Steven F. Sopher, O.D.
Optometrists have become technologically astute with a myriad of devices with which to diagnose and monitor ocular health findings. Approximately three years ago, I added the Cellchek (Konan Medical, Inc., Torrance, California), a specular microscope, to my practice. Why did I choose to add this particular instrument to my practice? I love technology and believe it is critical to add everything to my practice that will enhance the care I offer to my patients. Clearly, we as optometrists understand the important role of corneal physiology in our contact lens patients, in refractive surgery, and in cataract surgery. Yet, I have learned that it is difficult to truly understand what is going on with the cornea without a specular microscope.
The corneal endothelium is essential in regulating stromal hydration and maintaining corneal clarity. Corneal endothelial morphology can be characterized by evaluating several aspects of the endothelium including the number of corneal endothelial cells per square millimeter and the percentage of hexagonal cells. Some of the cells can become larger than others in response to trauma, cell death, or physiological stress, increasing the variation of cell shapes and sizes, which is called polymegethism. Pleomorphism refers to a decrease in the number of six-sided cells. Ideally, patients should have regular endothelial mosaics.
Integrating the Best Technology
My practice is high tech and all instruments are integrated with my electronic medical record (EMR) system. Once images are acquired with the specular microscope, they are placed into an OfficeMate folder so that the pictures can be stored and presented to patients as an educational tool. Computer monitors have been placed all over the office - in the fitting room, dispensary, examination rooms, the contact lens room, and consultation rooms. Using these images, I can present patients with quantitative evidence of a corneal problem, educate them regarding this finding, and propose possible treatment options.
Figure 1: Konan Cellchek endothelial cell count
Clinical Merit
Just as I have found immense value in performing retinal scans, I have come to appreciate the importance of having specular microscopy in my office’s armamentarium. One thing I have learned is that, when you start to look at a lot of patients with specular microscopy, you begin seeing more problems than you might have anticipated. Many older patients show demonstrable endothelial cell changes. If a patient has Fuch’s dystrophy, I can show them the specular microscopy images in addition to an animation created to demonstrate the different stages of endothelial cell loss.
In my office, I require endothelial cell counts for all contact lens patients. This point is made clear to all contact lens patients who come to me with the understanding that I will provide them with first-rate care. If I note changes in the endothelial cell size and structure or in their cell counts, I may suggest that we change their lenses to silicone hydrogel lenses or to higher Dk gas permeable contact lenses.
An endothelial cell count is considered normal if it is above approximately 2600 to 2800 cells per square millimeter. If the cell count drops below this level, the normal physiology of the cornea is at risk. If your patient requires cataract surgery, you must obtain a cell count. If the patient’s cell count is at approximately 900 to 1000 cells per square millimeter, there is a far greater likelihood of complications such as corneal edema and resultant loss of visual acuity. Patients should be made aware of any additional risks before proceeding with surgery.
In evaluating candidates for refractive surgery, if the cell count is in the high teens or in the low 2000 range, I would discourage them from going forward with the procedure. Having quantitative proof at hand is irrefutable evidence supporting your diagnoses and can help lead patients into making smarter decisions. Issues such as these could easily have been overlooked without the proper tools.
Differentiate Your Practice
One of the primary reasons patients visit their optometrists is to learn about new technology, new treatments, and to improve their vision both now and for the future. I have strived to create a different niche for my practice by offering very comprehensive examinations, avoiding just a problem-focused approach. Patients who come to my practice will soon realize that they are receiving a quality examination and are being evaluated with state-of-the-art diagnostic equipment. If they are primarily concerned with cost, they will seek care elsewhere. It is a distinct advantage to create the impression of having more advanced technology than other competing practices.
When I first began practicing, the most important goal was to refract the patient and, from the revenue viewpoint, selling glasses was important for practice profitability. Optometry is an entirely different profession today. Eyeglasses are still an important profit center, but optometry has now diversified into a more medical model and we must have the best technology to accurately identify any ocular health issues.
Net Cash Flow Advantage
Not only is a specular microscope a great diagnostic tool, but it is a significant source of revenue in my practice. I see approximately 50 new or existing contact lens fittings per month. These patients pay the $40 fee for specular microscopy as an out-of-pocket expense and this instrument is generating approximately $2,000 in revenue each month for a total of $24,000 per year on contact lens patients alone.
For Medicare patients, the code I use to bill for specular microscopy is 92286 (AMA CPT 2007, "Special anterior segment photography with interpretation and report; with specular endothelial microscopy and cell count"), which in my region pays approximately $145 for a bilateral test. I collect about 80% of this fee on approximately 8 to 10 patients per month. Financially, the Cellchek has proved to be a terrific addition to my practice and, in the past few years, has paid for itself 3 to 4 times over.
Win-Win Situation
Our success in practice is dependent on communicating successfully with, gaining the respect of, and providing the best possible care for every one of our patients. The cornea is the major refracting surface of the eye and we must have the tools to better understand its physiology. The specular microscope elevates patient perception, increases practice revenue, and serves as a highly effective educational tool.
The only real proof of our success in patient care is patient satisfaction and the effectiveness of the care provided. We should take pride in the services we provide and the specular microscope not only adds a wow factor to my practice, but it means better diagnoses for my patients.
About the Author:
Dr. Steven Sopher is founder and serves as Chairman of the Board and senior consultant to Eyemaginations, Inc., which develops animation and software tools for the optometric practice. Dr. Sopher has a unique background in software engineering and database design and has been a practicing optometrist in Baltimore, Maryland for more than 33 years.