Corneal Topography
A State of the Industry Report

BY GRETCHYN M. BAILEY
MARCH 1998

Manufacturers hope sales go up, as prices keep dropping. But why are so many practices still without this technology?

By now, you probably know of quite a few colleagues who revere the corneal topographer as an indispensable clinical tool. But despite many rave reviews, corneal topography sales have been sputtering, even as prices fall lower and lower. Now topography has broken the $10,000 price barrier, or the "glass ceiling" of the instrument world. Will the topographer take its place alongside the autoperimeter in optometric offices around the country and around the world? Or, will it remain the province of contact lens gurus and technology junkies?

Is It Price?...

Not to worry, says Dicon president and CEO Mark Miehle. He feels the drop below $10,000 will spur many practitioners to buy.

"The paradigm for this has been repeated time and time again in the optical industry. A lot of instruments have been taken off the chair stand and moved into the diagnostic test room," he says. "Autorefractors started out at $30,000. Now they're around $7,000 to $10,000, and they're being used on all patients. Autolensometers started out at $30,000. Now they're around $5,000 to $7,000. The trick toward automation is not unique applications, but applications that touch the entire patient base. That's when the optometrist says, 'If you can get me that for under $10,000 and I can use it for all my patients, I will buy that instrument.'"

Miehle is not alone in his suppositions. EyeSys Premier clinical affairs specialist Beth Soper also believes the drop below $10,000 will help boost sales.

"I think most companies, us included, weren't able to give the optometrists the type of product they wanted for the amount of money they wanted to spend. They wanted something very simple, very fast and under $10,000," she says. "I think price is a huge motivating factor. Our advisory group told us as soon as we get something under $10,000, we'll be able to sell it to optometry. There's something psychological about $10,000 that puts people over the edge."

Soper expects that the recent introduction of smaller, less expensive units will propel sales upward this year.

...Or Is It Need?

Price is not the issue, it's need, says David Headlee, director, refractive products group at Humphrey Systems. He says that even if topographers were free, if practitioners believe they don't need it, it doesn't matter what the price is. Every year since topography made its debut, optometrists have been saying they will buy it as soon as it gets to ... fill in the blank with your choice of price.

"The ultimate price barrier was $10,000," Headlee says. "We're below $10,000, and now I'm hearing $5,000. I think the average optometrist is not convinced that he needs the technology at this point. The top guys bought into topography early on. But can your average optometrist do this stuff without topography? Certainly he can. He's been doing it for years."

Corneal topography started out as a tool for refractive surgeons, and was marketed as such. But after most refractive surgeons had purchased the instrument and interest in refractive surgery waned, topographer manufacturers had to alter their sights in order to stay in business. But the transition from ophthalmologist to optometrist was not a smooth one, and it didn't convince optometrists they needed the technology, according to Headlee.

"We hope that in the future, we'll be better able to communicate to the practitioner the need for these devices," Headlee says.

Many practitioners see topography as the instrument for refractive surgery, corneal surgery, keratoconus and tough contact lens fits. "I don't see much out of the ordinary," they say, "so why do I need a topographer? Besides, I'm comfortable with my keratometer, and that doesn't cost $12,000."

Scott Lewis, president of Alliance Medical Marketing (distributor of the Keratron Corneal Analyzer), likens a topographer to a mink coat: "You see a mink coat that's $1,000, and you have $1,000. But you're moving to Florida, so you don't buy it."

Other Factors Add Up

When you factor in confusion in the marketplace, questions about reimbursement for topography and uncertainty of what the maps mean, you're left with a flat market.

Market confusion. About a dozen companies are vying for the few topographer sales each month, and each is looking for the advantage over the others by differentiating itself. This translates into a "my unit does this, and theirs doesn't do that" type of sales approach. Little wonder those doctors who aren't quite convinced they really need one decide to wait a bit longer. A lack of standardization also contributes to problems. One of the problems is that the contact lens manufacturers have different instruments, all of which have different scales, Headlee says. As a result, implementing the technology to benefit patients is difficult because the scaling is different. The good news is the ophthalmic industry and the American National Standards Institute are currently working on a solution to this problem.

Charging for topography. Many practitioners are unsure about how to make the topographer pay for itself. Bill managed care and Medicare? Up your comprehensive exam fee? Charge a few dollars per test? The solution lies within a combination of those three options.

Getting reimbursed from insurance for topography is difficult, acknowledges Ken Lebow, O.D., a past consultant to Humphrey Instruments and EyeSys/Premier.

"Bill it outside of insurance," Dr. Lebow suggests. "Bill it at a low fee, something that's reasonable that will give you information, or increase your professional service fee and include it within that fee."

Headlee agrees with increasing professional fees or charging a small fee for the test, although he mentions that certain corneal pathologies are reimbursable through Medicare. Check with your carrier for more information.

Tomey Advisory Board member Art Epstein, O.D., says the instrument's inability to treat patients causes practitioners to shy away from charging them for tests.

"Optometry has not been a diagnosis-oriented profession in the past," Dr. Epstein explains. "We've been a treatment-oriented profession -- the patient can't see, so we give them glasses. We've never looked at the skill of the diagnosis as something to be reimbursed for. Optometrists have tremendous amounts of trouble charging people for professional services. I think because the topographer is such a service-oriented instrument and there's no concrete end result that O.D.s feel is tangible, they have difficulty charging for that. That's why they haven't bought topography."

Map uncertainty. Topographers show practitioners beautiful maps with pretty colors. (Headlee sometimes refers to topographers as "refrigerator-art generators.") But does the average optometrist understand what each map is showing, how to identify subtle differences among them and how to use that information?

Some practitioners don't want a topographer because they don't know what to do with it, according to Robert Mandell, O.D., an emeritus professor at the University of California at Berkeley School of Optometry and a consultant for Dicon. He says that topography entails a higher learning curve than most people realize, but with the right training, all of the objections practitioners have gradually get worn down. Dr. Lebow agrees that there's a misunderstanding by practitioners in what the maps are telling them.

"For example, contact lens induced corneal warpage creates a map that has superior flattening and inferior steepening. Keratoconus creates a map with superior flattening and inferior steepening. If you put that map in front of a person without any additional information, he won't know what he's dealing with. As a result of that, a misdiagnosis can be made that the patient has keratoconus. It's both lack of manufacturer education and practitioners who aren't paying attention to the subtle differences with topography maps."

Not only can understanding the maps be confusing, but so can knowing which map to look at.

"It's not just press a button and get a result," explains Loretta Szczotka, O.D., M.S., at the department of ophthalmology, Case Western Reserve University and University Hospitals of Cleveland. "You have to choose which map you want -- axial, instantaneous, elevation, refractive. It could be confusing, but it shouldn't be. Each map has a somewhat different application. If you break it down and see what you're using it for, it really becomes quite simple. But the bottom line is it shouldn't be confusing because it's the corneal curvature we've been dealing with for years. It's just being displayed in a somewhat novel fashion."

Why Buy?

If your practice has many comanagement patients, or if you're a heavy hitter in contact lenses, chances are you already have a topographer or you're planning to get one. But what if you're Joe Main Street, O.D.? Why should you buy a topographer?

Consider the marketing angle. Some patients like to know that their doctor is on the cutting edge of health care. Others like seeing a neat picture with lots of colors. Hey, that's my cornea!

Disease detection also plays a role in corneal topography. You can catch more subtle changes than with a keratometer, and you have a better idea of what's going on with your patient's cornea.

The biggest new application for corneal topography seems to be contact lens fitting, specifically rigid gas permeables and orthokeratology. RGPs are more difficult to fit than soft lenses, and the extra information gained from topography may ensure a more successful fit, or a fit with less practitioner time and patient visits.

But, as Lewis points out, here's the chicken or the egg question: What comes first -- the RGP practice increase, indicating that you should buy a topographer, or do you buy a topographer to build your RGP practice? Most companies seem to be following the latter form of logic.

"Lately you hear a lot about optometrists retaining their patients," says executive vice president of Tomey Nick Lurowist:. "They don't want to fit a patient with soft lenses and lose them to a mail-order company. There seems to be a renaissance of interest in RGP fitting. Because of that, one would expect a similar renaissance in corneal topography."

But RGP fitting alone isn't enough to drive the corneal topography market, says Dr. Mandell.

"The market for rigid contact lenses, depending on who you talk to, is probably somewhere around 14 or 15 percent of the total contact lens market," Dr. Mandell says. "On that basis alone, few practitioners were really intrigued by the idea. "I think that in order for them to be successful, fitting systems have to first demonstrate a usefulness for soft contact lenses, and second demonstrate how the instrument can present an approach to fitting that's going to be any better than what the practitioner can do without it."

Bottom line: will topography make you a better fitter? Yes and no, says Dr. Szczotka.

"I don't think it's going to make the good, comfortable contact lens fitters any better, but it will make them more efficient. It does what you can do with the patient in the chair in half the time. For somebody who is not comfortable fitting rigid lenses, it absolutely can make that person a better fitter. But you still have to know what you're looking at, what the fluorescein patterns mean. It's not replacing a judgment call."

What Does the Future Hold?

Manufacturers predict that topography will replace the keratometer and become standard of care. When will that happen? They're hoping for sooner rather than later. Many topographers and contact lens fitting software programs are still in their infancy.

"I think the biggest deterrent in optometry has been the fact that the manufacturers just haven't delivered what they said they were going to," Dr. Mandell says. "The main thrust was toward fitting contact lenses. The early contact lens programs especially were not based on good, solid foundations. They were just seat-of-the-pants programs that were developed by people so they could get them out in a hurry."

Dr. Epstein agrees: "We're just now getting second generation machines, and they will interface with contact lens labs and lathes, and allow fabrication of custom contact lenses in ways that we've never dreamed of before. There's tremendous potential for revolutionizing the entire contact lens industry."

And alternatives to Placido disks will also venture upon the scene and improve contact lens fitting.

Most corneal topography manufacturers and practitioners agree that no one aspect of clinical practice will jump-start topography for all optometrists. Rather, a future that includes improvements in technology, lower prices, increased education and the expectation of greater documentation responsibilities involving corneal topography all contribute to the optimism currently felt by an industry poised for growth.

Gretchyn Bailey is a previous optometric technician and a frequent contributor to ophthalmic journals.

Topography Pearls From the Experts

• Use elevation maps if you want to predict fluorescein patterns. The fluorescein touch pattern will appear on the higher areas on the elevation maps.
• Keep in mind that poor fixation can cause a map to look keratoconic. Help the patient to refixate, and repeat the test. Some newer instruments assist with fixation.
• Topography can be helpful in fitting piggyback lenses. Place the soft carrier on the eye and take topography over the soft lens. The resultant topography can help with the RGP fit.
• A decentered soft lens can shift the corneal apex, and topographic evidence of this is a strong indicator for refitting.
• Topography should be one of the initial tests performed when a patient presents with reduced acuity of unknown origin. Irregular astigmatism and distortion will often be evident in some of these cases and can explain reduced acuity.
• Abnormal topography may not be the only reason for reduced acuity. While it can explain some visual loss, don't forget other possible, and potentially more serious, reasons for reduced acuity.
• Not all topographers are the same. Some have higher resolutions and can be used to detect subtle corneal surface changes, such as basement membrane dystrophy. You can actually see the maps and dots with some topographers.
• Topography is the only reliable way to follow ectatic disease like keratoconus, pellucid degeneration, Mooren's ulcer or Terrien's degeneration. Remember that lenses can modify the appearance and mask progressive change.
• Contact lens software can be used for virtual fitting of RGPs. The fluorescein patterns they generate allow practitioner-computer communication and serve as a common language. Color maps are pretty, but they don't tell much about how to actually fit the lens.
• Make sure you use effective refractive power, not K readings, when calculating intraocular lens power for a refractive surgery patient. Otherwise you may end up with a 5D surprise.

--Thanks to Dr. Epstein, Dr. Szczotka and Joseph Shovlin, O.D.