Doris wanted a second opinion. Her eyecare practitioner, whom I know well and respect, had recently diagnosed her with primary open angle glaucoma. He had prescribed Lumigan (bimatoprost 0.3%, Allergan) to lower her pressures. Doris's family history indicated that a sibling had glaucoma, large cupping and inconclusive visual fields. Her presenting visual acuities were 20/20 OU. Biomicroscopy revealed deep, open anterior chamber angles, which gonioscopy confirmed and in addition showed no angle recession and scant trabecular pigmentation. Tensions by applanation were: OD 17 mmHg, OS 17 mmHg. The large cupping and family history suggested a corroborative diagnosis of primary open angle glaucoma.
In every glaucoma workup, we routinely perform optic nerve fiber layer analysis and pachyme-try. The previous doctor had not performed these tests as part of Doris's glaucoma evaluation. Her average pachymetry readings were: OD 607μm, OS 624μm. Figure 2 shows her GDX results, which reveal large optic nerves with a vertical dimension greater than 2000μm and healthy retinal nerve fiber layers. She has an unusual combination of thick cor-neas and large optic nerves, but the additional information available to us through technology revealed that she didn't have glaucoma.
Long-Term Technology Savings
Doris is fairly young. She was 52 years old when we saw her for evaluation. Life expectancy tables predict that she will live for another 27.1 years. The current estimated cost for prostaglandin analogs is $1 per day. Ignoring any increase in drug fees, this translates to $9,855, excluding all office visits, tests and other intangible mental/emotional effects that living with a potentially blinding disease might have on her. At minimum, she would need annual visual fields, optic nerve photos, nerve fiber layer analysis and at least one comprehensive visit and one intermediate visit each year, for 2005 exam fees of about $550. Annual inflation aside, this translates to a cost of $14,850 over 27 years, with total lifetime fees to Doris and the healthcare system of approximately $24,700.
We charged Doris $461.25 for correctly identifying the true nature of her condition.
|Figure 1. GDX optic nerve fiber layer analysis reveals large optic nerves.|
Worth the Initial Cost
Although technology may initially cost a great deal of money, it invariably pays off in many ways. Associated fees typically allow technology to pay for itself in a few years. The Medicare reimbursement for pachymetry is unfortunately poor, but the information obtained can prove essential to correctly diagnosing glaucoma or the absence thereof.
In our practice, new technology has not only paid for itself, but has also created a remarkable amount of patient interest, referrals and assistance in educating patients about their ocular conditions. We've found that when we show patients their own lens-induced complications, they become much more compliant with prescribed lens care and replacement schedules.
Consider adding new technology to your practice every year. Not only does it help with patient diagnosis, treatment and compliance - it also makes practicing more enjoyable.
Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center. E-mail him at firstname.lastname@example.org.