A total of 90% of people said they want a doctor who uses the latest technology, according to a 2022 OnePoll and ModMed survey on what patients desire in a doctor. It’s no surprise, then, that this year’s “Optometric Management Reader’s Survey” included the top question, “what specific technologies should comprise the primary care OD’s practice in 2024?”

Through 40 years in practice and in staying up to date on the latest advancements in technology, I have purchased devices that:

1. facilitate the standard of care.
2. provide efficiency.
3. add a billable service to the practice.

(Full disclosure: Occasionally, I’ll buy an instrument purely for its academic value, which is usually a benefit to patient education. A tenet of my practice is that better patient education leads to better compliance, better overall care, and greater income.)

Here, I provide a list, broken up by refractive care and ocular disease management, that I have found fits the described criteria. Additionally, I’ve included items I consider optional (marked “o”), yet also offer clinical utility. A caveat: Each primary care practice is different, in terms of patient demographics and need. Therefore, this list should be seen through that lens. As an example, what I have deemed “o,” you may deem as a must-have.

General vision and ocular health care

• Acuity, external exam and pupil assessment. Occluders, Snellen acuity chart, penlight/automated pupillometer(o)/automated light reflex pupillometer(o), prism bars, exophthalmometer (increasing disease awareness specifically for thyroid eye disease and more accessible effective treatment)
• Stereopsis. Randot Stereotest, Worth 4 Dot test
• Color vision testing. Color plates (Ishihara/Hardy-Rand-Rittler), computerized versions (o)
• Keratometry. Manual keratometer, auto-keratometer (o)
• Refraction. Phoropter, retinoscope, loose lenses with trial frame, computerized phoropter (o)
• Biomicroscopy. Slit lamp, slit lamp camera for photodocumentation (o), fundus biomicroscopy lenses (90 D, 78 D), gonioscopy lens (to accurately diagnose and treat glaucoma
• Mapping the corneal surface. Corneal topographer
• Imaging the corneal endothelium. Specular microscope (o)
• Fundus or posterior segment assessment. Binocular indirect ophthalmoscope/20 D
• Blood pressure measurement. Sphygmomanometer: manual/wrist/other automated

Contact lens care

• Determination of refractive correction. Phoropter
• Contact lens surface assessment. Keratometer
• Mapping the corneal surface. Corneal topographer
• Measuring the radius of curvature of a rigid contact lens’ anterior and posterior surface.Radiuscope
• Contact lens power verification. Lensometer
• Corneal thickness assessment. Pachymeter
• Eye length assessment. A-scan ultrasound (o)

Optical

• Lensometry. Manual lensometer/auto-lensometer (o)
• Acetate or plastic frame adjustment. Frame heater – glass beads and blower
• Frame adjustment tools. Axis pliers, lens harpoon, swarf removal tool, etc.
• Lens dioptric power measurement. Lens clock
• Shaping the spectacle lens into the frame. Edger (o)
• Data storage on spectacle lens shape. Frame tracer (o)
• Pupillary distance measurement. Digital pupilometer

Glaucoma/optic neuropathies

Glaucoma cases can be simple, with classic findings of optic nerve cupping, corresponding visual field (VF) loss and/or elevated IOP; more often patients present with suspicious findings that need close monitoring for change over time.

• Intraocular pressure measurement. Tonometer, pachymetry-ultrasound, (o) corneal hysteresis
• Anterior chamber angle assessment. Gonioscopy, (o) Anterior segment OCT
• Identification and monitoring of structural glaucomatous damage. Optical coherence tomographer (OCT)
• VF assessment. Autoperimeter and Amsler grid
• Optic nerve head examination. Fundus camera – standard, wide field (o), confocal scanning laser ophthalmoscopy (o)
• Optic nerve and VF assessment. Corneal hysteresis (o)
• Retinal ganglion cell activity measurement. Electroretinography (o)
• Retinal nerve fiber layer evaluation. Scanning laser polarimetry (0)
• Functional damage detection. Visual evoked potentials (o)
• Contrast sensitivity assessment. Color plate test.

Dry eye disease (DED)

DED can be adequately diagnosed via a thorough patient history, clinical exam, testing for tear chemistry/tear volume or production, and the presence or absence of inflammation.

• Tear film assessment. Slit lamp, dyes (lissamine green, NaFl) with yellow filter, osmolarity, matrix metalloproteinase 9 testing (o)
• Meibomian gland health assessment. Meibographer (o), but highly advised.
• Ocular surface irregularity detection. Corneal topographer (o)
• Anterior segment structure and tear film assessment. Anterior segment OCT, slit lamp camera with monitor (for patient education and follow-up comparisons)

AMD/maculopathies/retinal diseases

• Fundus examination. Slit lamp/lenses, binocular indirect ophthalmoscope, gonioscopy lenses, and scleral depression (for acute photopsia and to rule out retinal holes/tears/breaks)
• Retinal nerve fiber layer thickness measurement. OCT
• Retinal and choroidal vascular structure assessment. OCT angiography (o)
• Field of vision assessment. Amsler grid
• VF assessment. Autoperimeter, Amsler grid, pachymeter – ultrasound or optical
• Adaptation from bright light to darker area assessment. Dark Adaptometer (o)
• Image acquisition to reveal changes in the fundus, such as retinal edema. Fundus camera (standard and wide field (o)/auto fluorescence
• Posterior segment lesion diagnosis. B-scan ultrasound
• Functional abnormality detection. Electroretinography (o)
• Functional damage detection. Visual evoked potentials (o)

Diabetic retinopathy

• Exudates, hemorrhages, neovascularization and retinal thickening detection. Slit lamp, direct ophthalmoscope
• Diabetic macular edema detection. OCT
• Retinal and choroidal microcirculation assessment. OCT-angiography (o)
• Disease progression evaluation. Fundus camera
• NVG assessment. Gonioscope

Purchasing golden rule

In addition to the three criteria listed earlier for purchasing technology, I have a golden rule that ultimately determines purchase: I calculate a very conservative number of procedures that we would be performing each month with the instrument under consideration. I then assess the reimbursement per procedure. By multiplying the income per procedure by the number of procedures per month, I get the monthly income. I compare that number to the monthly lease expense. If the income exceeds the expense by any amount, buying/leasing the technology is a no brainer. OM