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From Retinoscopy to Wavefront
Dori M Carlson, OD, FAAO
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Disclosure
Owner, Heartland Eye Care, PCServes on Advisory Boards for Alcon
and Allergan - Honorarium
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What technology has shaped our lives
recently?
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What Changed in 1967?
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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
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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
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AT&T put up the first cellular system in Chicago
Click icon to add picture
1983:
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Consider how technology has
changed to conduct an eye exam
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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
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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?
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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
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(Image: Alcon Inc.)
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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
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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
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00
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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?
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-
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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
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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
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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.
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Clinical Applications for Wavefront Technology
LASIKKeratoconusWavefront guided ophthalmic lenses
iZon, I.scriptionWavefront guided contact lenses
Waveform
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Case Report
86 yo WF Diabetic without ocular signsPseudophakic OUDry EyesEarly RPE changes in the macula
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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
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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
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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
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Case Report #2
85 yo WF Pseudophakic OUS/P YAG Capsulotomy OU1+ RPE changes in macula OU1+ drusen in macula OU
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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
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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
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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
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Health EvaluationClear corneasNegative rubeosis3+ nuclear sclerosis with 3+ Posterior
subcapsular cataract OD2+ nuclear sclerosis OSGoldman tonometry 20 mm Hg OUPupils equal and reactive
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Retinal Evaluation
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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
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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
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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
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Is It Time For a Change?