The Impact of Ultra-widefield Retinal Imaging on Practice Efficiency

US Ophthalmic Review, 2017;10(1):27–30 DOI:


In the current cost- and resource-constrained healthcare environment in the United States, characterized by declining government reimbursement and increased utilization scrutiny by managed care plans, providers are challenged to continue delivering quality care to more patients while also more effectively managing practice economics. Employing technology to improve practice efficiency is one of the most promising solutions to this dilemma. We have demonstrated that the integration of ultra-widefield (UWF) retinal imaging in our practice is cost-effective. It has allowed us to increase the number of patient encounters while simultaneously raising the quality of care, and increasing patient satisfaction.
Keywords: Ultra-widefield retinal imaging, UWF, practice efficiency, patient volume, cost-effectiveness, quality care, retinal periphery, patient satisfaction
Disclosure: Paul E Tornambe is a consultant to Optos.
Acknowledgments: Editorial assistance was provided by BioComm Network, Inc.

Compliance with Ethics: This study is based on data collected within the practice over a three year period as well as a review of the literature and did not involve any studies with human or animal subjects performed by the author.

Authorship:: The named author meets the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, takes responsibility for the integrity of the work as a whole, and has given final approval to the version to be published.

Received: February 06, 2017 Accepted March 10, 2017
Correspondence: Paul E Tornambe, 12630 Monte Vista Rd, Poway, CA 92064, US.
Support: The publication of this article was supported by Optos. The views and opinions expressed are those of the author and do not necessarily reflect those of Optos.
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit.

Ophthalmic medical practices in the United States are under unprecedented pressure to care for a rapidly growing population of patients, even as Medicare reimbursement levels continue to decline and payers are implementing payment programs based on cost and quality metrics. The Centers for Medicare and Medicaid Services (CMS) has continued to enact significant cuts to payment rates for a range of ophthalmic procedures, from glaucoma surgery to retinal detachment repair and various diagnostic imaging procedures. These are only the latest changes to the economics of care delivery to which ophthalmologists must rapidly adjust. More than ever, the financial viability of the ophthalmology practice depends on its ability to deliver efficient care – integrating cost, quality, outcomes, and patient satisfaction – within an ever-changing landscape of medical innovation, government regulation, payer intervention, and patient expectation.

Several years ago, we formally evaluated the relative efficiency of academic hospital center and small group practices by applying activity-based cost analysis to both settings.1 We found that the small group practice outperformed the academic medical center on nearly all markers of efficiency. In the latter setting, only four service lines – non-laser surgery (e.g., pneumatic retinopexy, pars plana vitrectomy, scleral buckling surgery), laser surgery (e.g., pan-retinal photocoagulation, retinal tear repair), non-optical coherence tomography (OCT) diagnostics (e.g., other forms of multi-modal imaging such as color, red free, autofluorescence, fluorescein angiography [FA], ultrasound), and injections – were profitable, with profit margins ranging from 62% for non-laser surgery to 1% for intravitreal injections. The largest negative profit contributions were generated by office visits and OCT imaging. The continued reduction of reimbursement rates for both diagnostic services and therapeutic injections in the intervening years has made conditions even more challenging for both types of practice and has increased the critical importance of evaluating and improving efficiency. Various models for measuring and comparing practicing efficiency are in development. For example, an efficiency index, calculated as a function of cost, number of patients receiving care, and the quality of care, has been proposed to measure the care delivery process for a given intervention within the ophthalmic practice.2 As such models are expanded to include outcome measures and are validated in larger inter-practice comparisons they may be useful in efforts to improve both the quality and efficiency of care.

Regardless of how efficiency is measured, it is increasingly clear that one key to the challenge of simultaneously improving practice efficiency and quality of care amid relentless financial pressure is the use of advanced technology – diagnostic and treatment systems that provide more useful clinical information, more rapidly, and with greater comfort or convenience for patients. An example along these lines is the positive impact on efficiency and quality of care in cataract and refractive practices produced by the integration of wavefront technology. The impact of this technology for digital refraction and optical path diagnostics was recently described, with the authors noting that the

speed and comprehensiveness of total visual system assessment improved outcomes, patient satisfaction and cost-effectiveness.3 We have seen analogous benefits in our practice from the routine use of ultra-widefield (UWFTM) retinal imaging using the Optos system. This paper will describe how the integration of UWF retinal imaging improved efficiency and quality of care, enhanced patient satisfaction, and allowed more patients to be examined during a fixed time interval in our practice. We show that the resulting increase in patient volume can improve cash flow irrespective of reimbursement rates or how payments for testing are bundled.

Elements of efficiency for diagnostic imaging The unparalleled field of view (sometimes called “pan-retinal” imaging), rapid, patient-friendly image capture, high-resolution, and easy transmission of UWF optomap® (Optos, plc. Dunfermline, Scotland) imaging make it well suited to enhancing the efficiency and quality of ophthalmic care. The Optos system provides the widest field of view of any retinal imaging platform.4 The high-resolution digital image it produces is obtained in a single, non-contact, often non-mydriatic capture lasting about a second; the image is immediately available for evaluation by the clinician and review with the patient on a computer screen or tablet. Cross-registration of different imaging modalities or prior images is instantaneous, supporting comprehensive evaluation of retinal pathology or disease progression. The systems are DICOM compatible and utilize cloud-based transmission and storage to facilitate image sharing with other offices and practices, as well as archiving as part of the medical record.

1. Murray TG, Tornambe P, Dugel P, Tong KB, Evaluation of economic efficiencies in clinical retina practice: activity-based cost analysis and modeling to determine impacts of changes in patient management, Clin Ophthalmol, 2011;5:913–25.
2. Chen A, Kim EA, Aigner DJ, et al., Index to estimate the efficiency of an ophthalmic practice, JAMA Ophthalmol, 2015;133:924–9.
3. Matossian C, Noreika JC, Total visual system assessment – integrating wavefront technology in refractive examinations, US Ophthalmic Review, 2016;9:41–5.
4. Witmer MT, Parlitsis G, Patel S, Kiss S, Comparison of ultrawidefield fluorescein angiography with the Heidelberg Spectralis® noncontact ultra-widefield module versus the Optos® Optomap®, Clin Ophthalmol, 2013;7:389–94.
5. Kaines A, Oliver S, Reddy S, Schwartz SD, Ultrawide angle angiography for the detection and management of diabetic retinopathy, Int Ophthalmol Clin, 2009;49:53–9.
6. Kernt M, Hadi I, Pinter F, et al., Assessment of diabetic retinopathy using nonmydriatic ultra-widefield scanning laser ophthalmoscopy (optomap) compared with ETDRS 7-field stereo photography, Diabetes Care, 2012;35:2459–63.
7. Kernt M, Pinter F, Hadi I, et al., Diabetic retinopathy: comparison of the diagnostic features of ultra-widefield scanning laser ophthalmoscopy Optomap with ETDRS 7-field fundus photography [article in German], Ophthalmologe, 2011;108:117–23.
8. Silva PS, Cavallerano JD, Sun JK, et al., Nonmydriatic ultrawide field retinal imaging compared with dilated standard 7-field 35-mm photography and retinal specialist examination for evaluation of diabetic retinopathy, Am J Ophthalmol, 2012;154:549–59.
9. Wessel MM, Aaker GD, Parlitsis G. et al., Ultra-wide-field angiography improves the detection and classification of diabetic retinopathy, Retina, 2012;32:785–91.
10. Kong M, Lee MY, Ham DI, Ultrawide-field fluorescein angiography for evaluation of diabetic retinopathy, Korean J Ophthalmol, 2012;26:428–31.
11. Silva PS, Cavallerano JD, Sun JK, et al., Peripheral lesions identified by mydriatic ultrawide field imaging: distribution and potential impact on diabetic retinopathy severity, MOphthalmology, 2013;120:2587–95.
12. Silva PS, Horton MB, Clary D, et al., Identification of diabetic retinopathy and ungradable image rate with ultrawide field imaging in a national teleophthalmology program, Ophthalmology, 2016;123:1–8.
Keywords: Ultra-widefield retinal imaging, UWF, practice efficiency, patient volume, cost-effectiveness, quality care, retinal periphery, patient satisfaction