a finance company that specializes in medical practices. ROI is great as we charge for the photos. The utilization rate is 60-70 percent. That means an average of 65 percent of our patients elect for Optos at an average of $44 ($49 for cash pay; $39 for VSP patients). The instrument yields around $15,000 in revenues per month. As we are a busy practice with two doctors 5.5 days/week, we calculate a revenue of approximately $180,000 per year. More than enough to pay for the camera. We’ve had our Daytona Optos for 4-5 years now.
Optical coherence tomography (OCT) has become a fixture in many practices. OCT utilizes near-infrared light to penetrate biologic tissue. This allows detailed analysis of the optic nerve, retina and choroid. Commonly seen conditions such as choroidal nevi, epiretinal membranes, drusen, vitreo-retinal traction, macular holes can be documented and followed in great detail. It has also become an essential tool in the analysis of optic nerve damage seen in glaucoma. After three scans are recorded, many units offer a “progression analysis” of several data points. Values such as retinal nerve fiber layer (RNFL), cup-disc ratios and ganglion cells are analyzed to reveal trends.
Many practitioners, like myself, involved in specialty contact lens fitting utilize the anterior segment scans to assess lens-to-cornea relationships. Fluid reservoir depth (or lens vault) can be accurately measured utilizing the digital ruler. In the same way, limbal clearance and the landing zones can be viewed. This information is extremely useful and supplements what the practitioner visualizes with the slit-lamp.
We have had an OCT for almost 20 years. Our current unit, the ZEISS CIRRUS 6000, is approximately 10 years old. As with most specialty equipment, we purchased it with a 36-month term lease-to-purchase. We paid around $38,000, with monthly payments of $1,055. Purchasing allows us to take advantage of the IRS Section 179 deduction, which allowed for a 35 percent savings on the instrument.
ROI: Testing with our OCT is billable at $125 for cash (as in scleral patients) and reimburses by insurance at around $40. We use our OCT frequently for glaucoma testing; vitreo-macular traction; epiretinal membranes, diabetic retinopathy and anterior-segment imaging of scleral lenses. While medical reimbursement is generally low, the ease of use and quality of information generated quickly more than offsets this. With apprimxately 28 tests performed per month, this instrument brings in $2,780 monthly in revenues, or $33,360 annually.
There is no doubt that interest in scleral lenses is booming, with more ODs adding scleral lens services to their practices. Scleral lenses have many benefits when fitting ectatic corneas whether from keratoconus, pellucid marginal degeneration, post-RK or post-LASIK. They are also indicated for treatment of dry eye disease (DED) and graft-versus-host (GVHD) disease. Practitioners are also finding them extremely useful for some athletes. It only takes a few cases before one discovers that fitting the scleral/conjunctival surface is not quite the same as fitting the cornea.
Many studies have demonstrated that the elevation, slope and tangent angles of the sclera are unique and often highly irregular. This is where scleral profilometry comes in. Currently, there are two different scanning strategies – Scheimpflug imaging and fluorophotometry.
A Scheimpflug camera takes a two-dimensional image of a three-dimensional solid object. Scheimpflug utilizes a rotating camera to take 25 “slices” of the tissue over 360 degrees. These are analyzed for elevation and slope. Some scleral lens manufacturers are able to import these data to facilitate designing the lens. A Scheimpflug camera is not reflection dependent, and thus, is not affected by tear film quality.
On the other hand, fluorophotometry utilizes sodium fluorescein applied to the tears to image scleral shape. A brightly colored image is generated along with digital measurements to accurately describe the scleral topography. As in the Scheimpflug system, data may either be imported directly to a particular lab or may be used to reference a database of designs from a variety of manufacturers. For this, the practitioner selects the lens of choice and the software recommends the sagittal clearance and landing zone values for a diagnostic lens. Data from the over-refraction may also be entered.
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Patient care is improved by this instrument, enabling lenses that fit better the first time with greater comfort. The number of remakes may be reduced, which saves the practitioner both time and money. Patients are more satisfied, as fewer follow-up visits are required to “get it right.” The doctor also benefits in being perceived as technologically advanced and a specialist.
In the field of scleral lenses, it is often found that the more cases one does the more challenging the patients become. As the reputation of being a specialty lens expert grows, so too will the referral base. Patients who have been unable to be helped elsewhere will come. Scleral profilometry can be a valuable tool to enhance chances of success.
ROI: Profilometers cost approximately $24,000-$40,000 depending on features. We do not bill profilometry separately. We include this cost in our professional fees. I estimate that profilometry cuts our remakes and follow-up visits by half or more. As we go more into “empirical fitting” and skip the diagnostic trial lenses, it will save even more, not only in materials, but chair time. In terms of dollars, I estimate this amounts to upwards of $20,000 annually.
Profilometry is not a reimbursable procedure for insurance purposes. We make sure that our evaluation fees are high enough to adequately compensate for the extra time involved for testing.
However, the non-quantifiable benefit of profilometry is the decreased chair time in the diagnostic lens fitting process, as well as enhanced chances of success with fewer visits. This is a major win-win for both doctor and patient.