Your startup costs can be broken down into one-time equipment purchases and recurring monthly expenditures. For now, we will focus on one-time ophthalmic equipment purchases.
During training you were exposed to a specific subset of ophthalmic equipment that is available. Most people I know have familiarity with Haag-Streit, Zeiss, and Heidelberg products. There is nothing wrong with sticking to the familiar and purchasing the same equipment you used as a resident or fellow. However, it's definitely worth it to go to trade shows (e.g. AAO, ASCRS, etc) and check out other company's offerings. You will likely find good equipment from companies you didn't know existed.
There is an unfortunate lack of independent ophthalmic equipment review sites, so I’ll do my best to give you my impressions of the options I considered. However, I encourage you to branch out and trial different brands at trade shows and other practices.
Ophthalmic Equipment
Autolensmeter
It’s hard to go wrong with autolensmeters and autorefractors. You could buy a manual lensmeter and manifest everyone rather than have an autorefractor, but the convenience of having these tasks largely automated is huge. This is particularly true when you have support staff of varying skill levels. I didn’t see a large difference between autolensmeters. I went with the LensChek Pro because it integrated with my EMR and measured IPD, UV coating, and contact lenses.
Topcon-CL-300 (used): $2750
LensChek Pro: $3800
Topcon LC-100 (used): $1695
Autorefractor (AR)
Again, not a huge difference in features between these machines. I got the one that integrated with my EMR. Be careful not to overspend on an AR. There are autorefractor-keratometer (ARK) devices available, but the keratometry values are not better than a dedicated keratometer. I got the OptoCheck Plus.
Topcon RM800 (used): $6000
Topcon KR8900 (used): $6500
Topcon KR8000 (used): $4995
Nidek Tonoref II: $8500
OptoChek Plus: $6595
Visual acuity system
Most practices won’t need a particularly fancy visual acuity system. Since they all do the same thing, I would just determine what is important to you and get the cheapest one. For example, if you are going to be measuring contrast sensitivity doing pediatric ophthalmology, having additional functions beyond simple Snellen/ETDRS measurements will be important. At the time I was buying, Reichert had an instant rebate that made them the clear choice.
Reichert Clearchart 4: $2187 (no rebate)
Ibex: $2000
Premier Acuity 1000: $1095
Lombardt CVS: $2195
Optical Coherence Tomography (OCT)
I can’t really think of a practice that would not benefit from having an OCT available (perhaps a purely cosmetic practice). These devices vary widely in price depending on the technology they employ. The swept-source machines are far more expensive than the typical spectral domain OCTs (SD-OCTs). For a non-retina practice, an SD-OCT is sufficient. As a cornea specialist, I wanted one that also did anterior segment OCT. This narrowed my search considerably.
Topcon Maestro 2: $50,000
Optovue RTVue: $30,000
Heidelberg: way too expensive; I heard near 6 figures for one of these so I didn’t even get a quote
The major differences between the Maestro 2 and the RTVue are functionality and build quality. The Maestro 2 also functions as a color camera, giving you posterior and anterior segment photos in addition to the typical macula and optic nerve OCT scans. It also can automatically create a retinal color photo montage, obviating the need for an optos or other wide-field imaging device.
The RTVue is a good budget device if you don’t care about taking clinical photos or wide-field imaging. I was unimpressed with the RTVue in general when I tried it at a meeting and was annoyed that it would require an expensive software package and additional hardware to match the functions of the Maestro 2. The final price to make it comparable to the Maestro 2 was around $40,000. I got a $10,000 instant rebate on the Maestro 2, making my decision easier.
Biometry
By far the most common biometers in training are the Zeiss and Haag-Streit products. Both the IOL Master (Zeiss) and Lenstar (Haag-Streit) do an excellent job. I had used them as well as the Pentacam-AXL and Topcon Aladdin before going solo. In general, they seemed to provide equivalent data. However, the on board formulas differ. So your choice of machine should be guided by your preferred formula suite and the functionality.
During training my favorite was the Lenstar though the IOLM 700 was also quite nice.
IOLM 500 (used): $18,500
IOLM 700: $70,000
Argos Movu (from Alcon): $87,000 (offered with $27K off for final price of $60K)
Lenstar 900: $36,000
Lenstar 900 APS: $38,000
Topcon Aladdin: $34,000
Pentacam AXL: $82,000
Scheimpflug imaging
This is a must for cornea specialists and anyone who plans on doing laser vision correction (LASIK/PRK). Since I fell into that group, I bought one from the outset. I had experience with both the Ziemer and Oculus products during training and my time as an academic ophthalmologist. The G4 and the HR do almost the same thing with a few differences.
The Pentacam line has no Placido disk based topography (the standard for current generation IOL formulas).
The G4 has higher order aberration analysis built in (unavailable in the Pentacam HR but standard in the Pentacam AXL).
Since they were essentially the same price used, I decided to get the unit that provided more functionality.
Ziemer Galilei G4 (used): $44,000
Oculus Pentacam HR (used): $45,000
Oculus Pentacam HR (new): $62,000
Oculus Pentacam AXL (new): $82,000
Exam chair/stand
I ended up with the Reliance products for my chairs & stands. There were substantial savings to be had by bundling the products at the time I bought them. Also, the 700 WC qualified for the ADA tax credit (see below). I don’t think you can go wrong here outside of getting a mechanical chair whose components may break if a patient exceeds the weight limit.
Reliance FX-920L: $6215
Reliance 700IC: $4512
Reliance 700WC: $4955
Wheelchair chair mover: $800-1200 (vendor dependent)
Marco Encore chair (used): $2450
Marco Deluxe 2 stand (used): 2650
Marco Encore chair (new): $5595
Marco Deluxe 2 stand (new): $4450
Visual field
I am not a glaucoma specialist and so did not have a strong opinion on which visual field machine is best. I had experience with both the Haag-Streit Octopus and the Zeiss Humphrey machines. For my needs, there was very little difference outside the price tag. Both the Octopus 600 and 900 provide the kind of visual fields I need for my practice, so I went with the less expensive option. The Octupus products also frequently have a $2500 rebate on Haag-Streit's website.
Octopus 600 pro: $16,155
Humphrey: $40,000
Yag/SLT laser
This is an excellent place to go with a used product from a reliable brand. Since I planned on doing some glaucoma, I bought a combination laser. If you aren’t interested in performing SLT, the cost of a yag laser should be at least $5,000 less. I’ve used both of the lasers below in the past and like the optics on the Ellex the most. In addition the Ellex unit was newer, which made my choice easier.
You may find that your surgery center already owns a laser, which would allow you to defer this purchase (perhaps indefinitely). If so you will save a substantial amount of money that can be used to meet your overhead instead. However, you will be forced to move patients to a secondary location for quick procedure and bill them at a more costly location (hospital/surgery center setting versus clinic setting).
Ellex Tango (used): $36,500
Lumenis Duet (used): $30,000
B-scan/A-scan
Your desire to have a b-scan/a-scan on hand may be different than mine. As a cornea specialist, I wanted to have some way to get an axial length measurement in someone with a dense corneal opacity or hypermature cataract. Fortunately for me, my vendor included an old used a-scan at no cost to me.
As far as B-scans go, you can get a dedicated B-scan for around $4,000-$5,000. One integrated with an a-scan is about another $500-$1,000. There is an alternate ultrasound that hooks up to your smartphone for about $2,000 (https://www.butterflynetwork.com/). One of my friends has this and really likes it. I didn't buy a B-scan right away.
Tonopen/iCare
Some form of tonometry that is easy for your future technicians to use is helpful. Both the Tonopen and the iCare go on sale pretty consistently. They get the same information with similar accuracy. I got Goldmann tonometers with my slit lamps, so the specific method didn’t make as much difference to me. There a little bit of a price difference between the different iCare models.
iCare (new): $5000 - $6000
iCare (used): $3000
Phoropter
I am not a fan of the electronic phoropters, so I got quotes on new and used Reichert +cylinder manual phoropters. I went with a used one for the savings.
New: $4695 - $5922
Used: $2950 - $3890
Slit Lamp
The pricing here is pretty variable depending on the kind of equipment you want. If you're a Haag-Streit fan, be prepared to pay for it. If you don't care, and want something used/more cost effective there are a lot of good options out there. I ended up trying all of the slit lamp brands below and wound up getting new Marcos. Even if you get the imaging module on the Marco slit lamps, you can get two for the price of one new Haag-Streit slit lamp.
Topcon (new) - $6,000-$8,000
Marco (new) - $7,000
Haag-Streit BQ900 (used) - $13,000
Haag-Streit BQ900 (new) - $19,000
Haag-Streit with imaging (new) - $26,000
Tables
Now that you have a bunch of equipment. You'll need some tables to put your AR/ARK, visual field machine, OCT, etc. Each table runs about $600 to $2,000 depending on the size of the table. The more expensive ones can hold more equipment. Your vendor should be able to recommend specific table sizes for your purchases.
Handhelds
Ishihara plates, Randot stereo testing, exophthalmometer, retinoscope, transilluminator, batteries/handles, prisms, etc. If you get the bulk of your equipment from a single vendor, they will most likely throw in a lot of these items to help seal the deal.
Shipping & Freight
You should not pay for shipping. This is one of the easiest line items to negotiate away. Typically you will have to pay the freight costs but that should be it.
Warranties
Purchasing an extended warranty really depends on your risk tolerance. Some quotes charged up to $10,000 for a 3 year warranty. I decided to avoid extended warranties. My vendor supplied an additional year of servicing after the manufacturer warranties ran out, which I deemed sufficient.
Taxes
Be sure to include sales tax for your state as a separate line item in your budget. My sales tax bill ended up being more than $10,000.
Rebates/Tax Credit
There are an incredible amount of manufacturer rebates out there. Most of my big-ticket items (e.g. OCT, VF, etc) had an offer of up to $10,000 off in instant rebates with equipment trade-in. Since I didn’t have any equipment to trade-in, my vendor offered to use the serial number from some of their old equipment to secure the rebates. In total I saved $14,750 from rebates alone. Since I got one chair and stand that are specific to wheelchair access, I was able to secure the Americans with Disabilities Act tax credit ($5,000). In sum my savings became $19,750 (which offset the sales tax and freight charges and then some).
The total I spent on all my ophthalmic equipment was $246,561 plus $13,560.86 in sales tax for a total of $260,121.86. If you don’t need Schiempflug imaging and want to wait on a SLT/Yag laser, your costs will go down substantially.
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