photography

A View on Anterior Segment Systems

Consider these five criteria before buying or updating your current camera.

Michael Mayers, O.D., F.A.A.O., Powell, Ohio

Because anterior segment photography enables us to clearly paint a picture for the patient regarding his ocular health's status, it is a valuable tool to achieve patient compliance to follow-up appointments and/or our recommended treatment. In addition, employing this technology can enhance your practice's image, as it provides a “wow” experience for your patients. (This leads to an increase in referrals.) If you're considering incorporating a new anterior segment system into your office or updating your current one, consider the following five criteria before making a purchase:

1. System types

Anterior segment systems fall into three categories:

► Slit lamp bracket adapters ($350 to $800). The adapter contains a platform on which your consumer digital camera rests. Specifically, it has an ocular designed so you can slide out the digital camera manufacturer's ocular and slide in the ocular designed to perform digital photography.

► Slit lamp adapter camera system with beam splitter ($5,000 to $8,000). To use this device, you unscrew your ocular ring from the slit lamp's main housing and then screw the oculars back into the slit lamp adapter.

► Anterior segment system with incorporated digital cameras ($10,000 to $50,000). The manufacturers of these complete systems design the digital camera exactly to the specifications of the slit lamp for different illuminations and filter settings.

Manufacturers of these systems and slit lamp adapter systems include imaging software that capture still images or live video. (Keep in mind that many capture software programs are designed to operate on a Microsoft Windows-based platform.)

Polymegathism and pleomorphism of the corneal endothelial cells in an extended hydrogel wearer, as seen through a complete anterior segment system.

2. EHR compatibility

Once the image is captured, it gets stored in proprietary capture software installed on your desktop computer. Then, the capture software must ‘talk’ to your EHR, or vice versa, to recognize the image you want displayed in the patient's electronic chart. Manufacturers use the term “The handoff” to describe the communication between the software and EHR.

To determine whether the system in which you're interested may integrate with your EHR, check the Integrating the Healthcare Enterprise (IHE) website (www.IHE.net). IHE promotes the coordinated use of established standards in EHR, such as Digital Imaging and Communications in Medicine (DICOM) and Health Level Seven International (HL7). DICOM is a standard platform for handling, storing, printing, transmitting and viewing images with other software via a network communication protocol. If equipment or software vendors are DICOM approved, this means they have met HIPAA compliance standards to communicate with other software programs. HL7 is a not-for-profit, ANSI-accredited standards-developing organization dedicated to providing a framework and related standards for the exchange, integration, sharing and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services. If your slit lamp photography software system and your EHR system are listed on the IHE site, the chances that they'll work together seamlessly increase.

3. Return on investment

Performing medically necessary anterior slit lamp ocular photography (92285) has a national Medicare reimbursement of $41.97 bilaterally ($30.63 technical component/$11.34 professional component). (“Medically necessity” may be defined as photo-documentation procedures that record the progression or lack of progression of an eye condition, such as corneal neovascularization, or track the treatment of an ongoing condition, such as a corneal ulcer). If you were to buy a $15,000 system and your lease payment through three years is $6,000/yr, you would have to perform roughly 144 procedures a year, or 12 per month, to break even (five-year lease options are also available to lower your payment per month).

That said, you should also check with your local Medicare and non-Medicare insurance carriers to determine their protocol for medically necessary conditions that justify slit lamp photography. For instance, if one or more of your carriers allows slit lamp photography for contact lens patients, think about your intangible return on investment here. Specifically, viewing their own corneal neovascularization, papillae on their tarsal plate or lens deposits on an overworn soft lens would likely compel a patient to switch to a more breathable lens or daily disposable lens, thus increasing contact lens profitability in your practice.

4. The “must-haves”

Although many different systems exist, I've found that most eyecare practitioners employ the complete systems (e.g. the slit lamp and camera paired together) (starting at $10,000). (See “Slit Lamp Manufacturers,” at the end.) Therefore, here are the “must-haves” for these systems:

► A fully loaded camera. Be sure the camera controls focus, aperture and also has a background illumination light. This is to aid in dimly lit photography. Another nice feature is a diffuser to prevent washout, and a builtin Wrattan filter so you don't have to hold one in front of the housing to accurately take your picture. All these features will save you or your staff time and frustration when capturing that perfect picture.

► Lux range. Be sure to ask the anterior segment imaging system vendor whether the system can handle bright illumination settings (broad beam for taking a scleral nevus picture) to low illumination settings (corneal staining picture). You want a system that can capture clear images in a very low lux environment to prevent image washout during photography/videography. (See “The Megapixel Myth,” at the end.)

► Frames per second (FPS). The higher the FPS, the quicker the camera will catch the picture at the exact moment you hit the slit lamp's capture button. That said, ask the anterior segment imaging system vendor whether the system is an “analog” or “non-digital” system. Although analog systems offer a high FPS, the picture resolution is equivalent to roughly 1.4MP. This is because the system converts the analog picture into a digital picture via a processing box. A true digital slit lamp camera, however, captures the digital image right on the chip inside the camera and does all the necessary picture corrections to make it “pop” to the observer. These corrections within the processing unit of the camera are white balance and gamma correction.

► Multiple layers of anti-reflection lens coatings. Anterior segment imaging systems that have multiple layers of antireflection coatings on their lenses yield an incredible depth of focus for anterior ocular imaging.

5. Practice incorporation

To lessen the effect an anterior segment imaging system can have on your office flow, be sure the system is easy to use and learn, makes handing off the software image to your EHR system easy and enables you to write your professional component directly in the patient's EHR, and that the manufacturer provides accessible IT support.

By considering these five issues, you'll be armed with the education you need to make the best purchase for your practice and your patients. OM

A special thanks to Matthew Wess of Veatch Ophthalmic Instruments for his knowledge and information in this field.

Dr. Mayers has served as a National Board Examiner and has lectured nationally on various topics. He is a fellow of the American Academy of Optometry and conducts clinical studies on contact lenses, contact lens solutions and dry eye. He practices in Powell, Ohio, where he founded Mayers Eye Solutions LLC. E-mail him at mayersod@gmail.com, or send comments to optometricmanagement@gmail.com.