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The corneal topographer: an affordable tool for today’s contact lens practice
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With the considerable cost of corneal topographers today, many optometrists have wondered how they can afford to bring one into their practices. But as many are discovering, the more appropriate question might be: How can you not afford to have one?
While many topographers today cost more than $10,000, the investment is one well worth making, said Kenneth Lebow, OD, in solo private practice in Virginia Beach, Va. “More than a justifiable expense, it’s a profit center,” Dr. Lebow said. “If I can buy a piece of equipment and have it generate enough income to pay for itself in the first year, I’m ahead of the game.”
Creating a source of income
Whether through insurance reimbursement or a direct bill to the patient, the source of income for corneal topography will often pay for the initial investment as well as generate additional revenue. Billing the patient directly for use of the topographer is comparable to a physician requiring separate payment for doing blood work on a patient, Dr. Lebow said. “If you charge $15 per patient for corneal topography as an additional fee billed directly to the patient and you perform 100 contact lens exams in a month, you’re looking at a $1,500 a month income,” he said. “Multiply that by 12 months, and you have $18,000. If a unit costs you $14,000, in the first year alone, not only have you paid for the equipment, but you’ve made $4,000.”
Another way to recoup the cost is to raise the contact lens examination fee, said private practitioner Arthur A. Medina Jr., OD, who specializes in contact lenses and refractive surgery. He typically charges $35 for a diagnostic evaluation that includes a follow-up visit. “I have incorporated it into my initial contact lens evaluation,” he said. “If a patient comes in for something other than an initial contact lens fit, and something clinically indicates that I need to evaluate and document the shape of the cornea, then I’ll explain to the patient that this test costs $35, much like when a visual field or fundus photograph is indicated.”
Private practitioner Walter L. Choate Jr., OD, FAAO, said that, although there has been an increase in his contact lens service fee overall, purchasing a topographer for the purpose of generating income should not be the only motivation. An increase in patient referrals and a reduction in chair time are benefits as well, he said. “I would buy it because it would make my contact lens fitting better, and it would make me better able to do pre- and postoperative management of my surgical patients, both cataract and refractive,” he said. “If you’re doing a better job and you’re more efficient, then the instrument justifies its cost on its own.”
Topography for all contact lens patients
Dr. Lebow said that while topography assists in fitting all patients for contact lenses, it is especially useful in identifying unique corneal situations, such as keratoconus, corneal warpage and corneal distortion. “With regard to rigid gas-permeable lenses, many graduating practitioners have a minimum exposure to rigid lenses, and their skills in terms of designing rigid lenses might not be what practitioners’ skills were 20 years ago,” he said. “This technology facilitates the fitting of gas-permeable lenses. Carrying it a step further, if you have a lot of corneal astigmatism and you need a bi-toric fitting relationship, corneal topography simplifies the entire fitting relationship.”
Dr. Choate agreed that a topographer is more useful for the difficult-to-fit patient, which is the reason for an increase in topography fees for those patients. “I feel like we’re able to take on some more difficult fits, and we’re getting more referrals for those fits,” he said. “So we carved that fee out separately in cases of corneal disease, surgical and pre- and postop management and specialty contact lenses. For all other patients, it is generally considered part of our evaluation services. My fees always tend to be tailored to the difficulty of the fit. The easier the fit, the lower the evaluation fee, and the more difficult, the higher it will be.”
Demonstrating corneal irregularities
Dr. Medina said that he finds the machine effective in showing corneal irregularities. “It’s helpful because it gives you the power curvatures of the corneal surface so you can see decentrations and irregularities. You can even see micro-distortions,” he said. “For irregular corneas, the EyeSys (Premier System 2000, EyeSys/Premier, Irvine, Calif.) software program will give you a fluorescein pattern of a lens that you select with a particular base curve or diameter, but it will not design a fit for you.”
Rather, he said, the topographer serves as a system that provides data about the cornea so the contact lens fitter may use his or her experience to determine which lens would best suit the patient’s needs. “It gives me additional data,” he said. “It gives me the power, curvatures and displacement of those power curvatures onto the corneal surface. It is very valuable, clinically, to see the corneal shape in three dimensions. However, there is not a foolproof fitting system for abnormal eyes. Maybe your lens inventory doesn’t have a particular diameter or base curve; in that case, you’re able to simply place those parameters in the software package, and it will illustrate for you what the fluorescein pattern would look like. I have found that those are very accurate to help you identify the correct lens.”
Even when used on a contact lens wearer with simple spheres, a topographer can help detect abnormalities when they would not be noticeable otherwise, said Dr. Lebow, who cited the example of a patient who had been inappropriately wearing his lenses overnight. “I knew that simply by looking at the corneal topography reading,” he said. “What you couldn’t see in a slit-lamp examination was readily visible with corneal topography. When you compare that to the baseline reading, it was even more clearly evident.”
Review results with the patient
Sharing the results of the topography reading with the patient provides a better understanding of the state of the eyes and how to deal with any problems the exam may have uncovered. “I’m fortunate in that I have my corneal topographer hooked up so the image is present on the computer screen in every exam room,” said Dr. Lebow, who uses the Atlas system (Humphrey Systems, Dublin, Calif.) “The patient will take the topography exam in the pre-test area, and then all of this will be brought up on screen in the exam room. When I go in to examine and talk to the patient, I can then show him or her exactly what’s happening.”
While many practitioners delegate the task of corneal topography to members of the staff, Dr. Choate prefers to do it himself. “The staff can do it, but I use it as patient education time.”
He uses the Alcon Eye Map EH-290 (Alcon, Fort Worth, Texas). “I spend time talking with patients about their corneal health, and it gives me a way to do that. I like to sit in front of the instrument and show them how we use the technology.”
In addition to educating the patient on how the condition of the eye relates to the printout, an office topographer boosts patient confidence by showing that the practitioner has access to some of the latest eye care technology available, Dr. Medina added. “It shows that you are making recommendations from documentable graphics from instrumentation that we didn’t have access to in the past and that your treatment plan is related to the anatomical and physiological structure of the eye,” he said. “It gives the patient that security of being in a high-tech, information-based practice as opposed to simple trial and error. There is obviously still a significant amount of professional judgment involved, but it certainly gives you more information on which to base that clinical judgment.”
Number of topographers increasing
While ophthalmologists have had corneal topographers in their offices for many years to check for keratoconus and subclinical keratoconus before performing refractive surgery, many optometric offices are not home to these machines. However, that number may be on the upswing. “I think the number is steadily on the increase, but I still don’t think enough optometrists have them,” Dr. Lebow said. “Part of the reason is the cost of the unit.”
Dr. Medina agreed that, during the next few years, the number of ODs who opt for topographers will likely increase. “Within the next decade, the majority of optometrists will use topography technology in day-to-day optometric and primary care,” he said.
For that to happen, practitioners should realize their options to more than pay for what is initially an expensive investment. Dr. Lebow urged other optometrists to realize the potential of using a topographer in their office. “I think, in general, practitioners need not be fearful to charge an appropriate fee for the services they provide,” he said.
Even more important than a monetary profit, the topographer’s greatest value will be recognized after using it for a while, Dr. Choate stressed. “Eventually, maybe topography will get to the point where doctors will realize that it’s making their job a little bit easier on them,” he said. “That’s where the true profitability comes in.”
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For Your Information:
- Walter L. Choate Jr., OD, FAAO, may be contacted at 607 Due West Ave., Ste. 111, Madison, TN 37115; (615) 868-4262; fax: (615) 860-2016; wchoate1@aol.com. Dr. Choate has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Kenneth Lebow, OD, may be reached at 345 Edwin Dr., Virginia Beach, VA 23462; (757) 497-5555; fax: (757) 499-2636. Dr. Lebow did not disclose if he had a direct financial interest in the products mentioned in this article or if he is a paid consultant for any companies mentioned.
- Arthur A. Medina Jr., OD, may be reached at 1110 McCullough St., San Antonio, TX 78212; (210) 225-4141; fax: (210) 229-9400; e-mail: artmedina@aol.com. Dr. Medina has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.