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 By Neil B. Gailmard, OD, MBA, FAAO, Editor April 29, 2009 - Tip #377 
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Instruments, Part 2

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Last week I discussed instrument purchases that have a direct return on investment and how to calculate projections for usage and revenue. Today, let's focus on specific instruments that offer a great bang for the buck even though the return on investment is indirect.

Here are some instruments that pique my interest:

Computerized refraction systems

These automated phoroptors have made great advancements in the past few years and they now truly offer the best technology available for subjective refraction. This is not a question of is it as good as a traditional phoroptor because it works exactly the same way, with real lenses, prisms and a Jackson Cross Cylinder. Of course the lenses are changed and turned electronically instead of mechanically, so lens choices are precise and fast. The lenses and the eye chart are manipulated by using an electronic control panel.

There are many advanced features with these systems that make them better than phoroptors. One example is the simultaneous display of a target during the cylinder test for axis and power, which allows the patient to see both choices at the same time. This eliminates having to remember the sharpness from one flip to the other and you don't have to repeat the choices. Another feature is the ability to compare the old eyeglass prescription with the new one by just touching one button. The integrated electronic acuity display offers many more types of eye charts and it can be programmed to your preferred sequence. It is fast and impressive!

Many of these systems are bought with the intention that the optometrist will use them, but I think we should also evaluate the potential for these instruments to be used by technicians under a doctor's supervision. I know the concept of technician refraction has been controversial in the past, but we must continue to seek ways to increase efficiency in clinical practice. As technology improves, old ideas must be constantly challenged. The subjective refraction is one of the most time-consuming tests we perform, so any savings there could be significant. Keep in mind that to delegate refraction is not the same as delegating prescribing. The former is data collection and the latter is a professional skill that takes years of experience and knowledge.

I'm studying the concept of technician refraction carefully and I'll bring you more in the future. Always follow the laws of the state or jurisdiction where you practice.

Corneal topography

Many practices still do not have a corneal topographer, but I think it is an extremely useful instrument that I would hate be without. Much more than a device that is used in managing keratoconus and pre- and post-op refractive surgery, I use it on every contact lens patient every year.

The topographer provides valuable data for monitoring corneal health and integrity. It is part of the annual contact lens evaluation that I perform in addition to the routine annual eye exam. We charge an additional fee for the contact lens evaluation and this is typically not covered by insurance (or part of the insurance allowance is applied to this fee). Providing advanced technology like this justifies a higher contact lens evaluation fee.

I strongly recommend using a topographer that is fully networkable, so a technician can perform the procedure in pretesting and the images are displayed in the exam room for the doctor to review. This creates a perfect opportunity for patient education about the shape of the cornea.

Automated lensometry

I often say that if an OD performed lensometry as often as his or her staff, he would own the best autolensmeter on the market. Lensometry is a tedious test that is done every day on every pair of glasses that is received from your lab, plus the glasses of every new patient seen. It can be challenging for newly- trained technicians to perform perfectly. With all the automation we see in other pretests, lensometry is the biggest obstacle to training new employees.

My experience with most autolensmeters has not been that great if you move beyond single vision lenses. I found that even in my hands, trying to neutralize a pair of progressive lenses was difficult. If I would measure the same pair of glasses twice in a row, I would get two different values. I need to know a patient's habitual Rx exactly in order to judge subtle acuity variances and to prescribe properly.

Fortunately, there is a new generation of automated lensmeters that are very easy, but accurate and repeatable. Some models work by just setting the glasses in a tray and pushing a button. Ask your instrument dealer about the new entries to this market.

Let me know your interest and questions about instrumentation for your practice.

Best wishes for continued success,

Read Past Tips Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week

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Send questions and comments to neil@gailmard.com.

Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.
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