Me, myself, and AI: The autonomous cataract practice

I run a solo medical and surgical cataract practice without full-time employees. Here is how it works, and why I think it represents an alternative pathway in ophthalmic practice.

I have had an unusual career in ophthalmology. After working as an employee at 2 different practices and gaining the skill set for high-volume cataract surgery, I started my own practice from scratch in 2011. I rented 1 suite with a shared waiting room, put a phoropter and slit lamp in it, and performed every task from biller to check-in. I slowly replaced myself with a staff member in each function as I grew. I eventually built the practice to several physicians and multiple locations and sold it to a private equity company. In 2024, I started again from scratch, alone, this time replacing myself in each area with avatars and automation as I grew.

What I am about to detail is not a theory of how a practice might work, or a business plan for a futuristic tomorrow. This is how I practice right now. I have patients on Monday morning, this Monday morning. I have surgery on Tuesday afternoon. This week, and every foreseeable week into the future.

Let me explain how it all works.

The plan

Every morning, at 9 AM, I plan to see 1 new patient referred for cataract surgery. One. Monday through Friday brings that to 5 cataract referrals a week, an average of 10 potential cataract surgeries a week, and, over time, 10 YAG capsulotomies a week. That is the entirety of the plan, so let’s think it through.

Ten cataract surgeries a week on Tuesday afternoon means ten 1-day post-ops on Wednesday and ten 1-week post-ops on Monday afternoon. Thursday afternoons are for the potpourri of patients who find their way in through word of mouth or insurance referrals for dry eye and glaucoma. I leave Friday afternoon off. I am looking for a balance that includes quality of life and personal time. That fills my afternoons, and each morning remains devoted to 1 cataract patient.

I spend the first hour of the day with my new cataract patient after their automated check-in. I perform the exam and all of their testing. While I perform the exam, I introduce them to the basic concepts. I remove the astigmatism from their refraction, then put it back in, then demonstrate it on my eye model. When it comes time to speak about corrective lenses for cataract surgery, they will understand. During the exam, I get to know them, what they want from their cataract surgery, what their hobbies are, and what they are hoping to achieve. Once the exam and testing are over, after approximately 1 hour, my surgical scheduler takes over.

My surgical scheduler is also me, or rather, a video and avatar compilation of me. My avatar slowly walks the patient through their surgical paperwork. He is incredibly patient and never minds being paused, rewound, or replayed. He is fond of answering the same question 100 times and never so much as bats an eyelash at it. While patients are doing paperwork, I am performing YAG capsulotomies as needed from prior months’ surgeries. Once paperwork is completed and scheduling for surgery is done (all automated via QR links), I rejoin the patient to answer any questions, review all paperwork, discuss all their options, and make sure they do not have even one item left to ask me about. From 11 AM to 12 PM is their time. Even if they run out of questions about their eyes and want to know where I grew up or if I play an instrument, their visit is finished when they say it is (Figure 1).

The revenue

I use Medicare payments as a low benchmark for cataract and testing reimbursement,¹ and use national disease prevalence rates to estimate which tests patients may need for glaucoma,² age-related macular degeneration,³ diabetes,⁴ and Fuchs dystrophy⁵ (Table 1).

Applying these assumptions to the weekly schedule gives a fair estimate of revenue at both the building phase of the practice (half volume) and its maturity (full design) (Table 2).⁶ Although the final numbers pale in comparison to a busy high-volume solo practice, I take them at face value, at approximately $850,000 at full design, and consider the other side of the coin: overhead expense.

Overhead expenses

This is an area in which this new modality of practice truly differentiates itself from the standard private practice model. Without staff, staff health care, payroll, payroll expenses, payroll taxes, payroll legal and administrative fees, and the need for managerial coordination, the overhead tops out under $250,000, even with greater equipment loan amounts than I have personally, having purchased some of my equipment outright (Table 3 and Table 4).⁷

How it runs

The keys to creating a practice like this include several steps. The first is planning. Every step must be chosen carefully in advance due to the unusual nature of this type of practice, and every step must have automation with the physician's oversight as its backdrop. The commitment to automation must be continuous. The world is changing in leaps and bounds, and I update my automations weekly.

• The setup and introductions. I chose a medically concentrated area (hospital adjacent, surgery center adjacent) and chose to introduce myself exclusively to the referrals I desired. In this type of practice, being overwhelmed is as bad as being underwhelmed. No advertising, no solicitation. Just an introduction to 3 to 5 referring optometrists to begin. Each introduction has to include why this is the most unique practice and the best fit for their patient. I typically say, “This is a concierge practice without the concierge fee.” I believe it to be true. I let them know I will spend the morning with their cataract referral, and they will leave satisfied. “My practice runs itself,” I am sure to mention. I give my chosen referring optometrists my card to be passed to the patient. It has a QR code on it. When the patient points their phone at it, it leads them through a self-scheduling menu. “Just fax me over the patient note and demographics,” I say to my referring physicians. A HIPAA-compliant large language model (LLM) analyzes every incoming fax, polls my electronic medical record (EMR) to determine whether the patient is new or established, and either creates a new chart with a self-scheduling link texted to the patient or files the fax to the existing chart. Voicemail messages run through the same system. This all happens automatically. I built it and I oversee it. I do not perform any task other than monitoring (Figure 2).

• The check-in. Even older patients less familiar with technology have a fair chance at automated check-in. I send 3 automated reminders prior to the visit that request the new patient paperwork (printout or online), identification, and co-pay. Most patients complete check-in this way. For the remainder, the electric me reminds them at the front desk. A motion sensor activates a TV as patients enter the office. An avatar appears and slowly walks them through scanning in their cards on their own phone, paying their co-pay, and completing paperwork. For established patients, it is just a co-pay reminder. The majority of check-ins are completed this way by giving patients a few minutes to get it done.
• Technician work and measurements. There are no shortcuts here. I do every refraction, though I use a machine that runs the algorithm and spins the dials for me. I take every IOLMaster (Carl Zeiss Meditec) measurement myself, and I find no changes in the accuracy of my measurements compared with when a technician did them. I had the company representative train me all over again when I bought the equipment. I find I know more about the eye when I do the testing myself. I already know if I have a dry eye patient, a corneal scar, a decentered ablation, or a retinal issue before I sit down to chat with the patient.
• Insurance understanding. The doctor can do the measurements and automate the check-in process, but how can a solo physician navigate the cryptic world of insurance? For this task, I have built a billing mind. Billing rules from my own knowledge and from consultant billers I employ are placed in a prompt combined with my fee schedule. Scripts organize the day's patients into batches, run them through insurance sites such as Availity, and feed the resulting reports into a HIPAA-compliant artificial intelligence (AI). The output is a “what will this patient owe” report for each patient (Figure 3). I run these past my consultant biller retrospectively and fine-tune the insurance “mind” every week. It is now rare for my consultant biller to find it in error.

• Recalling patients. Like every office, I have no-shows and reschedule patients all the time. I have scripts that download patient lists and place them in HIPAA-compliant bulk phone call and text programs. Even 100 patients to be rescheduled is just a few clicks. The list never goes down to zero, but it is manageable.

The things I do not plan to automate

• Surgery. Surgery takes place in a surgery center with full staff and all the bells and trimmings. The consents are cosigned by staff, the machines are the same, the routine is the same. There is no change here from the rest of my career. I rely heavily on the surgery centers I work with. They sterilize all of my instruments, provide preoperative and postoperative medications, and give me the strength in numbers that I think is best for all surgical procedures. Though I have no formalized statistics comparing my current results with my prior practice, there have been no cases of capsular rupture or endophthalmitis in this office to date, and refractive outcomes are within published benchmarks. This is expected given that my surgical technique is unchanged and surgery continues to be performed in fully staffed surgery centers.
• Back end billing. I do advise, at the very beginning of a new practice, that physicians become familiar with the back-end billing, posting, appeals, and claims process that is the financial furnace of the business. I have always felt it is poor form for a business owner to have a black box at the heart of his operation that is poorly understood. However, once it is learned, the sheer weight of it is best passed off to virtual staff. I have the same team that runs my EMR run my back-end billing.
• Advice. This may be more or less important at different stages of an ophthalmologist’s career. I keep a manager and billing consultant for questions that inevitably arise. Sometimes it is simply necessary to ask the person who has done it a thousand times.
• All forms of patient care. There is no patient question, medication refill, or patient request that I entrust to an LLM at this point. All medicine in my practice comes from me. Will I run a question past an AI? Sure, but it is subject to my final judgment. After 5 PM, all calls that leave messages are routed to my phone by text. If there is an emergency, it is on my cell phone.

What does it all mean?

Traditionally, ophthalmological practice over the past 50 years has broken down into fairly predictable patterns: academia vs private practice, and within private practice, group vs solo. There were always exceptions. Locum tenens, military, Veterans Affairs. But in general, the broad categories held true. I believe there is now another option, and like the options before it, it has its own ups and downs that need to be considered.

In this new type of autonomous practice, as I like to call it, the practice is designed around the physician. I built my practice around the type and amount of surgery I want. Nothing more, nothing less. I could have invested in tear film technology and built a clinic around dry eye had I wanted. My clinic is based on my ideal day. It has enormous responsibility falling on the shoulders of the owner. Need more cotton swabs? That was the owner’s job to order. On the other hand, one can drive the practice in whatever direction is desired. There are no board meetings or employee lunches. The day starts when I want it to and ends the same way. If my main goal is to be on the highway by 4 PM, I build my clinic to work that way. For me, this is the ideal semiretirement situation, and I have no plans to stop or to grow. It occurs to me that this is also a very interesting way to start an ophthalmological office. An owner who began in charge of every automation would have a very different and perhaps more futuristic growth pattern than has ever been seen before.

I won’t be taking that path. I am happy where I am. But I have a great interest in seeing physicians take charge of their own futures and their own practices. I think the ideal medical environment is one in which both the patient and physician feel very satisfied with the care that has been given and received. That very central tenet has been a struggle to meet these past few decades.⁸ That is part of the reason I feel an obligation to ring the bell and let my colleagues know: There has been a change.⁹ What you would like to do about it is up to you.

Oren N. Fass, MD

E: conciergeophthalmologydoc@gmail.com

Fass is a solo cataract and anterior segment surgeon at Denton Eye Consultants in Denton, Texas. He built his current practice from the ground up in 2024, integrating automation and AI-driven workflows across scheduling, billing, and patient communication.

Fass discloses the following commercial interests: He is the author of The Autonomous Physician (self-published book); the creator of The Autonomous Practice Blueprint (paid online course) and The AI Operations Lead (educational program for practice administrators); ModMed Ambassador; and a Keragon affiliate partner (receives commission on physician-referred signups to the Keragon automation platform). He has no other financial interests in any company or product mentioned.

References

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2. Ehrlich JR, Burke-Conte Z, Wittenborn JS, et al. Prevalence of glaucoma among US adults in 2022. JAMA Ophthalmol. 2024;142(11):1046-1053. doi:10.1001/jamaophthalmol.2024.3884

3. Singh RB, Stettler I, Romano F, et al. Prevalence of age-related macular degeneration in the United States: a Medicare-based analysis from 2014 to 2021. Ophthalmic Res. 2025;68(1):573-582. doi:10.1159/000548724

4. National Diabetes Statistics Report. CDC. 2024. Accessed September 15, 2026. https://www.cdc.gov/diabetes/php/data-research/index.html

5. Singh RB, Parmar UPS, Kahale F, Jeng BH, Jhanji V. Prevalence and economic burden of Fuchs endothelial corneal dystrophy in the Medicare population in the United States. Cornea. 2024;43(8):1022-1027. doi:10.1097/ICO.0000000000003416

6. Market Scope. 2024 United States Cataract Atlas Featuring the Market Scope Exclusive MedOp Index Analysis. April 2024. Accessed September 27, 2026. https://www.market-scope.com/pages/reports/440/2024-united-states-cataract-atlas-featuring-the-market-scope-exclusive-medop-index-analysis-april-2024

7. What independent doctors actually spend: practice overhead breakdown for 2026. GetPracticeHelp. March 26, 2026. Accessed September 23, 2026. https://www.getpracticehelp.com/blog/medical-practice-overhead-costs/

8. Fass ON. The hidden variable in the physician burnout debate. KevinMD. June 28, 2026. Accessed September 15, 2026. https://kevinmd.com/2026/06/the-hidden-variable-in-the-physician-burnout-debate.html

9. Fass ON. I use AI to run my practice with zero employees. Doximity Op-Med. June 22, 2026. Accessed September 15, 2026. https://opmed.doximity.com/articles/i-use-ai-to-run-my-practice-with-zero-employees