Pearls for the Refractive Technician Fadiah Alkhawaldeh, IMBA, COT, ROUB

Pearls for the Refractive Technician Fadiah Alkhawaldeh, IMBA, COT, ROUB Cleveland Clinic Cole Eye Institute OOS, Columbus, OH February, 2014 alkhawf@ccf.org

NO FINANCIAL DISCLOSURES

A Puzzle of an Eye Exam Approach the eye exam as a puzzle. Each test is a piece bringing us closer to a sharper image for our patients. Once the pieces are together, we have a complete picture of our patients visual potential and anticipated outcome.

Routine Exam Basics Chief Complaint: In their own words. Review of Systems & Pain Assessment: General health issues which may affect exam (migraines, seizures, thyroid, pregnancy, etc.) Past Medical History: Medical, Surgical, Familial. Current Medications & Allergies.

Eye Exam Basics Current Glasses Rx: Age, bifocal, trifocal, prism. Contact Lens Wear: Material, average wear time, length of time out of CL; Monovision. Visual Disturbances: Glare, halos, starbursts, dryness, flashes, floaters, FBS, photophobia, diplopia, headaches/pressure, decrease in vision (sudden / gradual).

Pieces of the Puzzle Visual Acuity & Dominance Confrontational Fields Versions / Ductions / EOM s Pupils Manifest Refraction Tonometry Pachymetry Diagnostic Testing

Visual Acuity & Dominance Myopia: -0.50D up to ~ -11.00D (surgeon dependent) >-11.00D may consider ICL, CLE, IOL (if old enough) Hyperopia: +0.50 up to +6.00D (surgeon dependent). >+6.00D may consider ICL (chamber depth important), CLE, IOL Astigmatism: Up to 6.00D (surgeon dependent) Spherical equivalent must be maintained for laser surgery Option for Toric or combination Toric & Femto / LRI surgery Dominance: To assess for monovision

Confrontational Fields Ensure range of peripheral vision Identify potential problems such as glaucoma May prompt other tests (visual field, DFE, B-Scan) Subjective, but sufficient for refractive

Versions / Ductions / EOM s Evaluate yoke and oblique muscle functions. Identify potential problems such as palsies, muscle weakness May be a cause for amblyopia, decreased vision, diplopia

Pupils Pupil Size: Treatment zone 6.5 mm with up to 2.5mm blend zone Ability to dilate - cataract surgery may require iris hooks. Glare due to large pupils, may be encountered with certain IOL s. Flap size: Standard with lasers ~ 9.0 mm hyperopic txs require larger flaps Halos mostly temporary due to blend zone

Manifest Refraction Determines type of treatment: Myopic Push plus, especially in young, high myopes Hyperopic Possible latency, especially in young adults Mixed Astigmatism can mask as hyperopia Accuracy within + / - 0.50D. Nomogram development & maintenance Surgical outcomes Always, always, always, PUSH PLUS!!!

Tonometry Increased pressure on eye with Femto procedures Suction ring Docking of cone Glaucoma Steroid response

Pachymetry Average corneal thickness between 535µ - 560µ Treatment varies depending on CT Higher myopes require thicker corneas for lasik PRK option for those with thinner corneas / ABMD ICL for high myopes with very thin corneas Symmetrical CT Inferior thinning could be indicator of KCN >20µ difference between eyes may indicate KCN

Monovision Dominant eye corrected for DVA Non dominant eye corrected for NVA Post op aim dependent on age: 40 45 years of age: -0.75D to -1.00D 45 50 years of age: -1.25D to -1.50D 50 60 years of age: -1.50D to -1.75D 60 plus years of age : -1.75D (Max -2.00D) Demonstrate in phoropter DVA & NVA with & without monovision Not permanent (unless with IOL).

Diagnostic Testing Topography: Identifies amount of astigmatism, type, warpage, KCN, PMD Done before other diagnostics; can be used as reference for refraction Pentacam / Galilei: Anterior & Posterior floats used to assess corneal thinning and KCN susceptibility Used for IOL calculations for s/p refractive patients Optovue: Spectral Domain OCT using 3-D technology to image cornea High resolution digital imaging of cornea & anterior structures ORA (Ocular Response Analyzer): Measures IOP & Corneal Hysteresis; Fairly good indicator of potential for ectasia BAT (Brightness Acuity Test): Tests for presence of cataracts as a result of glare PAM (Potential Acuity Meter): Tests visual potential for patients with cataracts & corneal opacities. C-Quant: Cataract Quantifier measures stray light using contrast sensitivity

Normal Topography

Normal Astigmatism

Normal Pentacam Galilei

Mild Keratoconus

Mild KCN Galilei Optovue

Advanced Keratoconus

Severe KCN

Severe KCN Overview Refractive

Severe KCN

KCN Mild vs. Advanced OD Mild KCN OS More Advanced KCN

S/P Penetrating Keratoplasty

S/P Penetrating Keratoplasty Overview Refractive

S/P Penetrating Keratoplasty

Pellucid Marginal Degeneration

PMD Overview Refractive

PMD Mild PMD Mild PMD Flat K s

Intacs & Ectasia

Intacs Overview Refractive

Ectasia Overview Refractive

Intacs Galilei Optovue

Ectasia

Ocular Response Analyzer (ORA)

Brightness Acuity Test (BAT)

Potential Acuity Meter (PAM)

Cataract Quantifier (C-Quant)

Questions