1. Early User Experience with Visante OCT
for the Anterior Segment
8 Shareef Mahdavi • SM2 Consulting • Pleasanton, CA 7
Optical Coherence Tomography (OCT), initially developed
Figure 1: Demographics of Survey Respondents
for high-resolution imaging of the retina, has more recently
found application in the anterior segment of the eye. OCT Practice Type
is unique for the front of the eye in that it allows precision
Refractive Only General/Comprehensive
imaging and biometry that previously was available only 9% 19%
with Magnetic Resonance Imaging (MRI) or immersion ultra-
sound. OCT also allows patients’ eyes to be imaged in a non-
contact manner, which is both practice and patient friendly.
SM2 Consulting was asked by Carl Zeiss Meditec (Dublin, Cataract &
Refractive
CA) to survey and summarize the experience thus far among 41%
the first group of customers who have acquired Visante® OCT Multi-Specialty
22%
for use in their anterior segment practice.
Data from both an online survey and live interviews indi-
Cornea
cate that Visante OCT is providing significant value in refrac- 6%
Other*
tive surgery as well as cornea and glaucoma diagnoses and 3%
treatments. The diagnostic imaging capabilities are aligned
# of MD’s in
with recently introduced technologies including Phakic IOLs Geography Setting Practice
and the femtosecond laser for Keratoplasty. Additionally,
US 20 Private 27 0* 1
Visante OCT provides a level of ocular detail that was previ- Europe 12 Institution 5 1 6
2 5
ously unavailable in an everyday clinical setting. This allows 3 6
4 or more 14
the physician to have an “offensive” strategy to assist with
surgical planning as well as a “defensive” strategy to docu- Total 32 Total 32 Total 32
ment pathology and post-operative complications. The ver- * One of the respondents is an optometric college that conducts clinical research
satility of the OCT platform suggests that over time and with
additional functionality, Visante OCT could become a “must
have” for anterior segment surgery.
Primary and Expanded Applications
Methodology and Demographics The most common reasons for acquiring Visante OCT tech-
An online survey was sent to the first 75 Visante OCT nology are for use in refractive surgery and anterior segment
customers, and responses were received by 32 of them, a 43% imaging. In refractive surgery, the device is primarily used for
response rate. Of the 32 respondents, 20 practice in the U.S. post-LASIK flap evaluation (62%), measurement of the residual
and the remaining 12 are in Europe. Interviews were conducted stromal bed depth (59%) and Phakic IOL planning (56%).
with one-third of the respondents to provide greater context and Additionally, 71% of respondents indicate they acquired the
understanding of Visante OCT's role in the practice. Among technology for imaging of anterior segment structures to better
respondents, half are either cataract and refractive (41%) or understand and describe the etiology of their diagnoses.
purely refractive (9%). The other half are comprised mainly What is interesting is how the use of Visante OCT expands
of multi-specialty (22%) or general comprehensive practices and migrates over time and with experience in the practice.
(19%). 27 of the 32 are private clinical practices, with the This can be seen in Figure 2, which summarizes uses into four
remaining 5 being institution-based practices. The distribution categories and then compares the actual usage (once in practice)
by the number of MDs in the practice indicates that the device with the planned usage at time of purchase. While the majority
is used in solo, group and large group practice environments. of practices purchased the device to assist with anterior seg-
These demographics are summarized in Figure 1. ment imaging (75%) and/or refractive surgery (94%), many of
1

2. those practices eventually began Figure 2: Visante OCT in Practice to incorporate than similarly
using Visante OCT for use in Increase in Usage after Installation advanced refractive diagnos-
glaucoma and/or planning of Planned application Actual application tics such as wavefront, where
corneal transplants. The major- surgeons generally report a
ity of practices in the survey 100% significant impact on clinic flow
now use the device in all four 91%
94% coupled with reliance on a single
areas. The versatility of the 75%
expert technician to get sufficient
75%
device and its emergence as an results for ablation planning.
53% 47%
“all purpose” tool for anterior
28%
chamber diagnostics is illustrated Frequency of Usage and
by comments provided by cornea Corneal Transplant Glaucoma Anterior Segment Refractive
Financial Considerations
Planning imaging
specialists and refractive sur- As described earlier, usage
geons. For instance, those who purchased the device primarily of Visante OCT often begins with a single purpose in mind by
for post-LASIK evaluation of the flap and/or residual stromal a single surgeon (who typically “championed” the purchase)
bed depth have begun using it routinely with pre-LASIK consul- and then migrates to other uses within the practice once other
tations. As one practice explained, “We use it with every single clinicians observe the ease of obtaining images and see the qual-
consult; it’s truly helpful ity of the images, many of
and has a ‘wow factor’ that Figure 3: Ease of Use which have never before
impresses patients, one of % that Agree
been available to the clini-
vs. Disagree
cian. As shown in Figure
Strongly Disagree Disagree Neither Agree Strongly Agree
whom described it to us as
a ‘catscan [sic] of my eye.’” The data
generated are 9% 53% 38% 91% vs. 0%
5, Visante OCT is used
easy to interpret
on average 11.5 times per
Ease of Use and Impact week across the survey
Getting good images
on Patient Flow does not depend on a
specific technician
12% 12% 12% 34% 28% 72% vs. 24% sample. In contrast with a
An important factor normalized bell-shape dis-
with any new technology The device is easy tribution, the frequency of
to use by doctors 3% 6% 38% 53% 91% vs. 3%
is evaluating how easy and technicians
number of practices along
it is to use in everyday the continuum based upon
practice. Several questions were asked to assess the ease of use usage was fairly evenly spread out. Although not directly mea-
among technicians and physicians, which are summarized in sured in the survey, interview comments indicate that the device
Figure 3. In the survey, 91% agree (somewhat or completely) gains significantly more use over time. “When we first got the
that Visante OCT is easy to use, while only 3% disagree with device, a lot of our physicians were scratching their heads and
this sentiment. And 72% feel that any technician can get good we lacked a process to order the tests,” commented one uni-
images, while 24% disagree and continue versity-based corneal specialist. “Now,
to rely on a specific technician to generate Figure 4: What term best describes the I don’t know what I’d do if they took it
impact of Visante OCT on patient flow
quality images. When it comes to inter- during a typical day? away. I’d feel like I lost my left hand.”
pretation of results, 91% agree it is easy Most new diagnostic devices gain a
to use and no respondent disagreed. market presence only after reimburse-
Assessing the impact on patient flow ment has been well-defined by third-party
None
yielded similarly positive findings: 74% 17%
payors. In the case of Visante, early adop-
of customers felt that the device had no tion is being driven in spite of the lack
Significant 6%
or minimal impact on patient flow, while Minimal of a defined reimbursement pathway (ie,
57%
only 6% stated that the device had a Moderate
there is no specific reimbursement code
significant impact on the movement of 20% in place). This is because Visante is being
patients through the clinic (see Figure 4). used both in refractive self-pay procedures
The findings from both of these (where there is no reimbursement as the
areas indicate that Visante OCT is easier test fees are typically included in the over-
2

3. all fee) as well as in diagnosis of dis- Figure 5: Usage of Visante OCT in the Practice Satisfaction
# of Patients Imaged Per Week
ease. The framework to show how Among respondents, 29 of 32
the device is being used is illustrated 10
Mean Usage
11.5 patients per week
(91%) indicate that Visante OCT
in Figure 6. (47 per month)
has met their expectations based
8
To date, only 15 of the 32 on their initial reasons for pur-
# of Practices
respondents indicated they had 6
chase. Given the additional usage
sought reimbursement, and they 4 that most customers have realized
have done so in one or more of the 2 beyond those initial reasons for
following ways: Private insurance: purchase, it is no surprise that in
73% (11 of 15), Government insur- 1 to 5 6 to 10 11 to 20 > 20 measures of overall satisfaction,
ance: 87% (13 of 15), Patient self- # of Patients per Week
22 of 32 (69%) reported being
pay: 53% (8 of 15). either very or extremely satisfied while only 1 customer (3%)
The frequency of submission of claims and the average expressed some dissatisfaction.
reimbursement reported in the survey were analyzed and are Frequently mentioned as reasons for satisfaction were the
summarized in Figure 7. Customers reported submitting an high image quality and resolution (15 mentions), ease of use
average of 17.8 claims each month (14 mentions), and pure amazement
(ranging from a low of 8 to a high Figure 6: Main Uses of Visante OCT that they now had a device able
of 25) for reimbursement. On aver- to capture these images within a
age, Visante OCT images were clinical setting (10 mentions). There
Visante OCT
reimbursed at $60.14 (ranging from were 9 out of 32 customers in the
$30 to $120). In Europe, by com- survey (28%) that indicated they
parison, reimbursement seems to were only somewhat satisfied, citing
be averaging in the range of 80-85 that they were hoping this device
Refractive Therapeutic
Euros per claim. Multiplying the would replace older technology they
average reimbursements by the aver- already owned (e.g., the Orbscan).
age number of submissions reported Main Uses Main Uses Other comments from this group
yields an average monthly revenue Pre-LASIK consultation Glaucoma angle imaging included their desire to see Visante
Post-LASIK flap evaluation Iris tumors/corneal anomalies
from Visante OCT reimbursement Phakic IOL Corneal transplant planning OCT upgraded with better software
of $1,071 in the US and 1,765 to extract data that is being col-
Euros in Europe. These rates are lected, the incorporation of corneal
Non-Reimbursable Potential for
indicative of what can be achieved (Part of refractive surgery fee) Reimbursement curvature/topography, and imaging
early on and should only increase capabilities that extend behind the
over time, especially once an official iris to precisely image the sulcus and
reimbursement pathway is defined in the US. the lens equator.
Given that the majority of use has been in non-reimbursable Customers were also asked how they respond to other physi-
elective refractive procedures, the fact that disease diagnosis cians who are considering the device for their own practices.
can help cost justify the device is a 85% of respondents indicated they
positive for the clinician. Using the Figure 7: Reimbursement for Visante OCT either completely agree (53%) or
Averages and Ranges
data in the survey as a baseline, it somewhat agree (32%) that they
appears that the device will break- would willingly recommend Visante
Low x=mean High
even over a 5-year period (useful OCT to their colleagues. Only 2 of
Number of cases submitted per month
life for a diagnostic device). With 32 respondents somewhat disagreed
8 x=17.8 25
increased reimbursement revenue and no one completely disagreed
Reimbursement per case
from a formal code, greater usage, with this sentiment. The distribution
$30 x=$60.14 $120
or both, the time frame for paying of responses to these two questions
Reimbursement per month
back the investment will be shorter. on satisfaction is summarized in
$540 x=$1,071 $1,125
Figure 8.
Based on data from 15 of 32 surve y res p ondents
3

4. Discussion Figure 8: Customer Satisfaction and Willingness to Recommend Visante OCT eral years to establish
The rapid rate new codes and rates.
of innovation in the How satisfied overall are you with Visante OCT? Visante OCT has an
Very Unsatisfied 0 0%
ophthalmic sector has Unsatisfied 1 3% additional benefit of
forced clinicians to Somewhat Satisfied 9 28% indirect reimburse-
Very Satisfied 14 44%
continuously evaluate Extremely Satisfied 8 25%
ment as part of a
new devices and ask Total 32 100% larger global fee for
themselves two basic "I would willingly recommend the Visante OCT to a colleague"
specific refractive pro-
questions: Completely Disagree 0 0% cedures. These tests
Somewhat Disagree 2 6%
“Will this tool help Neither Agree nor Disagree 3 9%
are embedded in a
my practice?” and Somewhat Agree 10 31% larger suite of services
Completely Agree 17 53%
“Can I afford to Total 32 100%
provided as part of
incorporate it?” the refractive package,
Visante OCT provides capabilities that heretofore never existed; collectively performed to drive better outcomes in these self-pay
its images fall outside the current paradigm of how the anterior procedures.
chamber is evaluated. This helps explain the dichotomy seen in The emerging definition of reimbursement incorporates the
the data and interviews, with some customers saying “this is a trend towards elective medicine, where patients themselves pay
neat device and I’m still trying to figure out all it can do” while – rather than wait for someone else to cover the expense – for
others express that “I use it everyday on nearly every patient.” the benefits of novel medical technology. Given this shift, it
As a sophisticated diagnostic tool, Visante OCT’s arrival is was surprising to see that only a small percentage of custom-
timely based on the following surgical developments: ers leverage the presence of Visante OCT in their practice. Less
1) Increasing awareness and need to reduce the risk of ectasia than a third (9 of 32) regularly show off this “new technology”
in LASIK. to their patients, and the majority (19 of 32) say they have
2) The advancement of Phakic IOLs as another tool in the observed no marketing value from the technology. In hindsight,
refractive armamentarium. the question would have been better asked as, “have you cre-
3) The revolution in corneal transplantation afforded by the ated any marketing value for your practice?” There are numer-
femtosecond laser and its role in keratoplasty. ous means of describing the device that can be implemented
With time and exposure, anterior segment Optical Coherence nearly free but can have a big impact on patient perception
Tomography is likely to move into the mainstream. Today it sits of the practice. One surgeon described this phenomenon very
with the “innovator” clinicians, who tend to be the very first to well: “Patients love all the tests and Visante has become a
adopt new technologies, simply because they are available. The practice builder. We tell them, ‘good news, there’s room for
situation is reminiscent of corneal topography 15 years ago; it your implant’ while we show them the images.” That moment
was viewed as a “nice to have” but the mainstream clinician becomes a differentiated event in the mind of the patient and
was not clear on its utility. All of that changed with the advent demonstrates how a new technology can create great return on
of the excimer laser, and today corneal topography is indispens- investment for the practice.
able to the refractive surgeon. With the 3 surgical innovations In summary, Visante OCT technology has the potential to
cited above (and likely many more to come), it is reasonable revolutionize the way surgeons plan and treat throughout the
to expect that OCT technology will improve and become more cornea and anterior segment. Customers are largely satisfied
vital to refractive, cornea and glaucoma specialists. and also want to see the technology improve in order to be
With respect to the second question posed above, the tra- more useful to them as well as evolve to standard use among
ditional view has been to evaluate each new technology based cornea and refractive specialists. The manufacturer (Carl Zeiss
upon the opportunity for insurance reimbursement. Given its Meditec) has a heritage of innovation in automated diagnostics,
relative newness in the marketplace, it was surprising to learn and Visante OCT provides another opportunity for the com-
that nearly half the customers surveyed were already obtaining pany and its customers to create yet another market category
reimbursement revenue. For new technologies, it can take sev- that improves patient care.
© Copyright 2006, SM2 Consulting. All rights reserved.
4