From Retinoscopy to Wavefront

Dori M Carlson, OD, FAAO

Disclosure

Owner, Heartland Eye Care, PCServes 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 1971 1% of households owned one In 1986 25% of households owned oneNow 95% of the households in the US

have a microwave8.5% 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 1995 1.6 million people 0.4% of world population

December 2005 1,018 million 15.7 % of population

March 2013 2,749 million 38.8% 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

Click icon to add picture

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 55Is it time for a change?

What makes Wavefront Technology different for determining refractive error?

Lower order aberrationsSphere, Cylinder & Axis

Higher order aberrationsRepresent between 15-20% of refractive error60 different types have been identified

TrefoilComaQuadrafoil

(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

-5.50 DS 20/20

-5.50 – 0.25 x 070 20/20

Refraction after the accident

+5.50 – 0.50 x 034 20/25

-5.75 – 0.25 x 070 20/20

Now aphakic

Fit with soft contact lens

Has some issues with night driving

00

SP – 71 yo WF Presents saying “everything is

blurry with my right eye”Pseudophake OURefraction:

+2.00 -0.50 x 100 20/30+1.00 -1.00 x 065 20/25

So is 20/30 really that bad?

-

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

LASIKKeratoconusWavefront guided ophthalmic lenses

iZon, I.scriptionWavefront guided contact lenses

Waveform

Case Report

86 yo WF Diabetic without ocular signsPseudophakic OUDry EyesEarly RPE changes in the macula

2011: -0.25 -1.00 x098 20/60 -1.50 -0.25 x 095 20/60 20/50 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

+1.75 – 3.00 x 098 20/30 -0.25 -1.25 x 100 20/40+ 20/25 when

binocular

2011

OD: 0-.25 -1.00 x 098 20/60

in 2011 she was 20/100 with this rx

2012

OD: +1.75 – 3.00 x 098 20/30

Case Report #2

85 yo WF Pseudophakic OUS/P YAG Capsulotomy OU1+ RPE changes in macula OU1+ drusen in macula OU

2011: +2.75 -2.25 x 110 20/30 +2.75 -2.25 x 090 20/25 20/25

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

+2.50 -2.50 x 105 20/25 +3.50 – 4.25 x 091 20/25 20/20

binocular

Case Report #3

53 yo WF presents for first exam since 2011Would like a new pair of glasses as she’s

not seeing real wellType 1 Diabetic for unknown length of timeHypertension, Hypercholesteremia Most recent Ha1c was 11.0, last time she

checked her Blood Sugar it was 298Onset 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

-6.25 – 0.25 x 072 -3.75 – 0.25 x 064

Wavefront Autorefraction – indicated it was a clean reading -13.25 – 0.25 x 009 -4.25 – 0.50 x 013

Final refraction -13.50 – 0.25 x 072 20/60 -4.75 – 0.25 x 064 20/40

Health EvaluationClear corneasNegative rubeosis3+ nuclear sclerosis with 3+ Posterior

subcapsular cataract OD2+ nuclear sclerosis OSGoldman tonometry 20 mm Hg OUPupils 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?