From Retinoscopy to Wavefront Dori M Carlson, OD, FAAO

Disclosure  Owner, Heartland Eye Care, PC  Serves on Advisory Boards for Alcon and Allergan - Honorarium

What technology has shaped our lives recently?

What Changed in 1967?

The Microwave: It Would Ruin the Fine Art of Cooking  Amana first introduced in 1967  In % of households owned one  In % of households owned one  Now 95% of the households in the US have a microwave  8.5% of those households have TWO

What Happened in 1982?  In 1982, the Internet protocol suite (TCP/IP) was standardized and the concept of a world-wide network of interconnected TCP/IP networks, called the Internet, was introduced  December million people 0.4% of world population  December 20051,018 million15.7 % of population  March 20132,749 million38.8% of population  In 2013: 82% of the households in the US have access to the internet

AT&T put up the first cellular system in Chicago 1983:

Consider how technology has changed to conduct an eye exam

And yet … Phororpters started to surface after the 1920’s with many looking like this in the 40’s The Ultramatic arrived in the 70’s

Hey doc, you have all this new technology but you still check my eyes with that thing… Male Patients between 40 and 55 Is it time for a change?

What makes Wavefront Technology different for determining refractive error?  Lower order aberrations  Sphere, Cylinder & Axis  Higher order aberrations  Represent between 15-20% of refractive error  60 different types have been identified  Trefoil  Coma  Quadrafoil

(Image: Alcon Inc.)

Causes and Symptoms of higher order aberrations  Corneal irregularity or scarring  Cataracts  Dry eye or irregular tear film  Trauma  Large pupils in dim lighting  Double vision  Blurred vision  Ghost images  Halos  Starburst  Low contrast  Poor night vision

JG 30 yo WM – Penetrating Metallic FB  Pounding on metal and split off a piece which passed through the cornea, lens and embedded in the retina  Refraction prior to the accident  DS 20/20  – 0.25 x 07020/20  Refraction after the accident  – 0.50 x 03420/25  – 0.25 x 07020/20  Now aphakic  Fit with soft contact lens  Has some issues with night driving

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SP – 71 yo WF  Presents saying “everything is blurry with my right eye”  Pseudophake OU  Refraction:  x /30  x 06520/25  So is 20/30 really that bad?

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Assumptions and Benefits of Wavefront  Assume the pupil is 4 mm in daytime conditions  Assume the pupil is 6 mm in nighttime conditions  A traditional auto refractor measures one point – essentially a pinhole refraction  Wavefront technology measures over 2,200 vectors so it objectively gathers more information about the visual system than a traditional auto refractor

 All provide an objective method for differentiating refractive error in bright or dim lighting conditions  Wavefront analysis can decrease chair time by using more objective measurements  By using the technology with an automated refracting system, you decrease chair time, increase ease of testing for the patient and create a WOW experience for the patient  Many integrate with EHR systems

What’s This?  -This is part of our refracting system. It measures your refraction or the prescription of your eyes. It measures it for daytime and night time, it measures your pupil size day and night and makes a topographical map of your cornea or the front of your eye.

Clinical Applications for Wavefront Technology  LASIK  Keratoconus  Wavefront guided ophthalmic lenses  iZon, I.scription  Wavefront guided contact lenses  Waveform

Case Report  86 yo WF  Diabetic without ocular signs  Pseudophakic OU  Dry Eyes  Early RPE changes in the macula

 2011:  x098 20/60  x /6020/50 binocular  Had an angle closure attack in her left eye during that year  Referred for a peripheral iridotomy  Patient returned and was unhappy with vision. Refraction done again without improvement in vision. Patient was referred to a retinal specialist who blamed decrease in vision on macular changes

 Returned in 2012 saying she still wasn’t satisfied with her vision  2012 – using wavefront analysis and automated refraction  – 3.00 x /30  x /40+ 20/25 when binocular

2011 OD: x /60 in 2011 she was 20/100 with this rx 2012 OD: – 3.00 x /30

Case Report #2  85 yo WF  Pseudophakic OU  S/P YAG Capsulotomy OU  1+ RPE changes in macula OU  1+ drusen in macula OU

2011:  x /30  x /2520/25 binocular  2012 she returned stating vision was getting worse  Entrance acuity was 20/30 OD, 20/40 OS, 20/30 OU  Refraction - using wavefront analysis and automated refraction  x /25  – 4.25 x /2520/20 binocular

Case Report #3  53 yo WF presents for first exam since 2011  Would like a new pair of glasses as she’s not seeing real well  Type 1 Diabetic for unknown length of time  Hypertension, Hypercholesteremia  Most recent Ha1c was 11.0, last time she checked her Blood Sugar it was 298  Onset of double vision earlier in the summer that has since resolved

Examination Findings  Entrance Acuity  CF OD, 20/50 OS  Right Intermittant Exotropia – not present in 2011  Lensometry  – 0.25 x 072  – 0.25 x 064  Wavefront Autorefraction – indicated it was a clean reading  – 0.25 x 009  – 0.50 x 013  Final refraction  – 0.25 x 07220/60  – 0.25 x /40

Health Evaluation  Clear corneas  Negative rubeosis  3+ nuclear sclerosis with 3+ Posterior subcapsular cataract OD  2+ nuclear sclerosis OS  Goldman tonometry 20 mm Hg OU  Pupils equal and reactive

Retinal Evaluation

Treatment Plan  Since the retinal exam did not show any signs of macular diabetic changes she has been referred for cataract surgery on both eyes  Hoping that once the vision is improved the exotropia will resolve  Discussed at length the ocular issues and how it relates to the poor control of her diabetes

 Surveys measuring patient perception or experience – no good surveys published  Do your own patient satisfaction survey  Consider asking specific questions about technology in the office  Consider your patient’s expectations

 Combined with automated phoroptors it can greatly decrease chair time and add efficiencies to your exam process  Wavefront technology is a tool that can aid in providing more individualized patient care

Is It Time For a Change?