My topographer

I commonly hear ‘I don’t need a topographer; I don’t see many keratoconic patients.’ This misunderstands what the topographers enables us to do. Unfortunately, its value is not taught at university, suppliers often don’t show the full benefits, and there has been a shift in priorities in the profession that has contributed to what instruments we need and want.

Skills and expertise in optometry are expanding, with independent prescribing (IP) qualifications, shared care, and so on. As optometrists fulfil these obligations and we take responsibility and work load off ophthalmologists, we must be careful not to de-skill in areas that optometrists are solely responsible for.

If refractive management is optometry’s key responsibility and the cornea is one of the primary refractive components of the eye, every optometrist should be able to interpret topography for information that is valuable for every patient

My topographer and the lack of understanding of topography is a symbol of this shift in optometry. If refractive management is optometry’s key responsibility and the cornea is one of the primary refractive components of the eye, every optometrist should be able to interpret topography for information that is valuable for every patient.

Expense and space are other concerns for practices. In practical terms, my topographer cost around £15,000 and has enabled us to offer ortho-k to patients. The practice now has around 150 patients, all of whom I could see for their annual test in just three weeks of full-time work. These patients are delighted with the benefits of ortho-k and happily pay £40 per month for their lenses, generating the business around £40,000 per year profit in this one area.

Just 10 ortho-k patients would pay off the £15,000 capital for a topographer over the four-year finance. Yes, it takes a few years to build an ortho-k patient base, but there are immediate additional revenues from dry eye and irregular cornea. Although I love my optical coherence tomography device, from a revenue perspective and from growing a financially viable patient base my topographer is much more important.

Early diagnosis

Keratoconus can be detected early with topography, and cross-linking can reduce its impact on a patient’s vision. I feel the same responsibility to my patients to screen them for keratoconus as I do for glaucoma. Topography gives me peace of mind that I am doing the best job I can.

Any patient under 40 presenting with symptoms (change in vision) or a change prescription may be developing keratoconus, and without topography we can easily misdiagnose. Doing topography on these patients helps provide better patient care and protects the optometrist from missing pathology.

Topography gives me peace of mind I am doing the best job I can

If optometry was to screen all under 40s with topography, we could effectively prevent keratoconus causing visual impairment in the UK. This, of course, would need NHS funding. If the optometry community was to campaign for this and raise awareness with the help of allied organisations, this might be possible.

Topography is also particularly useful as part of myopia management. Knowing that any refractive change is caused by myopia and not keratoconus is important to match the higher patient expectations that come with expensive myopia management options.

The main reason I cannot live without my topographer is that it helps me with refractive management. Helping folk see properly is something I try not to become complacent to. I get such satisfaction from fitting a kid with ortho-k, knowing they will have a childhood where they can swim or put a helmet on without considering their eyesight a disability, or a presbyope, when topography shows me they have a large angle lambda, and soft concentric multifocals won’t work. I can efficiently get them a solution, rather than relying on trial and error or guesswork. These are the patients I want to fill my diary with.