Do I need an OCT? If so which brand?

Editor’s note: for you non ophthalmologists reading this, an OCT (optical coherence tomographer) is a ultrasound imaging device that among other applications measures retinal thickness to determine if anti- VEGF injections are necessary for wet macular degeneration and diabetic macular edema, as well as measures nerve fiber layer thickness for glaucoma.

The OCT is frequently the most expensive equipment for a start up solo ophthalmology practice. Mine was 25% of my startup costs. How I envy the internal medicine docs and psychiatrists whose total startup costs were $20,000…

This guest post is by Matt Swanic of Las Vegas Eye Institute. When I opened Matt helped me select my equipment which to this day I am very grateful for.

We also want everyone to realize that there are alternatives to Zeiss products, as many of us have received poor service from them.

Here’s the post:

This is a great question that we get a lot on our Soloeyedoctors listserv.  The first question is relatively easy to answer. The answer is almost always going to be yes. However, even this depends on your market.  Sometimes you can get away with sending the patient down the street to a competitor but that is almost like saying “take a look at how fancy my competition is”, which may make your patient reconsider his decision to come visit your office.

Regardless I think it would be difficult to evaluate glaucoma in today’s day and age without an OCT. In fact, the OCT is one of my greatest determinants in need for further glaucoma evaluation (especially with new technology of GCC-Ganglion Cell Complex analysis).  And an OCT is almost a necessity for the modern cataract practice.  I get a macular OCT on any patient that I am considering a multifocal or extended depth of focus IOL, and on anyone with vision that is less than I expected postoperatively as an OCT is key to detect sub clinical CME.

So, with that part out of the way you, should consider do you want to get a brand new OCT or a used OCT.  If used, how old?  You could certainly consider getting a Zeiss Stratus OCT but honestly in 2018, its getting a bit long in the tooth. Zeiss hasn’t even supported it for years.  Yet, I think an argument could be made that it would get the job done to detect CME, epiretinal membranes, and RNFL analysis for glaucoma.  However, the Stratus just really has very limited resolution, is not going to be a practice builder, cannot evaluate ganglion cell complex, and has no anterior segment capabilities.  So, I’d recommend seriously considering a used Cirrus (Zeiss), used RTvue or Avanti (Optovue), Spectralis (Heidelburg), or a Maestro (Topcon).  For a new soloeyedoc I really don’t think a brand new unit is a good use of limited funds but we will discuss them at the end as well.

First, we will start with what you are most likely familiar with, the Zeiss Cirrus Spectral domain OCT.  I consider this to be a great option for the generalist because you already are likely very familiar with it and all its printouts from residency or a prior practice.  Most of us consider it the jack of all trades: it does everything well but really isn’t the top in any category.  It will give you detailed RNFL reports but unfortunately you often have to pay for the GCC package (I would recommend paying for it if you can afford it though.)  It does a good job at imaging the macula, but really they all do a good job in this regard.  It has anterior segment functionality for evaluating angles and can image the cornea, but has no real data analysis reports for the cornea.  Expect to pay about $32,000 to $35,000 used. (Note: Howie paid about $40,000 used when he opened in 2014, so he feels like he got his money’s worth.)

Second, we move onto Optovue’s product line of the Avanti and the RTvue.  They also have a line called the iVue but it really does appear quite flimsy and really is mostly marketed to optometrists.  I have the Rtvue that I purchased refurbished directly from Optovue.  I am a corneal specialist and this is really where this device shines.  It has analysis reports of the central 6mm of the cornea and a feature called total corneal power that analyzes the anterior versus posterior cornea to give you total corneal power for use on the ASCRS website in post LASIK eyes.  It works quite well in my experience, yet I still tend to find the Barrett True K formula the most reliable in these eyes.  The corneal analysis also helps you evaluate keratoconus suspects (for LASIK screening) and is invaluable in combination with a topographer. The Optovue has GCC analysis which I did not have to pay for as an option.  The GCC analysis is useful for evaluating glaucoma suspects. I will often find patients with questionable RNFL loss but then clearly obvious GCC loss that seals the diagnosis of glaucoma.  This device usually is also around $30,000 like the Zeiss.

Third, we move onto the Heidelburg Spectralis. This is like the Rolls Royce of OCTs but it has a price tag that matches the car. It has the highest axial resolution and produces beautiful images of the retina and cornea.  It has RNFL and GCC capabilities for glaucoma. It can image the cornea but unfortunately it doesn’t have the detailed analysis software seen on the Optovue.  It is sold in configurations that include digital photography as well as fluorescein angiography. These units can get to be well over $100,000 and are actually fairly difficult to find on the used market.

I find most people that buy them tend to be retinal specialists.  Because of their various configurations their prices are highly variable and I would expect to pay at least $50,000 for this device, but even used they often approach $100,000 when they including photography abilities.  However, if you are a retina doc that needs FA, this may not be unreasonable.

Moving on, the Topcon Maestro is a real sleeper in the OCT world and it can work very well for the soloeyedoc that may be short on cash, and on office space. Why? The Topcon has a digital camera built in.  Its imaging of the retina like the Zeiss and Optovue is more than adequate. Its digital camera gets the job done and will get you paid for digital photos in glaucoma and retina patients as well. The new one even can create wide field composites. There are many people that still think that this device doesn’t have a reference database for glaucoma.  This thinking is outdated. It not only has a reference database for RNFL, it also has one for GCC.  Unfortunately, the Topcon does not have anterior segment functionality, but for people who aren’t a cornea specialist, this is likely far from a deal breaker. This device is so affordable brand new that I would recommend going this route, plus a used device may not have a reference database for glaucoma.  Expect to pay about $45,000 new for this device. This is more than some of the other products but don’t forget that you don’t have to buy a separate fundus camera.

Finally, moving onto the latest and greatest brand-new technology: the main advantage of the newest devices like the Avanti and brand-new Zeiss OCTs is that they allow for OCT angiography. However, this technology is not standard on these devices and the licenses are usually several thousand dollars.  OCT angiography has a CPT code, but it may not be possible to recoup this investment easily.  The Avanti for instance is usually around $60,000 dollars including “show specials.”

However the license for angiography may be another $7000-8000.  Paying $67,000 for this device new that only allows the billing of one more code versus a $30,000 used machine is going to be hard to justify financially.  Especially as a new doc that may only do 5 OCT’s a week.

Buying new equipment for your office is a fun endeavor, but always remember that each device is just one tick in your checkbox of startup costs. You don’t want to blow the bank on one device and get wowed by fancy bells and whistles that are often not billable and may do little to retain or attract new patients.