Article Date: 3/1/2013

Wavefront Optimized Refraxion

Wavefront Optimized Refraxion

By linking autorefraction with wavefront aberrometry, Marco XFRACTIONSM explores an exciting relationship.

By Louis J. Catania, OD, FAAO, DSc

In order to optimize refraction by combining it with higher-order aberration data, Marco has developed what it calls the XFRACTION process. In my practice, where we’ve utilized EPIC work-stations and TRS-5100 digital refractors for 10 years, as well as Marco’s OPD-Scan series of wavefront aberrometers for about 8 years, we helped develop and utilize this process.

The idea of tying refraction with aberrometry began to evolve in the course of research several years ago when we began to see a potential relationship between vision and refraction. To explore this potential relationship, Marco decided to commission software that would evaluate patient data and present it to doctors in a practical way. I worked with the developers for 2 years as an advisor, helping them understand the concept of what we wanted to create. The end result is the XFRACTION process — a much-needed, effective, and practical clinical tool.

Clinical Benefits

At a glance, it’s easy to see how the XFRACTION process delivers a great deal of data, producing more than 20 measurements of the visual system every time you press a button on the joystick. The information is available if you need it during the exam, allowing you to simply select the measurements that are most important to each case.

For starters, we gain more valuable information from the system’s refraction than can be obtained from a routine refraction. Not only is the XFRACTION process very accurate and comprehensive, but it also incorporates pupillometry. We now understand the intimate relationship between the size of the pupil and the patient’s vision, and with XFRACTION, we have a more complete picture by controlling pupil size for both higher- and lower-order values.

The integration of wavefront aberrometry allows us to understand the visual phenomena experienced by our patients. In addition to what I see in the slit lamp and indirect ophthalmoscope related to vision, I also have access to refractive data I’ve never had before during an exam.

This helps in very practical, routine ways. For example, when a patient reports experiencing night vision problems, I can look at the fourth-order aberrations and analyze the problem. If a patient experiences doubling and halos, I look at third-order comas. For patients who don’t refract to 20/20, I can find out if it’s a functional problem or pathology. The data is all there.

For routine full exams, I use XFRACTION’s basic components: digital refraction, wavefront refraction, pupil size and total higher-order aberrations. I choose whether to use the remaining data gathered by the system based on each patient’s clinical findings. XFRACTION may also provide advantages in some cases when patients present with medical complaints. For example, XFRACTION can help me determine if patients have severe visual effects from their condition, or even mild ones from dry eye or other ocular surface disease.

We’re also learning a great deal about patients’ “just noticeable difference” (JND) from aberrometry. This is something we’ve never really applied in refraction because we didn’t have the higher-order data to put it together. Now we can determine this because we’re no longer relying on the “Which is better, 1 or 2?” method. We know that the best eyes still won’t discriminate between less than 0.1 diopters; in fact, 20/20 eyes can’t discern less than 0.2 diopters. Instead of relying on patients’ perceptions, we can now measure the JND scientifically.

Business Advantages

Every new technology we purchase has to not only enhance clinical outcomes, but also do it in a way that has no negative effect on our efficiency. The speed of the XFRACTION process actually increases efficiency while providing other business advantages.

Efficiency is a key to any successful practice. Most significantly, routine processes must be as efficient as possible to move patients through their visits. The XFRACTION system gives us a rapid, accurate refraction, providing the efficiency we need for business value without compromising the quality and accuracy of refractive readings. In addition, Marco’s XFRACTION devices all work effortlessly with practice management software and electronic health records, saving data entry time and reducing transcription errors.

Ultimately, these efficiencies give doctors more time, which they can spend with patients or fill with more medical or refractive patients to increase revenues. The choice of how to reinvest time — our most valuable commodity — is yours.

XFRACTION also offers different business advantages based on whom you choose to operate the system. If you feel comfortable delegating this task to your technicians, it saves you time and increases overall efficiency. If you choose to do the testing yourself, then you’re still using less time than with traditional manual refraction. The extra time can also be spent providing optical advice that has a great deal more weight coming from a doctor than coming from the optical area of your practice. This converts into a business value, as patients are potentially more likely to purchase the vision correction options that their doctor recommends.

Finally, because XFRACTION enables us to see and measure a patient’s JND, correction is more accurate. Fewer patients return with complaints, and if they do return, we are better equipped to help them, based on aberrometry and XFRACTION information. Higher patient retention and referral would also be a logical expectation.

Patient Rewards

We see the value of XFRACTION in terms of clinical and business results, but what does the patient see? Happily, XFRACTION is a technology that shows patients they’re getting something better, rather than relying on us to convince them.

With XFRACTION, patients immediately recognize that their doctor doesn’t use the same phoropter they’ve seen for decades. Instead, they see a digital refractor that has progressed with the rest of the world.

I used to think that the technology might be more of a potential risk or disadvantage with the geriatric population. Perhaps they’d want their refraction done the same way it had been for the last 60 years. Instead, those patients are very impressed, and that “wow factor” is often expressed literally with a “Wow!” The vast majority of patients think it’s great. And of course, younger patients appreciate a fresh approach as well.

The psychological effects of seeing new technology in the practice — particularly boosted confidence in the doctor — are a plus for new technology in general and for refraction in particular because that’s the cornerstone of our work.

What’s more, the process patients go through with this new hardware isn’t a dramatic shift. If we confronted them with something out of Star Trek, they might feel intimidated, but the EPIC, OPD-Scan and TRS digital refractors still have them sitting and looking through a device shaped like a refractor. It’s a seamless transition for them. I think patients also feel more comfortable with the automated process that gets them out from under the “Which is better, 1 or 2?” process. The XFRACTION process of digital autorefraction optimized by wavefront aberrometry, whether through the EPIC workstation or a TRS refractor in a standard refracting lane, generates real patient reassurance.

The system also has value for patients as a teaching tool — a way to show them their eye problems. For example, I can put a Zernike map on the screen, or print a hard copy, and explain that we want to see a nice, smooth color pattern. If their map appears half red and half blue, I explain that this indicates two focuses coming through the pupil and causing the problem. Or I might show patients their spherical aberrations with rings of blue and yellow to explain night vision halos and other problems. Point spread function (PSF) can also help them see the vision pattern they experience when looking at objects such as streetlights and car headlights.

Finally, instead of spending all of that time with patients behind the phoropter spinning dials, we can spend more time face to face, talking with patients, educating them and consulting on needed services. This is a much better patient education process, one that helps build comfort and trust between patient and doctor.

Proven, Essential Technology

Eight years ago, I tried to get doctors to understand the science of wavefront and optimizing refraction by combining digital refraction with higher-order aberration data. Then, I tried to apply it clinically to show the relevance of the data, yet all I could show was its “potential” relevance. Now we’re realizing that potential. Doctors don’t need me to show the real relevance of the data because they can now see how it works. Now my discussions with colleagues often turn to the subject of practice efficiency and continued growth – factors that I think make the technology indispensable, given the greater challenges our profession is experiencing.

This is the practical side of XFRACTION. The digital refraction component alone is much more efficient while actually enhancing quality. That means more time and potential revenue for you. The fact that patients will choose your practice with the latest technology over the practice down the street means continued growth. You’ll be better served having the technological edge NOW than if you wait (until you notice patients leaving). This change is especially important in refraction. As with other technologies that are becoming highly visible cornerstones of your practice, if you’re not functioning at the top level of care with these instruments, then you’re losing ground in optometry.

These new technologies are expensive – there’s no way around that. But they offer significant ROI through time savings per patient, fewer lens remakes, optical revenue gains, patient retention and competitive advantages to name a few. The most important thing to understand is that you’re not buying a box. You’re buying dynamic software and a partnership with a company. Any equipment provider you choose should work to help you understand the application, offer sophisticated training for you and your technicians and invite your feedback for regular software enhancements. Your investment will pay for itself financially, and it will give you a seat at the table of colleagues working at the highest level and even contributing to advances in technology. ■

images Dr. Catania is with Nicolitz Eye Consultants in Jacksonville, Fla. He performs clinical research, consults for ophthalmic companies and professional journals and writes and lectures worldwide. He can be reached at

Optometric Management, Issue: March 2013