During the pandemic, practices that rely heavily on optical and contact lens sales did not seem to fare as well as those who had a significant medical eyecare component; among investors, the smart money was squarely on medical optometry. At the same time, internet sales of spectacles and contact lenses were well beyond record highs. The strong message here: maintain a quality optical and contact lens practice, yes, but continue to build your medical eyecare component. Judicious investments in technology can help steer you in that direction.

Retinal Imaging

These systems have advanced significantly over the years. It’s a crowded field, with many new technologies competing for your attention—and investment dollars. New advances include higher resolution systems with confocal imaging (Eidon, iCare), ultrasound (DGH) and ultra-widefield imaging (Optos). OCT-A, though pricey, has allowed us to detect diabetic retinopathy early by revealing changes in the foveal avascular zone or peripheral non-perfusion.

But don’t lose sight of the value of autofluorescence or en face OCT imaging. These will become especially important should we have an approved therapeutic agent for geographic atrophy/dry AMD. OCT has become a necessity for optimal management of glaucoma and macular disease, but it offers so much more, as you’ll see in this month’s article detailing the sophisticated uses of OCT including interpretation of well-controlled vs. progressing glaucoma and anterior segment applications. AMD can also be diagnosed early and managed for progression with dark adaptometry (Maculogix) testing.

In-Office Procedures for DED

Practices with meibography also tend to offer in-office therapies. Over a decade ago, Drs. Donald Korb and Caroline Blackie discussed the dental model as an optimal future for optometry. The “brushing and flossing” element would be lid scrubs, of which there are many options; newer choices include the MYBO Clean daily eyelid cleaning brush, SleepTite light seals and Bruder mask hydrating compresses.

Like at a dental office, it all begins with imaging and advanced diagnostics, which might include not only meibography but also osmolarity and tried-and-true ocular surface staining. Our in-office procedures include blepharoexfoliation (Blephex), thermal pulsation (Table 1); intense pulsed light (Marco, Lumenis) and low-level light therapy (Marco).

Glaucoma Diagnostic Advances

Corneal hysteresis, which can be measured by the ORA device (Reichert) or adjusted with a CATS tonometer (Reichert), has become essential in my approach to glaucoma care. Another interesting metric is pupil testing; until the RAPDx device (Konan Medical), we didn’t have the accuracy to measure and detect the subtle APDs present in almost all patients with early glaucoma.¹

I often debate starting a drop in many of my glaucoma suspects/borderline cases, but a high hysteresis and no APD gives me peace of mind to simply follow that patient. Years later, they remain non-progressing/suspects.

Turning the Tables

Since optometry conducts 85% of all comprehensive eye exams, we likely see the majority of patients with cataracts. Some ambitious optometric practices even go so far as adding an in-office operating room and hiring a cataract surgeon. There are companies that specialize in this, such as iOR Partners. For the right practices, it’s generally very profitable.

Another important avenue for future revenue will be the sale of private-pay meds. It’s anticipated that therapies for ptosis (RVL) and presbyopia (Allergan to Orasis) will be offered through eyecare offices. Now’s the time to ensure your state allows you to participate.

Advances in technology lead to better diagnoses, which in turn lead to appropriate treatments—and it all sets your practice apart and insulates you from the cut-throat world of optical dispensing. Consider the lessons of COVID-19 as a clear direction for positioning your future practice.

Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here. 

1. Besada E, Frauens BJ, Makhlouf R, et al. More sensitive correlation of afferent pupillary defect with ganglion cell complex. J Optom. 2018;11(2):75-85.