New Eye Imaging Technology
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In the last several years, a company has developed, promoted, and sold systems to many eye doctors that they claim provides a better view of the retina (back part of the eye) without dilation. That assertion is indeed true.
This technology is available at one or more commercial eye care offices in Bay County, and I know of several independent practices nationally that have subscribed to the technology.
Is it really better for the patient?
Let's look at the facts - first, let's discuss what dilation of the eyes really is. Yes, it means "drops". When a doctor examines your eyes, he or she wants to take more than a quick, cursory look. What happens, though, is that your pupils (the center of the colored part) naturally constrict in response to bright light - and this limits the field of view, or extent of examination, of the observer. With normal size pupils it is usually possible to examine 30-40% or more of the retina without dilation - but not 100%. Why is this important? You don't know if something is healthy if you haven't looked at it. Historically, vision and life threatening problems have been detected (and overlooked) via (and without) dilation of the eyes.
That's why it's important.
Is it necessary every time an eye examination is performed? Opinions vary. My opinion is yes with some patients, not necessarily with others. That's another discussion.
The logistics of the dilation procedure require the patient to experience some blur and light sensitivity afterward, until the drops wear off. This is usually somewhat inconvenient to the patient, who may have to return to work or school.
The ability of the new instrument to capture a very large image of the retina without dilation is very convenient. Some patients still require dilation for maximal view, however. Sometimes the image isn't of very good quality.
Overall, this instrument seems to me to be a good addition to a complete eye examination. My problem is the business model and how the procedure is presented.
First, the business model. Generally, the company does not sell the instrument outright to doctors. I've heard that it will, but at an astronomical price. The typical arrangement is a lease, with a "pay-per-use" fee. The company charges doctors $X per image, and doctors are expected to charge patients $(X+Y) for the service (Y is some arbitrary profit margin). There may even be an arrangement whereby doctors would get Z number of uses per month for the minimum lease payment.
Can you see the potential conflict of interest here? First of all, if you have to perform the procedure on Z patients per month to break even, aren't you then motivated to offer the service to everyone? Does everyone need it?
I personally dislike the philosophy of offering patients a la carte medical services. As I've stated in previous columns, patients don't know what they need, that's why they seek professional services. Giving them the option shifts the care back to their control and conveys that the services are not as important. Also, I don't like "selling" patients extra services. Most rational patients want a thorough eye examination for a set fee, not someone attempting to talk them into additional services for additional fees. This happens too much in other industries, in my opinion. The problem with this business model with this technology is that you can't offer the service and have it be included in your examination fee; economically you would either price yourself out of the market or go in the hole fast.
Having said all that, there certainly are situations that warrant extra testing for an extra fee. These, however, are contingent on the patient's diagnoses and clinical presentation (just as they are in the ER or internist's office), not applied across the board to every patient.
How the procedure is presented, the second problem: I've heard it presented "Mr. Patient, would you like this procedure, it gives us a complete view of the back of your eye without dilation, and the cost is $40 more than your regular eye exam." Is the eye care professional implying that they were necessarily going to dilate the patient's eyes anyway? Really, in all cases? I have my doubts.
The real problem is the standard of care. Dilation is still the standard of care for a thorough eye examination. A commonly accepted definition of standard of care (this one is from medicinenet.com) is "the level at which an average, prudent provider in a given community would practice. It is how similarly qualified practitioners would have managed the patient's care under the same or similar circumstances." What this says is that from a medicolegal perspective, dilation is still the measuring stick whereby the examination is judged as complete. And dilation (at most offices) does not involve an additional fee.
Now, the question of "Does everyone need it?". I feel there is a difference between physically examining someone and photographing any deviation from normal - and simply taking a photograph. The former implies some clinical judgment on the part of the physician, while the latter implies a canned, assembly line approach. With that in mind, if there are no changes, it (the deviation from normal) doesn't need to be re-photographed, unless a significant interval of time has passed. How do you know if it's changed? You dilated the patient's eyes and look for yourself, then you know. This "chicken and the egg" discussion r
eminds me of the places that advertise a pair of glasses for $xx AND THE EXAMINATION IS INCLUDED! What if you don't need glasses? Is the examination still free, and do you have to pay for glasses you don't need? What correction do you suppose they'd put in glasses you don't need? If this technology is all it's cracked up to be, why isn't it being offered at the highest level - large universities or teaching hospitals, regional referral centers? Maybe it is, but I'm not aware of it.
In summary, the technology is great, convenient to the patient, efficient for the office's schedule, but doesn't absolve the physician of the responsibility to dilate patient's eyes. Also, the application and business model could stand some improvement. I don't have all the answers, but I do hope to make you an educated consumer!
I invite your questions and feedback
Or Contact Dr. Lee Newton at:
3720 E. Wilder Road, Bay City, MI
(989) 667-9393
3720 E. Wilder Road, Bay City, MI
(989) 667-9393
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Dr. Lee Newton, Eye Care |
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