Dr Martin Smith is the kind of aspirational optometrist you might associate with OCT, therapeutic prescribing, glaucoma diabetes and working hand in hand with the hospital eye service. And you would be right, he does all of those things. While Dr Smith has studied long and hard to attain his additional title, and clinical skills, he is also blazing the trail for the development of refraction within optical practice.
‘We have been using the same sight test charts since they were invented by Snellen in 1862, I think it is time for technology to give us something better,’ says Dr Martin Smith.
He explains that one of his first tasks when taking over his Lincoln practice 14 years ago was a programme of modernisation. He took over the practice as a 24-year-old, recently qualified optometrist with some experience of working in a high tech practice.
‘When I took over here there wasn’t even a computer in the building, the appointment diary was a book,’ he says. There was a rubber next to the dairy to make changes and reminders were all done by hand. The most up to date piece of equipment in the building was a projector chart.
He describes how the practice was modernised with the addition of a computerised practice management system, electronic phoroptor and fundus camera. The big change came nine years ago when Dr Smith started his doctorate and bought an OCT. The practice then carved itself out a reputation as a leading clinical practice for the area offering NHS clinical services utilising Smith’s independent prescribing powers and glaucoma specialism.
‘If you had set up a time lapse camera you would have seen everything change, every bit of equipment, every wall, chair, desk and every frame on the shelves. All except one thing.’ The projector had gone from being the most modern bit of equipment to being the oldest. ‘Why? Because I had no reason to replace it.’
Dr Smith (pictured) looked at other systems but they all did basically the same as his projector until at Optrafair he saw the Paskal 3D system from IPRO. ‘I had never seen anything like it, it was unlike any sight test chart I had seen and quite an entertaining experience.’ He says the effect that a boring and unengaging routine has on the patient should not be under-estimated and he has some harsh words for the profession.
‘There is a lot of inertia. I hadn’t changed the way I refract since I qualified, I haven’t changed anything, I’m using the same projection charts that I was 14 years ago. UK opticians are very conservative about refraction because they have always done it the same. No one ever changes the way they refract. I use the tests I do because they were the tests I started using when I was a pre-reg.’ He says that if you never change anything for that long how can it get better? ‘You are a little bit reluctant to make a change but I was so impressed with the system when I saw it at Optrafair. The benefits seemed so obvious to me.’
He says it is odd that the core function of an optician’s practice is so overlooked. A lot is said about clinical issues and optometrists love talking about OCT and images of the retina, but the paying customers come in because they want to know if they need new glasses or not, and that comes as a result of refraction.
‘We don’t analyse our refraction routine because we don’t want to have to change it. I think denial is the right word. I don’t think opticians want to look at what they are doing and ask; it is right? in case something isn’t right. Then it will have to be changed, they may have been doing something wrong and they might even have to have to do retests.’
Brian Ponsford, sales manager at IPRO, says some practices have been sceptical of a 3D system and are concerned it is ‘just a gimmick’ and that scepticism is not confined to practices. He says he offered the system to Cardiff University to use with undergraduates but they were not interested. He has now got the system into Plymouth University.
The Paskal 3D system that wowed Dr Smith at Optrafair will be surprisingly familiar to anyone in practice. The big difference is that it uses 3D technology and allows the patient to keep both eyes open during the entire examination.
Paskal 3D works by placing circular polarising filters in the phoropter head or trial frame. This allows the test types to be shown, on a 3D TV, to either eye without the patient knowing that they are only viewing with the eye the optometrist has instructed the Paskal system to select. It works very much like an enhanced projection system with the 3D system offering a more flexible and engaging examination. The 3D effect is stunning and the optotypes do appear to be behind images in the foreground and in front of a backdrop image. Because it is 3D it can determine things like eye dominance very quickly.
Paskal3D is designed to be used as the main refraction system rather than a ‘different test’. It can be switched back to simple 2D projection at any time and refraction completed in a traditional manner.
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.
However, IPRO and Dr Smith say the Paskal system also offers advantages when determining the distance vision correction for progressive lenses, picking up binocular vision issues and in uncovering minor phorias in older patients. The company also claims that because the experience is more engaging, natural and less stressful it achieves a more accurate refraction and puts the patient in a better frame of mind when purchasing spectacles. The hope is they will also spread the word by telling others about their experience.
Dr Smith says the examination is more engaging for the optometrist and the patient. The refraction also yields slightly different results. Dr Smith says determining accuracy with subjective refraction is a difficult thing to prove but he believes patients prefer the Paskal prescription.
Ponsford says the system is certainly quicker and defends the accuracy claims. ‘Because a traditional eye exam requires occlusion this is unnatural for the patient, puts them under more pressure and also requires adaptation. The eyes also have to compensate for one another and there is also a loss of brightness.’
‘Rather than destroying the binocular vision by switching over to the other eye and then opening both eyes up you do the whole thing with both eyes open,’ says Dr Smith. ‘Even playing around with it myself I found that you tend to get a similar result on the dominant eye but a slightly differently result on the non-dominant eye to doing it monocularly. From the exams I have done people seem to prefer it.’
Fritz Passman, co-inventor of the system, says the accuracy will always be affected by the experience and skill of the optometrist carrying out the exam. ‘The other thing is that you are always measuring the refractive balance of both eyes, so it is comfortable for the customer, so the results are accurate,’ he says. The big advantage of Paskal is that it does everything a traditional test does but opens up new possibilities.
Dr Smith agrees. ‘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 of accommodation in some people. This helps with PAL toleration.’ It should reduce the tendency to over plus people,’ he adds.
Passman says with 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.
While the system is new to UK practitioners 3D refraction has become commonplace in German speaking countries. Using the refraction to engage the patient has seen 3D refraction systems installed in around one third of German opticians. ‘Obviously it engages the patient more because it is more entertaining if nothing else,’ says Ponsford. ‘You have got balloons coming out and cats and dogs and things like this, it does engage people to a greater degree.’
IPRO also claims Paskal makes people more amenable to buying glasses as a result. ‘It’s the whole journey,’ says Ponsford. ‘People get white coat syndrome because they are unsure about what is happening and they get very tense.’ Because they are more relaxed and happy with Paskal they will be in a better frame of mind to buy, he adds.
Optometrists love showing off clinical technology, their OCT and the pictures of the back of the eye but this has not happened to refraction. Dr Smith says: ‘They haven’t changed the refraction bit in that time. Everything else has moved on and there is this bit in the middle, refraction, that you almost have to just get through, to get to the good stuff. Because Paskal is quite engaging it’s just makes it all a bit more interesting. And it makes the refraction and the spectacle prescribing bit more like the rest of it.’
He is becoming increasing convinced that refraction needs a rethink and that there is solid clinical sense behind how the system works. ‘It seems more and more to me that we do the whole refraction the wrong way in that the first thing we do is abolish the patient binocular vision. We’ve been doing that for the past 150 years,’ he adds.