Refraction Reboot How new technology is reshaping refraction's 'manifest' destiny By Andrew Karp Wednesday, June 25, 2014 12:01 AM Click here to download a PDF of th e Refraction Reboot Special Feature. Advanced technologies are improving the accuracy, efficiency and speed of the eye exam and refraction process. But potential game changers—such as virtual refraction, low cost, smartphone-based systems and online refractive eye exams—are starting to fundamentally redefine “refraction.” Find out why refraction is no longer just a matter of “better or worse” as new tools and techniques expand the range of possibilities for both eyecare practitioners and patients. NEW YORK—Imagine if you went to a hospital for surgery and the anesthesiologist asked you to breathe into a chloroform-soaked rag. No doubt you’d be shocked by such primitive, Civil War-era medical technology. Yet no one bats an eye when they encounter another mid-19th century medical technology: the Snellen chart. When used in conjunction with a manual phoropter, an instrument developed nearly a century ago, it provides a simple metric of how well the patient can see and prescribes the basic optical correction. * This subjective method for testing visual acuity—the manifest refraction—remains the cornerstone of the comprehensive eye examination. In fact, 95 percent to 98 percent of refractions are still done with a manual phoropter or refractor, according to Paul Karpecki, OD, FAAO, a prominent optometric practitioner, educator and author who serves as clinical and education conference advisor for Review of Optometry. Why has the old technology endured? The reason is simple, said Karpecki: “It’s very accurate.” Yet newer technologies for both objective and subjective refractions are quickly gaining ground. Electronic phoropters and other types of advanced refraction systems are being utilized by a growing number of eyecare professionals, either in addition to or in place of manual phoropters. Autorefractors and wavefront aberrometers are increasingly used in pretesting. Even manual phoropters are being updated with features that allow them to connect with other diagnostic devices and easily import measurement findings into EMR systems. These technologies are making refractions more efficient and patient friendly, while providing additional layers of clinical data and, in some cases, more accurate measurements. At the other end of the spectrum, a new class of lower cost, portable devices has been developed for measuring visual acuity and vision screening. Some make use of easily accessible smartphone technology, which make them particularly valuable in developing countries that lack full-service vision care providers. In addition, two potentially disruptive refraction technologies are emerging. The first, which will be introduced later this year, is an in-office virtual refraction system through which the patient can view photographic images projected onto a special mirror instead of looking through a phoropter at a Snellen chart. The second one, which is still in development, is an online refractive eye exam that patients can self-administer anywhere. This DIY approach, which is already generating much discussion within the optical industry—would allow patients to test their own vision, generate a prescription that would be authorized by an ophthalmologist and purchase eyeglasses online—all without any face to face contact with an ophthalmologist or optometrist. Clearly, refraction is in a state of flux, as new technologies redefine this fundamental testing process for both eyecare professionals and consumers. A close look at how these technologies are being used provides insights into how the eyecare field is changing. The Drive Toward Efficiency Dr. Arthur Medina says Vmax Vision’s PSF Refractor, pictured here, allows him to ask patients fewer “which is better” questions. Dr. Tad Kosanovich and technician Donna Thompson perform an autorefraction with Marco’s OPD-Scan Wave before using the Epic 5100 workstation (far left) for a subjective refraction. A major reason that eyecare professionals are investing in new refraction technology is the need to operate their practices more efficiently, which in turn leads to growth and greater profitability. “Outside forces such as HIPAA, EHR (electronic health records), meaningful use requirements, and the advent of ACO’s (accountable care organizations) controlling patient access are forcing practices to become more efficient,” observed Tim Petito, OD, manager of professional relations for Marco Ophthalmic, a leading supplier of diagnostic equipment. “Doctors have to see patients in the same or less time and absorb less reimbursement.” To meet this need, Marco and other manufacturers have developed refraction instruments with more automated features. As a result, some practices can now delegate the refraction process and data collection to technicians, with the optometrist or ophthalmologist analyzing the data, making decisions about the patient’s prescription when necessary, and confirming the final refraction. “Doctors are looking at ways to speed up their subjective refraction process but not sacrifice any quality in their final refraction,” noted Bob Gibson, vice president of marketing at Topcon Medical Technology. “We see a lot of doctors connected to EMRs and large practices with lots of lanes increase their work flow by automating the vision tester or phoropter. When they transcribe their final refraction, they no longer have to type it into the EMR, so there’s a digital transfer of data. If you eliminate one transcription error a month, it pays for the phoropter.” Phoropter Evolution Although most ECPs still use manual phoropters, a growing number are also using electronic phoropters and other advanced refraction systems to capture additional layers of diagnostic information. Some are even using these new instruments instead of their manual predecessors. “This area of the market only represents about a 5 percent penetration of the phoropter business, but it’s growing incredibly fast,” said Dr. Karpecki. Among the most advanced refraction systems on the market are the Epic 5100 workstation from Marco, Topcon’s CV-5000, the PSF Refractor from Vmax Vision, the iProfiler Plus from Carl Zeiss Vision and the Huvitz HDR-7000 digital refractor from Coburn Technologies. Although these multifunctional systems offer different combinations of features, all are designed for maximum efficiency and accuracy. Some also share an important advantage, Dr. Karpecki noted: “By pushing a single button you can help patients see the difference between their last Rx and their current Rx.” Dr. Barry Toyzer says his patients tell him that the Zeiss iProfiler and iScription system produce more “comfortable” Another key benefit offered by some of these advanced phoropters is their ability to measure acuity as accurately as .05 diopters, according to Dr. Karpecki. “It’s gotten to the point where lens processing technologies, because of free-form, can make more precise prescriptions,” he explained. “The technology of making the lens has caught up to the level of precision of the measurements that these instruments can make.” The cost of these units is offset fairly quickly, Dr. Karpecki said. “As you become more efficient you’re going to end up seeing a lot more patients,” he noted. One of the most innovative systems is the PSF Refractor. It was introduced several years ago by Vmax Vision, a relatively new player in the refraction market. Described by Vmax Vision as “a complete refraction lane-in-a-box,” it provides a 20-feet effective distance, eliminating the need for practices to have a 16 to 20 foot exam lane and increasing the practices’ working capacity and revenue without the need to create more space. The PSF Refractor uses Point-Spread Function (PSF) to measure patients’ subjective visual response to a point source. The system enables the correction of higher-order aberrations, resulting in refractions that are up to five times more precise than with a phoropter and measuring to .05D accuracy, according to Vmax Vision. Complementing the PSF Refractor are Vmax Vision’s Encepsion lenses, which are premium free-form progressive and single-vision lenses that are designed to incorporate the patient’s lifestyle and individualized fitting data. The system also comes with voice-guided instruction software which directs the patient through each refraction test, a feature that significantly reduces training time ensuring a consistent quality of testing, according to Vmax Vision. Arthur A. Medina, OD of Medina Eye Care in San Antonio, Texas is a fan of the PSF Refractor, which he said has some fundamental advantages over manual phoropters. “Although the basic design of the phoropter is simple, using it proficiently requires general understandings of the basics of geometrical optics and how to apply these principles to the task at hand,” said Dr. Medina. “In order to obtain reliable, repeatable data with a phoropter, technicians must first learn optical terminology such as accommodation, adjusting the spherical component, the axis and the Jackson-Cross cylinder technique. As formal optical training is required to acquire this level of comprehension, very few optometrists have attempted to train their staff on utilizing it, other than for very simple spherical components over contact lenses.” An important benefit of the PSF Refractor is that using it is not dependent on formal training, and training can be conducted entirely within the practice, Dr. Medina said. He noted that on average, a staff person can become proficient in the use of the PSF Refractor after performing 10 to 15 exams, which is significantly less than the six months average training time required for learning to operate the phoropter. “Although the PSF Refractor is technically automated, the subjective response remains crucial,” Dr. Medina observed. “Therefore, it is important to delegate the test to staff members who are able to listen carefully to the patient’s subjective response, who are able to determine patient’s comprehension of the verbal request and to get a strong sense of how reliable the patient’s response is. At the same time, by reducing the number of ‘which is better’ questions that it requires, the PSF Refractor reduces the scope for errors which arise due to inaccurate patient’s responses. “The PSF Refractor has an immediate ‘wow’ factor that I have not seen with other instruments in optometry in a very long time,” said Dr. Medina. “The last time I saw it was when we first started doing lasik, which was a big industry turn. After experiencing it, patients leave my office knowing that they have been exposed to the latest, most sophisticated and most eloquent technology available. They are making a variety of different comments, referring to the ease with which it determines the acuity, the shorter time required and its ergonomics. The most characteristic comment I get is: ‘I sure am glad I don’t have to tell you which was better—one or two.’” Although Vmax Vision is a newcomer to the refraction field, Marco is well-established. The Epic 5100 workstation, which combines an electronic refractor, auto refractor/keratometer, chart projector, auto lensmeter and motorized table, is Marco’s flagship refraction system. It uses half the space of a traditional lane, requiring an area of only five-by-six feet, which frees up more rooms for other procedures. Tad Kosanovich, OD of Englewood Eyecare and Optical in Englewood, Fla., has been using the Epic 5100 for seven years. He said it has helped his medically-oriented practice, which is located in an area with a big geriatric population, become more efficient. “Using the Epic system has resulted in significant time savings, which affords me more face to face time for dealing with a patient’s chief complaint,” said Dr. Kosanovich. “The time savings allows me to see even more patients per day.” Topcon’s CV-5000S features a small optical head to enhance patient communication and comfort. The Huvitz HDR-7000 digital refractor, distributed by Coburn Technologies, is the centerpiece of a complete digital refraction system. The VX 55 from Visionix lets users digitize their manual phoropter. In Englewood Eyecare and Optical’s preliminary exam room, a technician uses a Marco OPD-Scan unit mounted on the Epic to perform automated refraction, simK, corneal topo and wavefront analysis. After the technician takes these automated measurements, he slides the OPD-Scan to the side and then rotates the Epic’s phoropter into place to perform a subjective refraction. All the objective and subjective data is then dumped into the practice’s EMR. “After analyzing all that information, I will touch the manual phoropter less than half the time,” said Dr. Kosanovich. “And the times when I do use it are shorter. I’ll use it to make a small refinement to obtain a final prescription.” Dr. Kosanovich’s patients are impressed by the Epic 5100. “When they have a refraction, they know we’re on cutting edge of the most recent technology,” he said. “A lot of older folks have had dozens of eye exams over their lifetime, so they have something to compare it with. That’s the biggest benefit, from a practice-building perspective. From a business perspective, the small footprint maximizes the square footage in that preliminary room, and that allows me to have more high tech equipment in that space.” Another compact system, Carl Zeiss Vision’s iProfiler Plus, combines an ocular wavefront aberrometer, autorefractometer, Atlas corneal topographer and keratometer. But the iProfiler Plus’ most distinguishing feature is that it links to Zeiss’s i.Scription technology, which combines the subjective refraction with ocular wavefront aberrometry data, creating an individualized prescription to 1/100th of a diopter. Integrated with a Zeiss spectacle lens, i.Scription technology offers better night vision, as well as improved color and contrast perception, according to Zeiss. Those benefits are important for many patients at The Eye Doctors in Havertown, Pa., particularly those who are older. “When I ask patients, ‘How’s your night driving?’ that gets the discussion going,” said the practice’s optometrist, Barry Toyzer, OD. Dr. Toyzer said his patients report that Zeiss lenses made from the iScription technology enhance their depth perception and may subtly improve their color perception as well as their sense of visual comfort. “I’ve had patients say, ‘Doctor, this is most comfortable prescription I’ve ever had.’ It seems like they’re seeing more naturally, with less effort. This generates more patients and builds the practice,” said Dr. Toyzer. Dr. Toyzer began using the iProfiler plus three years ago. “What attracted me was the concept of high definition optics. Once I got comfortable with it, I found I was getting very accurate refractions,” he said. Rather than see a Snellen chart or point spread function display, patients see a picture of a hot air balloon when they look into the iProfiler plus. “I ask them to look at the stripes of the balloon,” explained Dr. Toyzer. “While they’re looking at the target, the machine bounces a wavefront of light off of their retina, through the patient’s optics and back out through their eye.” Dr. Toyzer said his patients like using the iProfiler Plus because “it’s a very whizbang piece of technology.” As he noted, “It’s quick, and very little effort is involved on their part. It’s good with patients who are not very communicative or who may be a little apprehensive about the exam process.” Dr. Toyzer takes the reading from the iProfiler Plus and puts it into his phoropter. “The iProfiler Plus gives me a more accurate starting point for a subjective refraction,” he said. “It also saves me time because it cuts right to the chase. The device gives me an indication of how reliable that reading is. For nine out of ten eyes, the patient will agree.” Another leading player in refraction technology is Topcon Medical Systems. The company introduced its top of the line CV-5000S Automated Vision Tester about three years ago. The seventh generation system’s feature set includes fast lens rotation and a small optical head to enhance patient communication and comfort. The CV-5000S provides a complete, 21-point refraction and features the KB-50S One Dial Controller with a 10.4” color touch-screen display. Complete connectivity allows data to be sent automatically to every CV system throughout the office and populated into the EMR. Topcon recently launched the “Topcon Online University” training system, featuring its CV-5000S Automated Vision Tester, the first in a series of online training modules. “The CV-5000S Online Training Program is designed for technicians, optometrists, ophthalmologists, and other eyecare professionals that are getting started with the CV-5000S Refraction System,” said Topcon’s Bob Gibson. “Through a combination of narrated videos, graphics and step-by-step instructions, the system highlights the key features and operating procedures of the system.” The newest contender in the automated refraction category is the Huvitz HDR-7000 digital refractor, distributed by Coburn Technologies. The centerpiece of Huvitz’s complete digital refraction system, the HDR-7000 can network with the Huvitz’s auto ref-keratometer, auto lensmeter, chart devices and a PC. Key features include a choice of 18 visual acuity test charts, 26 vision test charts and up to 35 user-defined unit test charts that support the most advanced eye test process; a dual cross cylinder lens supports a fast and convenient astigmatic test; automatic occlusion and convergence functions and independent PD adjustments for right and left eyes. Even manual phoropters are going high tech. Visionix recently introduced a new type of digital phoropter, the VX 55, that combines the simplicity and comfort of a manual phoropter with technological advances that allow for connectivity among diagnostic devices in the practice and easy importation of measurement findings into EMR systems. Users can digitize their manual phoropter and control the entire refraction process from a tablet, increasing efficiency and making refractions quicker and easier. There is little to no learning curve with the interactive tutorial guide screen and familiar interface, according to Visionix. Despite the advantages of these advanced systems, the manual phoropter still has some utility in the modern eyecare practice. “There are times when you have to measure binocularity, fixation disparity, eye alignment, and you’d still want a phoropter, although for the most part you can still obtain those measurements through other methods,” noted Dr. Karpecki. Refraction: The test performed during an eye exam to determine the eyeglass lens powers needed for optimum visual acuity. An automated refraction uses an instrument that does not require the patient to respond. A manifest refraction is the manual way to determine the best lenses, by placing various lenses in front of the patient’s eyes and asking, “Which is better, lens A or lens B?” Source: All About Vision * American Optical introduced the “Phoroptor” in 1928. Today, Reichert Technologies, part of Ametech, Inc. holds the trademark to the Phoroptor brand.