Article Date: 10/1/2003

Essential Tools for the Disease Practice

If you want to carve a niche in ocular disease management, then consider these indispensible tools.
BY ALBERT M. MORIER, O.D., Guilderland, N.Y.

Illustration by Patrick Gnan

I've been in practice since 1982 and have reaped many rewards by being able to treat ocular disease. Specialized equipment such as the digital retina camera and the nerve fiber layer analyzer aren't a financial drain on the practice, they're income generators, which help us with cash flow when income from the optical dispensary isn't up to par.

About a year ago, I told a retinal specialist friend of mine how delighted I was with my retinal camera both clinically and financially and he replied, "Al, it's not a bad thing to make money while providing better care to your patients." His succinct comment encapsulates the direction that all our practices should take.

Heading in a better direction

The technology available to us for diagnosing and treating ocular disease is plentiful and increasing. Despite these growing options, some practitioners are slow to evolve. If this describes you, don't be afraid of high technology. I've purchased several tools over the past several years that have aided my practice on several levels. I'll discuss these tools and how they've helped my practices in the following pages.

The corneal topographer

My corneal topographer has made fitting keratoconic and post-PK patients much easier as well as scientific. Patients who have reduced acuity from contact lens overwear are easily diagnosed and easily educated as to the etiology of their reduced acuity. These particular patients have abnormal conditions of the eye, which we as practitioners must treat just as we must any disease.

The printout clearly shows the damage to the patient and we all know that a patient who truly understands their condition is a much easier and more compliant patient to treat.

Optic nerve drusen.

The digital camera

Our next equipment purchasing decision was a little more difficult to make because of the cost. I had a company come in and set up its digital retinal camera with the camera in the special testing room and monitors in each exam room. Fortunately, my consternation over the purchase was unfounded, as the camera always produces a positive cash flow.

I have an anterior segment digital camera on my slit lamp, which I use to document anterior segment ocular disease. I also use the digital camera with cataract patients and set up the beam in retroillumination to show the size, density and position of their cataracts. Patients appreciate what the digital camera shows and they have a much greater understanding of what a cataract is.

I demonstrated this to a 65-year-old gentleman and he said, "This must be the machine my daughter told me about. That's why I came here for my eye exam." (And I wondered why he travelled 30 miles to come to my office.) Thus, this tool provides both direct and indirect benefits to my practice.

More importantly, the level of care I provide to patients who have diabetes, age-related macular degeneration, macular holes, ocular nevi and glaucoma has increased dramatically.

Again, the increased ability to educate the patient about their condition is tremendous. This week I did a follow up on a patient who presented three months ago with mild background diabetic retinopathy. I wanted a short-term follow up to gauge how quickly the glaucoma might be progressing. Surprisingly, there was a significant increase in the macula of the right eye and the software allowed me to put magnified images of the macula from three months ago and the new one side by side on the monitor. The increased dot hemmorhages was apparent to both myself and the patient.

I e-mailed the image to the patient's retina specialist and included the image in the body of a letter to her primary care physician. This beats putting pen dots on her exam form (as I've been doing for 20 years).

Glaucomatous disc of a 28-year-old woman.

Analyzing the NFL

Interestingly, my next decision to invest in equipment came easier the second time around. I chose a retinal nerve fiber layer analyzer based on its database and its portability, which allows me to use it in both of my offices.

A great way to monitor glaucoma. The instrument measures the birefringence of the retinal nerve fiber layer as an indicator of its thickness. It helps in the early diagnosis of glaucoma as well as helping to monitor the progression of glaucoma in patients who are under- going treatment. It's not meant to replace the information you get from visual fields, but it's a great adjunct.

Easier for patients. When using the retinal nerve fiber layer analyzer, the patient is seated at the instrument for less than five minutes and must maintain fixation for four one-second scans of the disc. The instrument doesn't require any patient responses as in the visual field tests. We all know how difficult it sometimes is to diagnose glaucoma.

That's why having more information, which retinal nerve fiber layer analyzers provide, is a great help. Even with patients whose results are borderline, you're still at a much earlier stage of the condition than you would be with just the visual field information. My patients love the instrument and often remark how much easier it is than the visual field test.

The pachymeter

Another tool that's rapidly becoming as important in your office as the refractor is the pachymeter. Fortunately, pachymeters are small, light, portable and relatively inexpensive. A good unit that you can use between two exam rooms or two offices costs between $2,500 and $3,200.

Just look at the study findings. The Ocular Hypertension Treatment Study (OHTS) (Gordon et. al, Archives of Ophthalmology, June 2002) showed that in patients with risk factors (e.g., thinner central corneal thickness), medical treatment decreased the onset of glaucoma by 50%.

A study by Dr. Silvia Orengo-Nania of the Houston Veterans Medical Affairs in Texas (Archives of Ophthalmology 2001;119:23-27) showed that blacks tended to have thinner corneas than did whites. Hence, it's important to factor in central corneal thickness when you decide whether to treat a glaucoma patient.

How it will help you. Pachymetry is appropriate in other conditions such as Fuch's dystrophy, post PK corneal rejection, corneal edema and patients who have cup-to-disc ratios of more than .3.

Pachymeters also have peripheral effects. Not only do my associates, my staff and I enjoy using them on patients but the patients are impressed with the equipment. And these tools certainly separate us from the local commercial competitors.

Congenital hypertrophy of the retinal pigment epithelium which bears watching

Punctal plugs and more

Ocular surface disease is common in our practices but unfortunately, it often goes unattended. Inexpensive tools we all should have in our offices are jeweler's forceps and a selection of collagen inserts ranging in size from .2 mm to .5 mm for the diagnosis of aqueous deficient dry eye.

Collagen inserts. These inserts lasts two to four days before they dissolve. Optometrists see the vast majority of contact lens patients yet greatly underuse this procedure. Contact lens patients who describe decreased wearing times are prime candidates for collagen trials.

Extended duration plugs allow occlusion for as long as two months. This duration is excellent for both pre- and post-LASIK patients.

Silicone plugs. These nondissolvable plugs are designed to stay implanted for a lifetime but allow you to remove them if needed.

Expand your scope

We're lucky to live in these interesting times with its constantly advancing technology. It's an exciting period in which to practice if we embrace and put this technology to good use. These new technologies will help make diagnosing many of the common ocular diseases easier. And they make going to the office invigorating and fun.

True, our optical dispensaries produce significant cash flow but expanding and developing the disease side of your practice only makes for a more diversified and stronger practice. Take advantage of the tools that are available to expand your ocular disease practice and see how your practice benefits.

Dr. Morier is in private practice in Albany and Schenectady, N.Y. He's also a clinical instructor in clinical ophthalmology at Albany Medical College.


Important Tools for Clinical Practice

Dry Eye
Schirmer strips or Zone Quick Threads, collagen plugs (short and long acting), fluorescein and Lissamine Green strips, punctal dilator, good listening skills

Two methods to check IOP (e.g., NCT, Goldmann), tonopen, threshold visual fields, frequency doubling fields, nerve fiber layer analyzer, gonio prisms (three mirror and four mirror), digital retinal image capture or stereo retinal camera, pachymeter, retinal thickness analyzer

Retinal Disease
digital retinal image capture, binocular indirect ophthalmoscope, direct ophthalmoscope, +78D or +90D hand lenses, contact laser/diagnostic fundus lens.

Corneal Disease
slit lamp keratometer (manual or auto), anterior  segment digital camera, pachymeter


Optometric Management, Issue: October 2003