I'm beginning to think that corneal topography does not get enough respect. There are still many eye care practitioners who don't own a topographer and many who have one but don't utilize it on a regular basis.

I'm not quite sure why interest in corneal topography is lower than other instruments, such as retinal cameras or nerve fiber analyzers, but I have some suspicions and I think many practitioners are missing the boat. While topographical imaging is not a necessity for prescribing a contact lens or for monitoring ongoing contact lens wear, I find the data provides many clinical advantages. Contact lens care is a large, important part of our practices and I'm interested in providing the highest level of service, not a basic level.

Furthermore, contrary to popular opinion, a corneal topographer can generate significant revenue for a practice. While that may not be the primary reason for using the device, I'm not ashamed of earning higher fees by providing a higher level of care. I think the misunderstanding about generating revenue from topography stems from the realization that it may not always be billable to medical insurance plans. It's true that insurance coverage varies widely for corneal topography and one would need a supported corneal diagnosis if the procedure were covered at all, but it's a mistake to assume that billing and coding is the only way to earn fees in eye care. Contact lens care is typically a non-covered service on medical plans and it is often covered by an allowance on vision plans. That makes it a private pay service, which is still the best kind.

The clinical advantages

Corneal topography is the premier technique to monitor corneal shape and integrity. We were all taught to use a keratometer for this purpose, but that is like comparing an automobile to a skate board. I capture and review corneal maps for all contact lens patients at every annual eye exam. I'll admit that analysis of the topographical images is usually very quick, but that's the beauty of it. I can see at a glance what is going on and I can assimilate a great deal of information. Granted, the corneas of most contact lens wearers are within normal limits, but that does not reduce the value of the test. Most fundus photos are normal also, but we still gain a huge amount of information from them.

Patient education

Nothing has helped me explain astigmatism, localized corneal edema, or other corneal abnormalities better then showing a person a 3D image (not just the color map) of his own cornea. Reviewing the corneal maps in front of the patient sets your contact lens services apart from the average practice. Patients realize they are getting the best care possible because they see you use the latest technology for contact lens fitting and management. I often say something like, "We take these computerized images of your cornea every year so I can monitor the shape and curvature of the front of your eye where the lens sits. This data helps me check the fit of your contacts while monitoring the health of your corneas." I may go on to comment on some unique factor or just conclude that all is normal and looks good.

The financial aspects

I rarely charge a separate fee for corneal topography in my practice and it is even rarer for me to try to bill an insurance plan for it. I simply include the procedure as part of my initial contact lens fitting service and it is also included in the ongoing contact lens evaluations that are performed yearly along with a comprehensive eye exam. I charge a separate fee for contact lens fittings and for contact lens evaluations; they are itemized in addition to the eye exam fee. Contact lens fitting fees and evaluation fees cover additional tests that are only performed on contact lens wearers. Corneal topography is one of those tests. I can't tell you how much to charge for contact lens evaluations or fittings, but I think most practitioners don't charge enough. It's elementary to conclude that doctors who include topography as part of their services would be justified in charging a higher fee than those who don't.

Features to look for in a topographer

• Easy for technicians to operate. I don't want a special instrument that is so tricky to use that only the doctor can do it. This leads me to prefer table-mounted instruments that have a chin rest and head rest for the patient and operate with a joystick and a video monitor for alignment. It should be easy to line up and snap an image.
• Easy to network. I want to display the corneal maps on a flat screen monitor on the desk in each exam room so the doctor can review the images in front of the patient. This same computer and monitor would also be used to view retinal photos. Some topographers are difficult to network or require multiple licensing fees. Multiple-use instruments, like autorefractors that have a simple topographer incorporated may not be network ready.
• A topographer that has a separate computer; not integrated. I like to see the measuring part of an automated instrument plug into any generic PC or laptop and have the software provided separately. This allows you to not overpay for a built-in computer that is too slow from the beginning and it allows you to service or replace the computer when that part of the system fails. All computers fail eventually, often sooner than we like.