Article Date: 2/1/2011

Providing Patients With the Best Technology

Providing Patients With the Best Technology

Discover how my personal experience with a system translated into better visual outcomes for my patients.

By John Warren, OD

With all the interest surrounding the move into primary eye care, including treatment of ocular surface disease, glaucoma and posterior segment diseases such as macular degeneration and diabetic retinopathy, many of us are guilty of leaving our “bread and butter” behind. The gains in technology in the diagnosis and treatment of ocular disease have been incredible, resulting in much better access to superior care for most of our patients. I'll bet that just about everyone reading this article has added one or more devices devoted to the treatment of ocular disease in the last 5 years. How many of you have done the same when it comes to the diagnosis and correction of refractive errors?

Because there's only one reimbursement code for refraction, and it's not something that's usually billed to major medical plans, there's no “new revenue” stream to be tapped into when it comes to refraction. That doesn't mean there haven't been any tangibly valuable improvements in the gathering and analysis of refractive error data. Whether you see a direct or indirect return on your investment when upgrading your refractive care technology, your patients all come in contact with your lensometer, autorefractor and phoropter during your eye care cycle. In fact, it's usually the portion of your professional care that has the biggest impact on most of your patients' visual well being.

We've been correcting lower-order refractive errors for so long that as eyecare providers we take them—and their correction—for granted. Not only can we provide a superior measurement and correction of lower-order aberrations than ever before, now we can measure and correct higher-order aberrations, either directly with new technology in eyeglasses and contact lenses, or indirectly by taking these aberrations into account both during and after we complete the refractive data-gathering process.

Taking Another Look at Refraction

Until recently, I was a lensometer, retinoscope and manual phoropter practitioner. That changed in 2007 at the AOA meeting in Boston when I personally underwent refraction with a “refracting system.” One of the Marco area managers used a 3-D Wave (auto-refractor, topographer, pupillometer and aberrometer combination unit) and an RT-5100 to perform a refraction on my post-RK presbyopic eyes. After seeing how quick and easy the refraction process could be, I looked into the specific capabilities of automated refracting systems.

The programmability of the systems automates the whole refraction process, from lensometry and autorefraction to the subjective testing, and finally the comparison of the current subjective refraction to the habitual prescription from lensometry. With button-pushing sequences, the phoropter is set up for each test in order, the chart is changed to the one desired and the refraction progresses smoothly from start to finish. If other testing is required during the refraction, or if the patient can't undergo one or more tests, you can “freestyle” as needed, abandoning the programmed refraction or continuing as desired.

Within 15 minutes, after discussing the system and all of its capabilities, I was talking about delivery and installation times. The decision was that simple. Let me share some specifics of my decision-making process.

Investing in Technology

The first consideration I measured was what I call the “Patient Experience.” The testing sequence and the tests themselves made the entire refraction process much simpler and easier for me as the patient. First, the accurate autorefraction resulted in a good starting point for the refraction. The second benefit was the ability to make a direct comparison between the “choices” during the cylinder axis and power tests. The TRS-5100 uses a split prism to show the patient both choices at the same time, which is a much easier decision process for the patient. This results in fewer questions and patient responses, and a much faster process. Third, was the ability to show the patient the difference between their habitual prescription and the new subjective prescription. They were able to easily see—and value—the difference between the two prescriptions, making it much simpler because patients can see what the change in prescription will do for them visually.

I chose to use the 3-D Wave as my autorefractor in my refracting system. Even though I already had a stand-alone topographer, the 3-D Wave provides so much additional data in one quick and simple testing stop that I chose it over a traditional AR/keratometer unit. The 3-D Wave provides me with several autorefraction values for each patient, topography, aberrometry, pupillometry and an external eye image in less than 30 seconds per eye. The multiple autorefraction values tell me how the patient's vision changes from the center of the pupil to the periphery of the pupil. Many patients undergo a small to moderate shift in sphere and cylinder power as well as cylinder axis as you move further from the center of the pupil.

I've described one such patient and the impact that this information had on his visual outcome in a sidebar to this article, but suffice it to say that I use the multiple refractions and aberrometry data every day with many patients.

Dr. Warren is in private practice in Racine, Wis. E-mail him at

Additional Data Makes a Difference
A 24-year-old patient presented for a “routine eye exam” with very vague complaints of poor vision. Under some situations, his vision wasn't as clear as he thought it should be. Entering uncorrected visual acuities were 20/20 in each eye.
His subjective refraction was
■ − 0.50-.50×91 OD
■ pl − 0.25×57 OS with 20/20 BCVA in each eye.
As you can see from his 3D Wave, there is a significant shift from his central refraction to the mid-periphery and periphery, approximately a -1.00 diopter shift in each eye.
At the conclusion of his refraction, even though he had not mentioned any visual concerns during patient intake, I asked him “is your night vision pretty crummy?” His answer was “how in the world did you know that?” I showed him the 3-D Wave and explained what it meant, much to his satisfaction. After showing him the difference between his daytime subjective refraction and the wavefront-optimized nighttime autorefraction, the patient was blown away by the increased clarity in low-light conditions.
I prescribed eyeglasses for wear in low-light situations such as driving at night, watching movies and so on. Having the information from the 3-D Wave as well as the ability to demonstrate the different prescriptions resulted not only in revenue from the pre-scripton, but also a new patient who is now a fan.
The final prescription used for his spectacles was:
■ −1.00-50×91
■ − 0.75-.50×57
While I didn't correct any higher order aberrations in this case, by utilizing the data from the 3-D Wave along with the results of the subjective daytime and nighttime autorefraction, I was able to identify this patient's vision issue and correct it.

The true power of an automated refracting system is in the integration of all of the components into a true system for evaluating the visual system of our patients. Having all of the data that we gather in one location to allow for comparison by the patient as well as doctor is very powerful. Patients can easily see, and value, the benefit of a prescription change as well as the impact that a special prescription can have on their nighttime vision.
It only took experiencing a refracting system once for me to realize what I'd been missing with my “tried and true” refraction tools. There's not one day that I regret having chosen to upgrade to my refracting system. My patients notice and appreciate the upgrade, too!

Optometric Management, Issue: February 2011