Boomers Disease Dectection Growth - Kansas Optometrickansasoptometric.org/pdfs/Speaker Handouts for Convention 2014...Optimize Revenue FIRST YEAR GLAUCOMA ... “3 Reasons your Optometry

Boomers and Disease Detection with OCT:

Catalyst for Optometric Practice Growth

COPE 38496-PD

Michael Chaglasian, OD

Boomers and Disease Detection with OCT KOA 2014

Michael Chaglasian, O.D. 1

Boomers and DiseaseDetection with OCT:

Catalyst for Optometric Practice Growth

Michael Chaglasian, OD, FAAOIllinois Eye Institute

Illinois College of [email protected]

Disclosure:Boomers and Disease Detection with OCT: Catalyst for Optometric Practice Growth

Michael Chaglasian, OD, FAAO

COPE # 38496-PD

This course material and information was developed independently of any assistance.

I do have the following financial arrangements to disclose:

Alcon– Honorarium/Advisory Board Allergan - Honorarium/Advisory BoardCarl Zeiss Meditec - Honorarium/Advisory Board

Objectives:

1. Understand the increasing prevalence of ophthalmic disease in the typical optometric practice.

2. Identify what the risk factors and clinical indicators are in patient examinations that suggest the need for OCT imaging.

3. Learn how to read and review OCT images of patients with diabetes, glaucoma, AMD.

4. Understand how latest generation spectral domain OCT instruments have improved their ability to detect and monitor disease.

What is a “Boomer”

A baby boomer is a person who was born during the demographic post-World War II baby boom,between the years 1946 and 1964, according to the U.S. Census Bureau.

The “Problem” is an Opportunity

America's 78 million baby boomers are turning 65 at a rate of one every 10 seconds

(3 million to 4 million per year).

Healthcare has become a big issue for baby boomers.

Over 60% of adults ages 50 to 64 who are working (or have a working spouse) have been diagnosed with at least one chronic health condition, such asarthritis, cancer, diabetes, heart disease, high cholesterol, or high blood pressure,

according to a report from The Commonwealth Fund.



Where does optometry and OCT technology fit?

Possible Indications for Performing OCT

Elevated IOP > 21mm Hg C/D >.5 or Asymm. > 0.2 Poor visual field test-takers Narrow anterior chamber angles High myopia Personal or family history of

- diabetes- glaucoma- hypertension- field defects

Suspicious Optic Nerves- Marcus Gunn pupil- Acquired color defect- poor confrontation fields- Disc pallor

Unexplained decreased vision Drusen / AMD Numerous maculopathies and

retinopathies

And Many Others

Requirements of OCT Technology

Validation / Accuracy / Improved Outcomes Peer reviewed articles in the literature Not sales/marketing hype

Cost Effectiveness Can be challenging. Survey your patients for three months Consider “added value” to your practice

Ease of Use / Ease of Interpretation

OCT out performs Photography

Conclusions: For detection of a variety of retinal irregularities

evaluated in the current study, volume OCT scanning was more sensitive than non-mydriatic retinal photography in our asymptomatic individuals.

OCT detected clinically relevant disease features, such as subretinal fluid, that were missed by FP, and had a lower ungradable image rate.

It is likely that OCT will be added to photography screening in the near future for chorioretinal disease.

The Retinal Disease Screening Study: Prospective Comparison of Nonmydriatic Fundus Photography and Optical Coherence Tomography for Detection of Retinal Irregularities IOVS February

2013 54:1460-1468;published ahead of print January 15, 2013.



Growth of OCT (2009) OCT Coding / Billing 2013

92132- Used for cornea and narrow angle diagnoses Some carriers/insurances are not covering

92133- Used for ALL Glaucoma and optic neuropathy

diagnoses

92134- Used for ALL (approved) Retinal diagnoses Mutually exclusive and cannot be billed on the same

day as 92133. Can be billed with 92132. None can billed on same day as fundus photos, 92250

OCT Coding / Billing 2013

Must be based upon “Medical Necessity” and entering CC / reason for visit Reason for diagnostic test? Directly stated or easily implied Will it effect diagnosis or treatment? Always requires an “Order” and an

Interpretation and Report

2013 Avg. Reimbursement:

$45-48 Each of these new codes is considered unilateral or

bilateral

Frequency varies with diagnosis Obtain List of covered ICD-9 codes

(Medicare LCD)

John Rumpakis, OD, MBA

http://www.revoptom.com/content/d/coding___and___practice_management/c/36039/

“Here’s the bottom line:

Your patients’ medical insurance is not the same thing as your malpractice insurance.”

Optimize Revenue

FIRST YEAR GLAUCOMA PATIENT REVENUE

VISIT # TOTAL FEES PER VISIT RUNNING TOTAL

FIRST $164 $164

SECOND $288 $452

THIRD $224 $676

FOURTH $ 55 $731

FIFTH $144 $875

SIXTH $ 55 $930

SEVENTH $ 55 $985

1Rumpakis, “Putting an Economic Spin on Glaucoma”, Optometric Management, Marc

•The OCT model can help you improve your billing and coding

•Help you build glaucoma and retina patients

•According to Dr. John Rumpakis, a new glaucoma patient can require procedures valued up to $985 the first year.1



ADDITIONAL INCOME DUE TO IMPROVEDCASE DETECTION

One ROI Example:

OCT only 13.5 per month or 3.4 week for breakeven

Procedures for each Glaucoma suspect and diagnosed, 2nd and 3rd visits2

92014 Ophthalmological services, comprehensive medical examination $ 113

92250 Fundus Photography $ 47

92020 Gonioscopy $ 26

92083 Threshold Visual Fields $ 52

76514 Corneal Pachymetry $ 12

92012 Ophthalmological services, intermediate $ 77

92132 Dqiagnostic Anterior Digital Imaging, - Spectralis $ 38

92133 Diagnostic Posterior ONH Digital Imaging, -Spectralis $ 42

Income generated by two follow-up visits of each glaucoma suspect $ 4072. Rumpakis, Putting an Economic Spin on Glaucoma, Optometric Management March 2004, pp 53-54.

There is no guarantee that your Medicare carrier will pay for these procedures when performed on the same day. Please contact your local Medicare carrier to determine appropriate billing guidelines.

It’s definitely not getting easier.

http://www.revoptom.com/content/c/22520/

“3 Reasons your Optometry Practice is decreasing in value”

1.Technology

2.New Patient Ratios- Boomers!!

3.Resistance to the Medical Model

http://www.optometryceo.com/2013/01/23/3-reasons-your-optometry-practice-is-decreasing-in-value/

Chad Fleming, OD, FAAO

CASE EXAMPLES

Spectral Domain OCT

Time Domain OCT SPECTRALIS

Stratus

Spectral Domain Comparison

Typical SD OCT

SD OCT w/tracking & Noise Reduction



Spectral Domain: Many Options Spectral Domain: Many Options

Optical Coherence TomographyRS-3000 Advance NOT FDA Approved for US Sales

Still Valuable: But Perhaps Limited Future(I am unaware of any timelines)

GDx

Stratus

SD-OCT Spectralis40,000 scans per sec.

SD-OCT - Heidelberg Engineering

Eye Tracking

Cross section scanReference scan

Eye Movement

The reference image tracks eye movement, and the cross section is moved to match

EYE TRACKING

SPECTRALIS®



Eye-Tracker Controls Scan Location in Real Time

Eye tracker recognizes eye movement and repositions scan pattern

Data acquired during eye movement is discarded

Stored data is free of motion artifacts

Cirrus™ HD-OCT

Cirrus™ HD-OCT

X6.5

Optovue: RTVue

Optovue Family

35

Optovue: iCam and Normative DB



OCT Gives You a Powerful New Perspective on These Most Common Ophthalmic Diseases

Pre & Post- Cataract Complications2 million patientsdiagnosed annually

AMD6 million patientsdiagnosed annually

DME5 million patientsdiagnosed annually

GLAUCOMA3 million patientsdiagnosed annually

“The thought that these devices can diagnose glaucoma in the absence of corroborating clinical evidence is, in my opinion, the most common (and potentially dangerous) misunderstanding.

The limited normative databases against which scans are compared can never cover the remarkably varied appearance and structure of the optic nerve we encounter in normal individuals.”

James Brandt, MD

What are practitioners' most common misunderstandings of imaging technology?

Red Disease!

Red Disease CASE AK

54 year old woman Recently moved from Poland VA = 20/40 and 20/50

-14D myope

Current Medications Dorzolamide TID Timolol BID

Complaints of topical SE’s with drops



CASE AK

Glaucoma Madness• Plethora of information

• Nothing Definitive in Early Stages• Nothing Stable• ONH –IOP-C/D Ratio• Pachymetry• Gonio – family history• Ethnicity –Stereo Photos• Pallor – Rim Area• Asymmetry-Blood Flow• Visual Fields

FRUSTRATION

Increasing Prevalence of Glaucoma

IOVS, Special Issue 2012, Vol. 53, No. 5

Increasing Prevalence: African American




Increasing Prevalence: Hispanic


Glaucoma At Risk Review

African-AmericansGlaucoma is the leading cause of blindness among African-Americans. It is six to eight times more common in African-Americans than in Caucasians.

People Over 60Glaucoma is much more common among older people. You are six times more likely to get glaucoma if you are over 60 years old.

Family Members with GlaucomaFamily history increases risk of glaucoma four to nine times.

Hispanics in Older Age Groups

Glaucoma At Risk Review

AsiansPeople of Asian descent appear are at higher risk for angle-closure glaucoma.

Steroid Users40% increase in the incidence of ocular hypertension and open-angle glaucoma in adults who require approximately 14 to 35 puffs of steroid inhaler to control asthma.

Other Risk FactorsOther possible risk factors include: high myopia (nearsightedness), diabetes,

Hypertension, Central corneal thickness less than .5 mm

OCT for Glaucoma

RNFL

Optic Nerve Head

Ganglion Cell Thickness

65 yo with Hx of OHTN x 3 yrs 38 yoGAT= 22 OD 25 OS



CirrusRNFL

Optic Nerve Analysis

Optic Nerve Cross Sections

Visual Fields Combined Report



The Ganglion Cell Complex (GCC)

Inner retinal layers provide complete Ganglion cell assessment:

• Nerve fiber layer (g‐cell axons)• Ganglion cell layer (g-cell body)• Inner plexiform layer (g-cell dendrites)

Images courtesy of Dr. Ou Tan, USC

RTVue: RNFL and GCC

NEW for Glaucoma: Ganglion Cell Analysis

Measures thickness for the sum of the ganglion cell layer and inner plexiform layer (GCL + IPL layers) using data from the Macular 200 x 200 or 512 x 128 cube scan patterns.

Carl Zeiss Meditec, Inc Cirrus 6.0 Speaker Slide Set CIR.3992 Rev B 01/2012

Anatomy:Ganglion Cell Layer and IPL

Cirrus: Ganglion Cell Analysis

The analysis contains:

Data for both eyes (OU)

Thickness Map –

shows thickness measurements of the GCL + IPL in the 6mm by6mm cube and contains an

elliptical annulus centered about the fovea.

Deviation Maps –

shows a comparison of GCL + IPL

thickness to normative data.

Thickness table –

shows average and minimum thickness within the elliptical annulus.

Glaucoma SuspectInitial 3 years later



RTVue and Cirrus OCT Topography of Retinal Ganglion Cells

Curcio CA, Allen KA.. J Comp Neurol 1990;300(1):5-25

• Large variation in total ocular

axonal count (0.5 to 1.2 mil)

amongst normals and thus

large variation in normative

databases.

• However, the variation in

ganglion cell numbers in the

central macula is small.

Posterior Pole Asymmetry Analysis

• A new SPECTRALISsoftware feature to help assess RNFL and GCL loss by mapping retinal thickness across the posterior pole

• Potential to detect earlier RNFL loss compared to RNFL thickness circle scans, fundus photos or visual fields

Glaucoma Case Study 1: Asymmetry of Ganglion Cell Analysis

Glaucoma Case Study 1: IOP 28 OD, Early VF Defect, Inferior RNFL

defect

Posterior Pole Case Study 2



New Reports – RNFL & Post. Pole

Posterior Pole Assessment RNFL & P. Pole AsymmetryProgression Analysis:

Absolutely Essential

Progression Analysis: Absolutely Essential

Detecting Structural Progression of Glaucoma

A Key Component of Glaucoma Management

Cirrus HD-OCT GPA AnalysisGuided Progression Analysis

Two baseline exams are required

SS = 10Baseline Baseline

Registration SS = 10Baseline

Registration SS = 8

Third exam is compared to the two baseline exams

Sub pixel map demonstrates change from baseline Yellow pixels denote change from both baseline exams

Registration SS = 9

Third and fourth exams are compared to both baselines. Change identified in three of the four comparisons is indicated by red pixels; yellow pixels denote change from both baselines

Image Progression Map

Change refers to statistically significant change, defined as change that exceeds the known variability of a given pixel based on population studies

Cirrus HD-OCT GPA Analysis

Trend Analysis: Summary Parameter

A Regression Line is drawn to determine rate of change for all the data that has been collected over time.

Less variability with Structural/OCT testing as compared to Functional/ Visual Field testing.

TSNIT Progression Graph TSNIT values from each exam are shown Significant difference is colorized yellow or red Yellow denotes change from both baseline

exams Red denotes change from 3 of 4 comparisons

0

50

100

150

200

250

0 50 100 150 200 250

RN

FL

T (m

icro

ns)

TSNIT



New Updates on Cirrus HD-OCT (Zeiss):Ganglion Cell Analysis

Ver 6.0

Updated Guided Progression Analysis (GPA™)Optic Nerve Head information now included

• Average Cup-to-Disc Ratio plotted on graph with rate of change information.

• RNFL/ONH Summary includes item “Average Cup-to-Disc Progression”.

• Printout includes an optional second page with table of values, including Rim Area, Disc Area, Average & Vertical Cup-to-Disc Ratio and Cup Volume. Each cell of the table can be color coded if change is detected.

Ver 6.0

Updated Guided Progression Analysis (GPA™)

81

Page 1 Page 2

Ver 6.0

Provide the best possible glaucoma care to your patients

1The Eye Diseases Prevalence Research Group. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122(4):477-485.

2Classe JG. Glaucoma--a clinicolegal review. J Am Optom Assoc. 1997; 68:389-394.

•Find more glaucoma suspects

•Diagnose glaucoma earlier

Glaucoma is a leading cause of blindness in the US

Over a million people in this country have glaucoma but don’t know it.1

Failure to diagnose open-angle glaucoma is a leading cause of liability claims involving eye care practitioners.2

Retina Retina AMD

1.47% >40 age have Macular Degeneration

Over 7 Million at risk for AMD Drusen >125um

1.75 million individuals in US w/significant AMD15% of the white women older than 80 yearsAMD will increase by 50% to 2.95 million in 2020

Source National Eye Institute Citations and Abstracts from April 2004 Archives of OphthalmologyPrevalence of Age-Related Macular Degeneration in the United States The Eye Diseases Prevalence Research Group



AMD Risk Factors

Smoking Smoking may increase the risk of AMD.

Obesity Research studies suggest a link between obesity and the progression of early and intermediate stage AMD to advanced AMD.

Race Whites are much more likely to lose vision from AMD than African Americans.

Family History Those with immediate family members who have AMD are at a higher risk of developing the disease.

Gender Women appear to be at greater risk than men.

Many faces of AMD

Dry AMD Dry AMD

HD Raster with Enhanced Depth Imaging (Cirrus)

HD 5 Line Raster

Classic CNVM

20/40 CF@ 5 ft



Advanced RPE AnalysisGain new insights on your AMD patients

• RPE Elevations. If the RPE is raised above a baseline plane, a new proprietary algorithm for Cirrus maps and measures the area and volume of the elevations.

• Sub-RPE Illumination. If the RPE is absent or has lost integrity, the OCT beam penetrates into the choroid. A new proprietary algorithm for Cirrus can determine when this occurs and then map and measure the affected area.

RPE Elevations Sub-RPE Illumination

92

PED Missed PED

Idiopathic CNV

Retina

Retina-Diabetes

1 in 17 Americans or 16 Million with Diabetes 10.2 million US adults 40 years and older known to have

Diabetes Mellitus (Proliferative/Non or DME) 4.1 million US adults 40 years and older have diabetic

retinopathy 3.4% or 4.1MM of Population w/vision threatening

retinopathy

Source National Eye Institute Citations and Abstracts from April 2004 Archives of OphthalmologyThe Prevalence of Diabetic Retinopathy Among Adults in the United States



DME CSME

Full Thickness Macular Hole

Macular Hole

Vitreo Macular Traction: OCT

Anterior Segment Moduleprovides a close up view of chamber angles

Anterior Segment Imaging



Lasik Flap Cornea, Angle & Sclera Mode

Cirrus HD-OCT Anterior Segment Imaging

Images courtesy of Martha Leen, M.D. & Paul Kremer M.D. Achieve Eye and Laser Specialists, Silverdale, WA

Cirrus Anterior Segment Imaging

Cirrus HD-OCT scan of normal cornea. Layers identified with colored arrows as follows: tear film (blue), epithelium (white), Bowman’s layer (red), Descemet’s/endothelium (green).

Cirrus Anterior Segment Imaging

Cirrus HD-OCT image with a visible angle recess (blue arrow). Schlemm’s canal is very well clearly seen (red arrow).

RTVue Clinical Applications

GlaucomaRetina Anterior Chamber



MultiColor Technology

MultiColor image composed of three selective colourlaser images

Infrared, green and blue reflectance

Automatic color balance to match fundus appearanceon photographs

Limitations:

Optic disc colour doesnot match natural appearance

Uveal pigment appears pale

MultiColor

The Versatility of MultiColor Imaging

View images of individual laser colors to gain better understanding of anatomic and pathologic detail at different depths within the retina

ERM, RNFL, macular pigment

blue reflectance

blood vessels, blood, excudates

green reflectance

drusen, RPE, choroid

infrared reflectance

Image courtesy of S. Wolf, MD, PhD, Bern, Switzerland

Online Education Widely Available

http://www.elearning.zeiss.com/

How do you view all of this data and image imformation?

Image Management System.

Designed for EyeCare



“Why would I need more than an Electronic Health Record (EHR) system for my ophthalmic practice?

IMS

A Few Definitions

Acronym Term

DICOM Digital Imaging and Communications in Medicine

EHR Electronic Health Record

EMR Electronic Medical Record

IMS Image Management System

PACS Picture Archiving and Communication System

HIS Health Information System

PMS Practice Management System

117117

The IT Landscape in an Ophthalmic Practice IT integration is key

IMS

EHR / EMR

Medical charts. Documentation of clinical decisions, treatments and prescriptions

PMS or HIS

Manages the practice business (administration, scheduling, accounting, billing)

Manages and archives diagnostic reports and images.Viewing, comparing and reviewing ophthalmic data

Medical data standard protocols

What does an EHR alone offer?

Clinical Management EHR/EMR IMS (PACS)

Medical charting √

Treatment Plan √

Ophthalmology exam templates √

e -prescribing √

Report storage √ √Raw data storage from instruments √

Central scheduling of patient tests √

Side-by-side report viewing √

Customizable viewer for images and reports √

Combined reports from instruments √

Full resolution images (Fundus Images) √

Practice Management

Billing √

CCHT Certification √

AARA Certification √

Clinical Management EMR/EHR

IMS (PACS)

Medical charting √

Treatment Plan √

Ophthalmology exam templates √

e -prescribing √

Report storage √ √

Raw data storage √

Central scheduling of patient tests* √

Side-by-side report viewing √

Customizable viewer for images & reports

√

Combined reports from instruments √

Full resolution images (FundusImages)

√

Practice Management

Billing √

* A feature that helps reduce errors in formatting patient records

What can EHR + an IMS offer?

An Image Management System helps:

•Reduce errors

•Save time

•Better appreciate patient’s diagnostic data

Clinical Need IMS Feature

Store all test data & reports on a server

Broad device connectivity via DICOM & file imports

Perform change analysis (GPA) Centralized, raw data storage

See your HFA data in your EHRA single FORUM - EHR interface with manyEHRs supported

Review reports in contextDisplay VF, OCT, fundus photos, structure-function GPA side by side

Clean up legacy recordsMerge tool to find & merge multiple patient records using a variety of match criteria.

Innovative analyses Combined Visual Field - OCT Reports

Patient education Customizable viewer for images and reports

What clinical needs can an IMS uniquely address?



An IMS can integrate patient data in unique waysExample: VF-OCT combined report

Zeiss Forum Viewer Software

Zeiss Forum Viewer Software Zeiss Forum Viewer Software

Zeiss Forum Viewer Software Zeiss Forum Viewer



Zeiss Forum: Combined ReportForum Glaucoma Workplace

Forum Glaucoma WorkplaceFORUM 3.2

What‘s new ?

131

Clinical Displays – Auto-selection rules

Cataract 1.Display is set to 3 x 1 (fixed arrangement)

2.The following documents are selected automaticallyA. Left panel: Overview report from CZM Atlas

B. Middle panel: Macular Thickness Analysis Report from CZM Cirrus or Stratus

C. Right panel: IOLMaster report

3.The most recent visit date will be selected. All documents must be from the same date

4.Laterality (R/L) according to the user selection: IOLMaster report with laterality ‘Both‘ is selected in both cases (R/L)

132


Glaucoma (OCT-VF-FI)1.Display is set to 3 x 1 (fixed arrangement)

2.The following documents are selected automaticallyA. Left panel: ONH and RNFL Analysis report or RNFL Thickness Analysis report from CZM Cirrus

B. Middle panel: SFA report from Humphrey Field Analyzer

C. Right panel: COLOR Fundus Image


4.Laterality (R/L) according to the user selection: ONH / RNFL report with laterality ‘Both‘ is selected in both cases (R/L)



133


Glaucoma OU (OCT-VF-FI)1.Display is set to 3 x 1 (fixed arrangement)

2.The following documents are selected automaticallyA. Left panel: COLOR Fundus Image of the right eye

B. Middle panel: HFA Visual Field and Cirrus ONH (/RNFL) Combined Report

C. Right panel: COLOR Fundus Image of the left eye


134


Glaucoma Progression (FI)1.Display is set to 2 x 2 (fixed arrangement)

2.The following documents are selected automaticallyA. Top left panel: COLOR Fundus Image from the patient’s latest ( / current) visit

B. Top right panel: COLOR Fundus Image from the patient’s 2nd latest ( / last) visit

C. Bottom left panel: COLOR Fundus Image from the patient’s 2nd earliest visit

D. Bottom right panel: COLOR Fundus Image from the patient’s earliest ( = first) visit

3. Laterality (R/L) according to the user selection

135


Glaucoma Progression (OCT-VF)1.Display is set to 4 x 1 (fixed arrangement)

2.The following documents are selected automaticallyA. Left panel: GPA Optic Disc Cube report CZM Cirrus – Right eye

B. 2nd panel from left: GPA report from Humphrey Field Analyzer – Right eye

C. 3rd panel from left: GPA Optic Disc Cube report CZM Cirrus – Left eye

D. Right panel: GPA report from Humphrey Field Analyzer – Left eye

3.The most recent GPA reports will be selected.

136


Retina Overview1.Display is set to 3 x 2 (fixed arrangement)

2.The following documents are selected automaticallyA. Top left panel: COLOR Fundus Image

B. Top middle panel: RED FREE / GREEN Image

C. Top right panel and bottom panels (left to right): 4 phases of a FA or ICG series: i. Early phase (earliest image within 0 s and 25 s), ii. Earliest image within 25 s and 1 min, iii. Earliest image within 1 min and 2 min, iv. First image after 2 min


4.Laterality (R/L) according to the user selection

137


AMD Progression (OCT)1.Display is set to 4 x 1 (fixed arrangement)

2.The following documents are selected automaticallyA. Left panel: Macular Thickness Analysis report (Cirrus or Stratus) from the patient’s earliest (= first) visit

B. 2nd panel from left: Macular Thickness Analysis report (Cirrus or Stratus) from the patient’s 2nd earliest visit

C. 3rd panel from left: Macular Thickness Analysis report (Cirrus or Stratus) from the patient’s 2nd latest ( / last) visit

D. Right panel: Macular Thickness Analysis report (Cirrus or Stratus) from the patient’s latest ( / current) visit

3. Laterality (R/L) according to the user selection

Image Management Systems

Topcon Synergy

OIS Symphony Web

Canon Retinal Imaging Control Software

Kowa DigiVersal

EHR Systems Generally don’t offer as

much functionality

All should be “DICOM” compliant



Retain the glaucoma/retina patients that you identify

Increase patient retention rates by:• Diagnosing patients early

• Educating them on glaucoma and retina pathology

• Managing them with state-of-the art technology

YOU WILL MAXIMIZE YOUR RETURN ON INVESTMENT WHLE PROVIDING BETTER PATIENT CARE

OCT in Optometric Practice:

[email protected]

Documents

Boomers Disease Dectection Growth - Kansas Optometrickansasoptometric.org/pdfs/Speaker Handouts for Convention 2014...Optimize Revenue FIRST YEAR GLAUCOMA ... “3 Reasons your Optometry