Practitioners find corneal topography valuable for all patients

Issue: July 1998

BySusan E. Marren, OD FAAO

ST. CLOUD, Minn. - Although most new technology involves significant financial investment, corneal topographers are a valuable addition to optometrists' practices. Even former skeptics agree.

Burt Dubow, OD, FAAO, in practice here, was resistant to owning a corneal topographer at first. "My first thought was, `Why do I want to spend so much money on a keratometer that makes me a pretty picture?'" he said. He finally chose to acquire one when he began seeing pre- and postoperative refractive surgery patients. Now, he says he had "no clue how useful it would prove to be" in his practice.

Dennis W. Kennedy, OD, from Westland, Mich., said, "I first started using the corneal topographer while working at TLC The Laser Center. I quickly realized that corneal topography was an essential tool in monitoring the healing patterns of the PRK patient. Once I began to follow my patients in my own office I missed not having topography results to assist me. It was primarily for that reason that I decided to purchase a corneal topographer. It did not take long for me to realize the importance of topography with regards to my contact lens patients. What better tool to evaluate the integrity of the corneal surface? I have now included corneal topography as a routine part of my comprehensive evaluation."

Monitoring corneal health

Both doctors find they use the corneal topographer for reasons other than they expected. "We offer topography as an optional test, such as fundus photography, to screen corneal health," said Dr. Dubow. "We use topography on all contact lens patients prior to or during fitting and then annually thereafter to monitor corneal health. We use it pre- and postoperatively for refractive surgery patients and pre- and post-cataract surgery and any other corneal surgery.

"We quickly instituted the corneal health screen as an option for all patients because we recognized that it truly was going to become the standard of care for corneal evaluation," he continued. "We were getting information from topography that we were getting from no other source."

What kind of information does it provide? According to Dr. Dubow, you get a vital overview of the corneal health.

"I use the topographer on every patient who comes into my practice because it gives me information on one of the three major components of vision," said Dr. Kennedy. "I can see the retina and the lens, but I can't see the cornea that well. Corneal topography gives me a clue to the entire surface of the cornea."

Provides peace of mind

"I use it mainly to show patients how their corneas are recovering following surgery," Dr. Kennedy said. "This is such an emotional procedure. Visual recovery often takes several weeks, sometimes months. Patients are nervous about whether or not they made a mistake in deciding to have the procedure done. Their vision isn't the way they thought it would be as soon as they thought it would.

"But when they see the topography each time they come in and they see an improvement in the uniformity of the cornea, it is a real tangible reassurance," Dr. Kennedy continued. "I would not want to follow these patients without a topography system. It also helps me see islands and other conditions that may indicate the patient needs to go back to the surgeon."

Use for contact lens patients

"A few years after we got the topographer, we discovered its value in designing and prescribing rigid gas-permeable lenses," said Dr. Dubow. "We almost always design them on the topographer and order them from that." At his office, Dr. Dubow and his colleagues use the fluorescein-trial software to order contact lenses.

Dr. Kennedy uses his topographer more for encouraging good compliance with cleaning regimens and wearing schedules than for fitting contact lenses. "You can tell patients about the corneal changes from noncompliance, but if they're wearing the lenses all day long and their vision is halfway decent, they don't hear you. I show them their map and a map of a normal cornea, point out the irregularities and explain the potential complications. When they see that, they tend to be compliant," he said.

Mark Shust, OD, FIOS, from Philadelphia, bought a corneal topographer a few years ago for orthokeratology. Now, he uses it for all contact lens patients. "The map is especially helpful for identifying corneal eccentricity and how rapidly the cornea flattens from the center out," he said. "In many cases, the curvature in the mid-peripheral and peripheral cornea has a great impact on the fit.

"I do a significant amount of orthokeratology, and it is virtually impossible to do it without a topographer," Dr. Shust continued. "In ortho-K, it helps establish who are better candidates because ortho-K tends to work better in patients with corneal eccentricity. This helps me to intelligently counsel these patients."

For practice management

Dr. Dubow is pleased with the way his EyeSys corneal topographer appears to his patients. "It's one of the most impressive tests you can do. Patients get excited about it. The value to the practice is incredible," he said.

Dr. Kennedy said, "I have set a new standard: I sit down with my contact lens patients at the fitting and show them their map and explain that we will do this yearly to follow the progress of their corneas. If they go to another doctor who doesn't provide this service, they will notice."

Should all OD's have one? "Absolutely," said Dr. Kennedy. "When I first started fitting contact lenses, the standard of care was a Burton lamp. Now, the standard of care is a slit lamp. Today, the standard of care for corneal curvature is the keratometer, but I believe that tomorrow the standard of care will be the corneal topographer."

How do you choose?

Dr. Shust chose a Humphrey topographer that was loaned to him by the company for a few months. Dr. Dubow feels he was not very astute when he purchased one, but feels he was lucky because he chose one that he has since determined is very good. "I happened to choose the EyeSys. I still feel the EyeSys is best overall. Software, ease of incorporation into your practice in terms of space required and company support are critical. Technicians need to be able to handle the instrument. It is also important that the company plans to develop further ideas," he said.

How do you charge?

"From a financial standpoint," Dr. Shust said, "most practices can justify the cost of the corneal topographer primarily because it allows for increased revenues. You can build the fee for topography into your regular fee or charge separately. I think, especially for the contact lens population, these services tend to be very useful.

"I have been using a separate fee for corneal topography for fitting contact lens patients with very little resistance," he continued. "I think I will simply incorporate the topography fee into my overall fees; it is useful enough that the doctor rather than the patient should decide whether or not to use it."

Dr. Kennedy added, "I charge one fee for all comprehensive examinations, which includes the cost of the corneal topography. I increased my contact lens evaluation fee by $10 and that more than covers what I pay for my corneal topographer. I feel the doctor should make the decision about whether or not corneal topography needs to be done; this should not be a patient option."

Dr. Kennedy said he cannot imagine working without corneal topography.

For Your Information:

Burt Dubow, OD, FAAO, may be reached at P.O. Box 7654, St. Cloud, MN 56302-7654; (320) 253-0365; fax: (320) 253-9401; e-mail: Burtdubow@aol.com. At one time, Dr. Dubow worked as a consultant to EyeSys. He no longer has any financial or consulting relationships.

Dennis W. Kennedy, OD, may be reached at Vision Associates of Westland, 38979 Cherry Hill Rd., Westland, MI 48186; (734) 326-2160; fax: (734) 326-9678; e-mail: DWKTLC@aol.com. Dr. Kennedy has no direct financial interest in any products mentioned in this article, and he is a paid consultant for TLC The Laser Center.

Mark Shust, OD, FIOS, may be reached at Fox Chase Eye Associates, 7801 Hasbrook Avenue, Philadelphia, PA 19111; (215) 745-8300; fax: (215) 342-1111; e-mail: MARKS@blackboard.com. Dr. Shust has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any company mentioned.

Susan E. Marren, OD, FAAO, can be reached at 503 Fourth Street, Riverton, NJ 08077; e-mail: Smarren@aol.com. Dr. Marren has no direct financial interest in the products mentioned in this article, nor is she a paid consultant for any company mentioned.