Well equipped

Investigating in the latest optometric diagnostic technology can improve patient eye health—and expand your business.

Well Equipped Header
By Melanie Padgett Powers, AOA Focus, June, 2014, pages 41-47

As a child growing up in the shimmering, hot South Carolina sunlight, Lori R. Roberts, O.D., basked in the rays, riding horses and bikes and swimming at the neighborhood pool. It was the 1970s and '80s, and children weren't slathered in sunscreen and certainly didn't wear sunglasses and sunhats. Her parents didn't consider what UV exposure could do to their children's eyes.

Fast-forward to the 21st century, when Dr. Roberts bought a macular pigment optical density (MPOD) device for her optometry practice in Mount Pleasant,  South Carolina. Using a technique called heterochromatic flicker photometry, the machine measures a person's macular pigment (MP) thickness. A thinner MP can lead to age-related macular degeneration.

Dr. Roberts decided to become familiar with the noninvasive device by testing it out on herself and her staff. On a 0 to 1 scale, less than .21 is considered low density. Dr. Roberts was shocked when she scored a .19, though she is only 40 years old, but then she started thinking about all those hot, long summers spent outdoors.

"Newer studies are showing that 80 percent of UV damage happens before age 18," she says. She realized her assumption that low scores would occur primarily in patients 65 and older was inaccurate.

Dr. Roberts, who is the chair of the AOA New Technology Committee, uses the MPOD device to test patients at risk for macular degeneration. She recommends eye health supplements to those with lower scores, comparing follow-up tests to the baseline and adjusting vitamin recommendations if necessary. It's one of many tools Dr. Roberts and other optometrists are adding to their practices to provide the best patient care available today.

Improving eye health with the latest technology
Keeping up with the latest optometric diagnostic equipment can be pricey, as the technology seems to advance at lightning pace. But investing in and incorporating the latest tools into a practice could improve patient eye health, expand an OD's business and create more efficient processes.

There is not one agreed-upon checklist of new equipment ODs must have. It depends on the individual practice. Optometrists who treat primarily children or young adults, or who focus mostly on prescribing glasses and contact lenses, will need different equipment than those who focus on various eye diseases or have an aging patient population.

One type of newer technology that many ODs are now using frequently is high-resolution spectraldomain ocular coherence tomography, or SD-OCT.

"My OCT gives me a really detailed look at the retina that I wouldn't have otherwise," says J. Eric Paulsen, O.D., a solo practitioner in Sturgeon Bay, Wisconsin "When I bought it, I thought I would use it once in a while."

In fact, another optometrist in the small town of about 9,100 residents suggested they split the cost and share the device. But that didn't work out because Dr. Paulsen realized he was using OCT almost every day. The technology allows him to see the different layers of the retina and under the surface of the retina, providing a much more scientific diagnosis than before—with a noninvasive procedure.

OCT helps Dr. Paulsen diagnose posterior vitreous detachment and retinal detachment. And it's invaluable in the diagnosis and management of age-related macular degeneration and glaucoma. Optometrists who suspect age-related macular degeneration can use OCT to examine the layers of the retina, avoiding or supplementing invasive fluorescein angiography.

OCT measures the thickness of the retinal nerve fiber layer, which becomes thinner as glaucoma progresses. The device also analyzes the optic nerve head and the ganglion cell complex. Dr. Roberts says if the ganglion cell complex shows a patient is at high risk for glaucoma, an optometrist may want to follow the patient more often, about every six months, and conduct an early-morning pressure check, when the nocturnal glaucoma may be more present.

A photo worth 1,000 words
Another device optometrists should consider is a digital fundus camera. The newest cameras offer strikingly clear photos that help with diagnosis and allow optometrists to look at photos of the retina side by side over time, making it easier to detect changes.

When Dr. Roberts started her practice in 2004, she knew she wanted to invest in a digital fundus camera, though she admits the $25,000 price tag at the time was difficult to come up with. "But it's been worth it," she says.

Late last year, Dr. Roberts noticed a tiny hemorrhage in a patient's retina. She recommended the woman see her primary care doctor, who diagnosed her with hypertension and prescribed medication. Six months later, Dr. Roberts examined the patient again and the hemorrhage was gone.

"It's so neat to show the patients pictures, and we can follow their progress," she says. "It helps the patient understand what is going on with their body."

The price of digital fundus cameras has dropped significantly, to less than $20,000, plus insurance does reimburse for using the camera.

"They are a lot less expensive and a lot higher quality than they were five years ago," says Michael Chaglasian, O.D., chief of staff at the Illinois Eye Institute and associate professor at the Illinois College of Optometry in Chicago.

Other diagnostic technology optometrists might want to consider include:

  • Corneal topography or mapping. Dr. Paulsen says the technology is invaluable in creating contact lenses for his patients. "It's a time saver. I take the topography, scan it and send it to my lens manufacturer," he says. "The manufacturer can see all the idiosyncrasies of the cornea and can make a much better-fitting lens."

  • Automated perimetry or visual field machine, which continues to develop with better technology. "If you're going to manage glaucoma, you need to measure any visual field loss," Dr. Paulsen says.

  • Osmolarity device. Optometrists use the handheld device to collect a tiny sample in nanoliters of a patient's tears, which are then analyzed through a sophisticated computerized docking system to measure the tear film osmolarity. "It's really changing the way we look at dry eye and the way we manage and treat it," says Andrew S. Morgenstern, O.D., a health care consultant with the firm Booz Allen Hamilton who works at the Vision Center of Excellence at Walter Reed National Military Medical Center in Bethesda, Maryland. Available only from TearLab, the device does have a reimbursement code but can only be used by a Clinical Laboratory Improvement Act-certified lab or lab with a CLIA Waiver certificate. Optometric labs can often qualify for waivers because they administer tests considered simple enough by the federal government to not have to meet the more stringent CLIA lab guidelines.

Improving and expanding practice
New technology can help optometrists improve their patients' eye health. But the benefits go beyond that. Once a practice gets past the learning curve inherent with new tools, its practitioners may find the new equipment saves time, allowing the staff to add more patient appointments in a day. For example, an automatic refractor speeds up the refraction process, says Dr. Roberts. That is time she can use elsewhere.

While most health care providers can always use more time, Dr. Roberts says it will be even more important when the ICD-10 code set takes effect. (Implementation was delayed again in April until at least October 2015.) ICD-9 includes about 13,000 codes, but the morespecific ICD-10 will have 68,000 codes. "ICD-10 may slow us down in the beginning," she says. "How do we make our exams quicker without jeopardizing patient care?"

ODs are also seeing a time savings with the use of OCT technology. "It's hard to translate efficiency into dollars, but if you can fit in three more patients a day because of faster equipment and processes ..." Dr. Chaglasian explains.

OCT Device

OCT devices not only help analyze the retina but also examine the nerve fiber to monitor glaucoma.

Image courtesy of J. Eric Paulsen, O.D.

Use of new technology can also help optometrists expand their practice. Dr. Paulsen began working more closely with rheumatologists thanks to his OCT device. Patients with arthritis or lupus who are taking hydroxychloroquine (Plaquenil) are at risk for retinal toxicity. Dr. Paulsen measures the thickness of the ganglion cell complex, and if he detects it is getting thinner, he alerts the rheumatologist to a possible toxicity.

"Rheumatologists are now sending me new patients to measure that," he says.

Optometrists can also attract new patients if the ODs specialize in treating certain eye diseases that affect older Americans. From 1946 to 1964, 76 million babies were born in the United States. The oldest of these baby boomers are now in their late 60s, and AARP estimates that for the next 15 years about 8,000 boomers will turn 65 every day.

Overcoming technology barriers
Despite the numerous benefits cutting-edge technology can offer, a primary barrier for most optometrists is cost. Equipping a practice with the latest tools can be overwhelming. For example, an OCT machine now costs about $40,000 to $70,000, experts say.

"There's so much advancement going on right now, it makes your head spin," Dr. Paulsen says. "It does come down to the dollar. Is it a big bang for the patient or is it a new toy for you?"

Reimbursement can often play a large role in an optometrist's decision. Can the practice recoup the cost, or is there not yet a code for the device use? OCT reimbursement has dropped in half from when she bought the machine three years ago, but Dr. Roberts says the advantages for her patients and practice made the purchase worth it.

The AOA New Technology Committee recently evaluated a lens fluorescence biomicroscope that detects autofluorescence of the crystalline lens, which can aid in early detection of diabetes. The Food and Drug Administration approved the device in 2013, but insurance companies are not yet reimbursing for its use, Dr. Roberts says.

"It would be so much more reassuring if insurance would pay for preventive measures," she says. "I think that holds a lot of doctors back."

Financial options include seeking a loan, leasing equipment, buying used or manufacturer reconditioned machines, or taking advantage of "show discounts" offered by exhibitors at optometry conferences. In addition, manufacturers will often let providers take the equipment for a "test drive," trying it out for 30 days or so to see if it fits into their practice.

Dr. Paulsen says his challenge has been "getting the bank to give me the loan." To make his case, he makes sure he is prepared with organized and detailed financial statements, illustrating he has a sound practice.

Dr. Roberts' advice? Be patient and research. She spent 18 months looking into OCT equipment before buying the pricey device. She encourages other ODs to spend a lot of time asking exhibitors detailed questions and testing out equipment, while also talking to colleagues with similar practices about their experience and satisfaction with their new tools.

Once optometrists have done their homework and decided on which equipment is right for them at the right time, they may discover numerous benefits for their practice.

"There's a wealth of new, cool technology that will help you run effective and efficient patient care," Dr. Chaglasian says.