UPFRONT

The Bottom Line

JASON S. SLAKTER, MD

In this issue of Retinal Physician, we have an excellent review of the status of autofluorescence imaging, a new technology to assess the structure and function of the retinal pigment epithelium in several disease stages. This is another in an ongoing string of new diagnostic modalities that have been introduced in the retina specialty over the last couple of decades. We have seen the advent of digital fluorescein angiography (FA) and fundus photography, followed by the addition of indocyanine green angiography. The introduction of optical coherence tomography (OCT) revolutionized our subspecialty, allowing the opportunity to more accurately assess the cross-sectional status of the retina for diagnostic purposes and for monitoring of treatment effectiveness. More recent developments in the area of spectral- and Fourier-domain OCT imaging have further advanced this diagnostic approach. Other modalities, including multifocal electroretinogram and automated microperimetry, provide us with additional valuable information for improving the care of our patients.

All this new technology, however, does not come without a price tag. Many of these instruments cost between $50,000 and $100,000, and some of the newer instruments cost even more. Certainly, teaching institutions and large practices often have the financial resources to acquire these instruments soon after their introduction. That may not be the case for the solo practitioner. One of my patients asked the other day, "Will my local retinal specialist, who is in private practice by himself, have all the equipment that is in your office to be able to properly take care of me?" Given the particular condition this individual had, I felt comfortable answering in the affirmative, but I began to think about just how much of this equipment is critical for the basic care of a retinal patient. The answer is not a simple one. Much depends on the particular complexity of the disease state, as well as the treatment options the physician may wish to offer the patient. Diagnostics such as FA, color fundus photography, and 2-dimensional (time-domain) OCT imaging are likely to be considered basic necessities in today's era of therapeutics. Going forward, some of these other more advanced instruments may become more crucial for categorizing patients for newer, more targeted therapies.

DON'T FORGET THE BASICS

The concern, of course, is where the money is going to come from to pay for this new equipment, particularly in an era of diminishing reimbursement and higher practice-management costs. The solution may lie in physicians banding together to purchase instruments on a "time-share basis" or actually merging practices to form larger entities that can handle the overhead. As we in the retinal community tackle this issue, I would like to remind everyone of the 2 most valuable diagnostic tools that we have available today: a detailed medical history and a thorough and complete clinical examination. In this era of expanding technology, let's not forget these basics of the medical profession.