equipment overview
What's New in the Lane?
Before replacing traditional diagnostic equipment, consider all the information you need to make the best buying decision.
BY SHELDON H. KREDA, O.D., F.A.A.O., Lauderhill, Fla.

Make my life easier, make my job easier -- give me a hand in the exam room. Take the phoroptor for instance. Here's a relic that should have seen its day a long time ago. Considering other high-tech advances around the office, you'd think such an essential tool would get a bit more attention.

Phoroptors have undergone some recent face lifts, but the addition of lights and digital controls has done little to change the examination process. I need a better way to perform a subjective refraction. Instruments that improve my posture while I ask, "Which is better, 1 or 2?" just don't cut it as a major leap forward. I expect more.

ILLUSTRATION BY MARK HEINE

By now I'd expect a compact, computerized examination system capable of objective and subjective refractions (distance and near), binocular vision tests, color vision and screening fields. All this should be rolled up into a single instrument -- like a Swiss Army Knife for eye care. An instrument that would perform these tests would not only make my life easier, but would also ease patient anxiety and frustration (I'm certain the Jackson cross-cylinder test is a direct violation of the Geneva convention).

There must be an easier solution given the technology of today. Humphrey made a subjective refraction system back in the 1970s. It was a technological marvel for the time (considering it pre-dated the microprocessor), but it was abandoned at the dawn of the autorefractor. If developed to its full potential, the impact of this innovative technology on modern practice may have been enormous.

Subjective refraction aside, it may be time for you to make some other equipment additions and changes. Consider the following factors when assessing a particular piece of equipment:

• cost
• return on investment
• patient care benefits
• operating information
• dimensions.

In the following examples, I apply these factors to pachym-etry, perimetry and ophthalmoscopy to make a more informed purchase decision. I recommend that you use the same approach when considering the replacement of any piece of lane equipment.

PACHYMETRY

Pachymeters are an essential instrument to practice optometry. The American Academy of Ophthalmology considers pachymetry the standard of care to diagnose and treat glaucoma. This is a new standard to which optometry must comply. Therefore, if you are to diagnose or treat this disease, you must have access to a pachymeter.

You can select many brands and models ranging in different features, accuracy, price, ease of use and portability. I chose a battery-operated model, which allows testing within any of our exam rooms.

Cost: The cost is modest, considering many of today's high-price optometric necessities. Less than $3,000 buys a quality instrument. At this price, financing shouldn't be a consideration.

Return on investment: Insurance pays about $28 per patient per lifetime. Therefore, less than 100 patients would cover the purchase price. If you only used it once a day, you'd be making money after just a few months.

Patient care benefits: Based on the results from the recent ocular hypertension study (OHTS), we test all glaucoma suspects and glaucoma patients.

Pachymetry is extremely useful for laser-assisted in situ keratomileusis (LASIK) pre-op workups because it helps determine an individual's candidacy before referral to the surgical center. Our pachymeter measures the thickness of the corneal epithelium. It's also useful in evaluating contact lens patients for corneal edema. We even use it to test patients who have corneal dystrophies and degenerations such as Fuch's dystrophy or keratoconus.

Operating information: This instrument is easy to use and it's simple to teach technicians how to use it. I have my tech perform the test (which takes less than two minutes) most of the time.

Dimensions: You can take pachymeters anywhere. Place nonportable units on tables or shelves in exam or testing rooms. Store portable units anywhere while not in use.

PERIMETRY

If you have one of those big old clunkers of a perimeter, then consider an upgrade. Perimeters have become compact and portable. These scaled-down workhorses have shrunk the cost, space and time needed to perform a visual field examination. Insurance pays for a wide variety of ocular diagnoses, so providing better care for your patients is also profitable.

Cost: If you use your own laptop or PC, then you can purchase a perimeter for less than $6,500. Most offices have a computer that runs their office management system. Some even have their computers networked with workstations in each exam room and in the tech room.

Using existing equipment allows you to store fields on your computer in the room with the perimeter and then later bring up the field for viewing at another workstation.

There's no additional license fees to add software to workstations. This allows us to eliminate hard copies and to review test results directly from any computer in the office. Not only do we save on printing, but I get to use the powerful diagnostic tools built into the software.

Return on investment: Insurance pays about $58 per test (depending on the reimbursement profile in your area). Many offices screen all patients, adding a $15 fee to their comprehensive exam. The reimbursement per patient is even higher when you factor in the subsequent tests necessary to follow most pathologies. You can lease these instruments for about $200 per month. Use it only once a week and you're in the black.

Patient care benefits: These instruments allow both screening or comprehensive visual field examination. As previously mentioned, many doctors screen all patients annually. Threshold capabilities include the typical 30-2, 24-2 and 10-2 exams, so we test all the usual suspects: Glaucoma, neurological, optic nerve, retinal and macular. That's enough to keep this instrument humming and dust free.

Operating information: Perimeters are computer controlled and have intuitive software. This simplified operation allows your technician to take charge. We schedule our visual fields in blocks for our tech. The results are then stored on the computer for analysis at a later time, thereby preventing interruptions in our normal schedule.

Dimensions: For offices that lack the space for a full-size perimeter, your time has come. You can tuck these instruments away in existing exam or contact lens rooms and bring them out on demand. Doctors who have multiple locations can take further advantage of their light weight and portability by sharing the instrument between offices.

OPHTHALMOSCOPY

Apply this same process to all categories of equipment, including wavefront analyzers, corneal topographers, refraction systems, digital imagers, and nerve fiber and optic nerve analyzers. It's also important to stay ahead of the latest advances, even with the most traditional pieces. For example, upgrading your binocular indirect or handheld ophthalmoscope is probably the last thing on your mind, but think again.

Binocular indirect ophthalmoscopes have become lighter and more functional. Small pupil instruments allow examination of patients who dilate poorly. High magnification accessories allow viewing the fundus in greater detail. Better optics and diffusers have afforded enhanced image quality and wider field. Video capability aids in documentation and demonstration, which can be a nice practice builder.

Even the direct ophthalmoscope hasn't escaped a modern transformation. The old handheld ophthalmoscope is like an old wooden tennis racquet -- outdated. One new panoramic ophthalmoscope offers five times the viewing area. It's simple to use and provides some well-appreciated space between you and the patient. It's a comparatively minor investment for such a frequently used instrument.

Invest in your future

Most of us weekend warriors think nothing of buying a new racquet or club, but we scrimp on the tools of our trade.

An investment in the technology is always a smart move. Anything that makes my work better and easier is well worth it.

Dr. Kreda practices in a primary care setting in Lauderhill, Fla. He's a frequent lecturer and author. You can contact him at eyerx@peoplepc.com.