Download Retinoscopy to Wavefront 4

From Retinoscopy to
Wavefront
Dori M Carlson, OD, FAAO
Disclosure
 Owner,
 Serves
Heartland Eye Care, PC
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 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 1995 1.6 million people
0.4% of world population

December 2005 1,018 million
15.7 % of population

March 2013
38.8% of population

In 2013: 82% of the households in the US have access to the internet
2,749 million
1983:
AT&T put up the first cellular system in Chicago
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


-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 OU
Refraction:
+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
 LASIK
 Keratoconus
 Wavefront
iZon,
guided ophthalmic lenses
I.scription
 Wavefront
guided contact lenses
Waveform
Case Report
 86
yo WF
Diabetic
without ocular signs
Pseudophakic
Dry
OU
Eyes
Early
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
S/P
OU
YAG Capsulotomy OU
1+
RPE changes in macula OU
1+
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 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
 -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
 -4.75
– 0.25 x 064
20/60
20/40
Health Evaluation
 Clear
corneas
 Negative
rubeosis
 3+
nuclear sclerosis with 3+ Posterior
subcapsular cataract OD
 2+
nuclear sclerosis OS
 Goldman
 Pupils
tonometry 20 mm Hg OU
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?