Chris Bennett headed up the A1 to find out more
Refraction is the most recognised, yet unchanging, element of an eye examination – something Dr Martin Smith says it is time to rectify.
October 5 was switch-over day for Martin Smith Opticians. From that day every patient coming into the practice has been refracted using the Paskal3D system something Dr Smith says he is absolutely confident about. Paskal could be adopted overnight as the main system, rather than a ‘different test’, because it can be switched back to simple 2D projection at any time and refraction completed in a traditional manner.
Paskal was showcased last autumn during an open day at Martin Smith Opticians in Lincoln, which has invested in the new system. Dr Smith first saw the system at Optrafair and was wowed by its use of 3D. He says the system is more entertaining and engaging for the patient, and the practitioner, but also sees clinical benefits too.
Installation of the system is simple and requires little IT infrastructure. The system consists of a 3D TV, iPad and an Apple TV 4 box. The system is controlled with an app on the TV box and the iPad. All of the functions are remote controlled and communicate using Bluetooth. The cost would typically be less than £3,000, two thirds of which is a one-off licence fee.
To enable the 3D effect to work circular polarising lenses are placed in the phoropter head, it can also use a trial frame. At first glance the system looks like any other computerised refraction suite, until you look at the monitor without a 3D lens in place.
What the patient experiences is a stunning 3D image viewed with both eyes open throughout the exam. What they will not be aware of is that the optometrist is testing each eye in turn by using the 3D system to covertly occlude the other eye. They experience an engaging eye exam and do not have to undergo the visual stress of occlusion or binocular upset.
The systems maker, IPRO, and Dr Smith say the Paskal system also offers clinical advantages. These include determining the distance vision correction for progressive lenses, picking up binocular vision issues and in uncovering minor phorias in older patients.
Dr Smith says: ‘It’s certainly more interesting. The other thing is that when you are doing the final test the target is effectively on the horizon so the final test of a stereoscopic chart appears to be further away than the monitor.’
In effect the patient is looking at a wall that is some way away from the monitor rather than 4m away, which stimulates some degree in accommodation is some people. This helps with PAL toleration. ‘It should reduce the tendency to over plus people,’ he adds.
Fritz Passman, co-inventor of the system, says with today’s high quality lenses, especially progressives, fine tuning the prescription is important. Traditional methods can leave some plus in the distance portion of the prescription that the Paskal system can take out. ‘Accommodation is our enemy, we have to do everything to keep the customer relaxed and to find a little bit more minus,’ he says.
Dr Smith stresses that from a patient perspective the test is easier and more enjoyable and adds that those effects should also be felt by the optometrist. Conducting the exam is much more interesting than black and white letters and the 3D offers possibilities for children’s testing and low vision.
There is also very little training needed to get started with the system, he says. ‘The actual refraction element of it is the same. You are still reading letters on the wall you are just doing it under different conditions and it’s a bit more fun. It’s really easy. I could have picked it up and started using it right away. You are still switching between the left and the right eye but the patients don’t really notice that.’ He also maintains that Paskal 3D offers clinical benefits. ‘It’s very easy to identify people who have unstable binocular vision, it’s immediately apparent when you start doing the test that there is something you need to correct.’
IPRO’s claims over accuracy are harder to pin down. Determining accuracy is ‘impossible’ says Dr Smith with subjective refraction but he does suggest a slightly different result is determined in the non-dominant eye and that his initial patients have preferred the result.
Accuracy aside speed is one advantage of the system that is apparent, says Dr Smith. ‘I think one advantage is that you are not doing one monocular refraction and then another monocular refraction and then trying to correct all of the errors that you have just made by doing it again but with both eyes together. Even using the chart as a 2D chart I have found that it is slightly faster. People also seem to respond to the screen better than they do to the projector.’ The optometrist can choose from up to 80 tests and a personalised test series can be saved to the iPad, this can be changed and new tests inserted at any point in the examination. The practitioner’s own images can also be selected to replace the standard ones which come with the system. This puts the patient further at ease.
The nature of 3D means an eye dominance test can be carried out simply before each exam and a switch made between eyes at any point. There are a range of optotypes available which can be randomised or magnified and setting options to mimic different refraction distances.
Passman is keen to allay fears that some patients will not be suitable for 3D testing or that 3D could be visually stressful. Non-tolerance may be due to a variety of phorias or binocular issues, says Passman. ‘There are a few, up to 10% of patients won’t be suitable for 3D viewing, because of large phoria, strabismus or other conditions so the system can be switched to be used with occlusion and 2D charts.’ Passman says that for most patients refraction with 3D is not like 3D cinema where people were watching moving 3D images for long periods of time. ‘Intolerance shouldn’t be an issue. No headache at all by testing in 3D,’ he says. Dr Smith says anyone who does have a problem with the 3D are exactly the ones who probably need help with prisms, something which may well have not been identified before.
In Germany more than 3,000 opticians use 3D testing systems
While the system is new to UK practitioners 3D refraction has become commonplace in German speaking countries. Passman says Dr Smith’s comments on his early use echo the experience in Germany. The routine is familiar, he says, it is the interaction between patient and optician that changes. ‘The communication between the optician and the customer, that is the only thing that is new: the questions and the story may be different but the refraction, the work, is the same,’ he says.
To persuade optometrists to change their refraction routine Paskal has to offer benefits and the hope is that by making the eye exam experience more enjoyable loyalty, satisfaction and footfall will improve as patients feel the benefit for themselves and talk to friends and family.
In Germany there are 3,000 3D systems in operation and they have been taken up by independent practices looking to differentiate themselves from the chains with modern techniques, technology and a better experience for the patient. ‘The customer has the choice to go to the optician that he likes. There are all the big players so the traditional optician has to do a better thing for his customers to stand out from the crowd.’ He also says it is a natural fit for practices selling top end product. ‘When you are talking about eighths of a dioptre with high end lenses like Rodenstock and Carl Zeiss we have to move with them.’
Big bang day for Martin Smith Optician was the day after his launch party on October 5 this year with all eye examinations being Paskal 3D from day one. ‘I am so confident about the system that I am not changing appointment times,’ he says.
