Article Date: 1/1/2012

Maximize Digital Fundus Photography
fundus photography

Maximize Digital Fundus Photography

You can get the most out of this investment by performing three steps.

Frank Celia, Contributing Editor

When digital fundus photography was first introduced, it was widely seen as an updated and convenient version of traditional photography — a way to document the retina through time minus the hassle of film development, and the photos could be stored on one's hard drive. Few eyecare practitioners thought it would have much use in on-the-spot posterior segment evaluation.

In addition, other imaging technologies, such as optical coherence tomography (OCT), which became available around the same time as digital fundus photography and included bells and whistles (e.g. three-dimensional, cross-sectional views of retinal layers, computer-assisted glaucoma progression analysis, etc.), perhaps made a photo you could save on a hard drive seem commonplace.

But, once clinicians began noticing that in certain circumstances digital photo could improve upon what could be seen, the digital fundus camera's worth as a diagnostic device rose substantially. A notable example of this occurred in an offshoot paper of the Ocular Hypertension Treatment Study, in which digital fundus photography outperformed visual exams by a considerable margin in aiding in the detection of optic disc hemorrhages.1

Digital fundus cameras can often help detect early signs of problems, such as retinal pigment epithelial changes, via their wide field of vision, provide an alternative view on patients who move around or blink too much and filter options that help highlight and contrast retinal structures difficult to distinguish via the naked eye, explains Murray Fingeret, O.D., chief of the optometry section at the Department of Veteran's Affairs Medical Center in Brooklyn, N.Y.

Robert M. Cole III, O.D., who practices privately in Bridgeton, N.J., adds, “Our care has improved because of [the digital fundus camera]. There are things that show up on a photograph that might easily be missed on a visual exam. And the return on investment is phenomenal. You can buy a nice fundus camera for around $25,000 to $30,000, even less sometimes.”

The digital fundus camera's utility goes beyond documentation and is affordable, making it a wise investment, say those interviewed. Yet, when using any diagnostic device, you want to maximize its use, in terms of both patient care and practice management, to ensure you get the most from your investment.

Here, your colleagues discuss how you can accomplish this with your digital fundus camera.

1 Delegate its use

Because digital fundus cameras are easy to master in a short period of time, you can and should delegate their operation to your technicians to maximize their use in terms of practice management, say those interviewed. In fact, many practices make their digital fundus cameras part of the pre-screening. This way, by the time the optometrist enters the exam room, the fundus image is already displayed on a computer screen.

Conversely, some practices only photograph patients who have known or potential posterior segment problems. In this strategy too, support staff can be integral. For instance, when Dr. Cole first implemented his camera, he says his approach to who got screened was somewhat haphazard. He says he would order one [a photograph] when he thought it necessary. But soon, he says, he discovered he was over-looking patients who would benefit from photos. Now, he says he directs his administrative and technical staff to flag patients scheduled for a photo screen before he sees them. This has improved both patient care and the camera's revenue stream, he says.

Delegation also benefits patient comfort, says Charles Lannom, O.D., who heads a private group practice in the Minneapolis suburb area.

“Patients can get uncomfortable being under intense lights for long periods of time during the visual exam,” he explains. For this reason, a digital photo is sometimes the best view that can be obtained for patients who have photophobia, in particular, he says.

2 Use it to provide patient education

Explaining one's condition verbally sans image can take up a lot of chair time due to the condition's complicated nature and the patient's lack of eyecare education, say those interviewed. Therefore, instead of using your digital fundus camera for just diagnostic and documentation purposes, maximize its use by also using the images to facilitate patient education, and save time.

“It's often difficult to explain to someone the minute details of the retinal vasculature,” notes Dr. Lannom. “But when I can show it to them [patients], it gives them a much greater appreciation of what I'm talking about.”

In the past, such talks usually involved referring to plastic models or images in a textbook. But cameras offer far more personalized examples, he says. “Most importantly, we are using the patient as our model or picture,” observes Dr. Lannom. “If there is pathology we are tracking, we can specifically relate to the patient's issue. Furthermore, we can zoom in on an area of concern— again unique to the patient.”

He adds that he also uses the photos to help prevent the onset of retinal disease in patients at risk, as doing so often prompts patient compliance to his recommendations. Dr. Lannom uses the example of a diabetic patient who's not yet displaying diabetic retinopathy: “I can show this patient why it's important to stay on their meds and watch their diet…� he says.

3 Use it as a screening tool for healthy patients

Another way you can maximize the use of your digital fundus camera to get the most from your investment on the device: Offer it to healthy patients, say those interviewed. The industry standard is that this is permissible as long as you disclose to the patient beforehand that the service falls outside the standard of care (i.e., is not medically necessary), requiring him to pay out of pocket for it. In other words, you must explain to the patient that neither Medicare nor other insurance carriers reimburse for this service, even if the screen uncovers pathology.

At the Brea, Calif., private practice of David G. Kirschen, O.D., Ph.D., new patients are given a consent form outlining the health benefits of the photo screen and asked to sign it if they wish to receive it, he says. But after patients become known to the practice, they are asked verbally at subsequent office visits whether they would like another photo taken. (See “Testing the Waters,” below.)

If you discover pathology via the screening process, educate the patient that Medicare will reimburse for the fundus photo at the follow-up appointment. To obtain this reimbursement, practitioners use a different camera setting, such as a higher pixel resolution than before, to get an enhanced view of the specific area, and, therefore, demonstrate that additional information was obtained. This differentiates it from the original service.

Dr. Lannom says roughly 20% to 25% of his patients opt for the out-of-pocket service, for which he charges $35. He adds that of these patients, he schedules about 5% for follow-up visits. The national average Medicare reimbursement payment for a fundus photography session is about $73, say published reports. Thus, between the screening exams and medical-surgical billing, the camera generates a considerable return on investment, he says.

“[The digital fundus camera] probably paid for itself within a year,” Dr. Lannom estimates. “Based on ability to generate income, it is probably one of our most affordable pieces of equipment.”

The digital fundus camera is an important adjunctive tool in the ongoing struggle to achieve the very height of quality patient care, say those interviewed. As a result, great efforts should be made to exploit this technology's proven strengths. The three steps outlined above illustrate how you can go about getting the most out of this investment. OM

Testing the Waters
Several years ago, when David G. Kirschen, O.D., Ph. D., decided to add a digital fundus camera to his practice, one of the big questions he faced was how much to charge for the service. He hit upon a unique strategy, which turned out very successful, he says.
“Before we got the camera, I interviewed the first 20 patients who came to my office,” he recalls. “I asked them: If I had the ability to take a picture of the back of your eye so that I wouldn't have to dilate you, how much would that be worth? Ten dollars? Twenty dollars? And on upwards. I began to get push back at about $40. So that's how I chose $38 as my original fee.”
That figure may not work for every practice, he cautions. Much depends on the practice's basic examination fee. That is, the camera fee must stay well below the exam fee in order to appear reasonable. But for his practice, the $38 fee worked. He says his patient-capture rate runs in the 70%-to-80% range.
Dr. Kirschen says all of his first-time patients receive a dilated fundus exam. Only on subsequent office visits are they are allowed to substitute a digital photo screen. If they choose to undergo one, they sign a consent form agreeing that neither Medicare nor other insurance carriers reimburse for this service. The consent form also outlines the screen's potential health benefits.
“After reading the consent form, about 15% of patients ask to speak to me about it. They ask if they really need it, and I explain the benefits,” he says. Many patients, especially ones with jobs to return to, are highly motivated to avoid dilation, he adds.

1. Budenz DL, Anderson DR, Feuer WJ, et al. Detection and prognostic significance of optic disc hemorrhages during the Ocular Hypertension Treatment Study. Ophthalmology, 2006 Dec;113 12):2137-2143.

Mr. Celia is a freelance medical writer based in the Philadelphia area. E-mail him at, or send comments to

Optometric Management, Volume: 47 , Issue: January 2012, page(s): 41 - 43