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Advanced Eye AnalysisDigital diagnostics can help to promote

patient education.

By George O. Waring IV, MD, FACSWith the advent of advanced digital diag-nostics comes a wonderful opportunity for patient education. My mentor Dan Durrie taught me the value of an advanced eye exam with his advanced ocular analysis. At the Magill Vision Center, we use advanced diagnostic technology not only for clini-

cal assessment but also to educate patients. Marketed as an advanced eye analysis, this exam takes patients on a digital tour of their eyes to create a truly visual experience. (Editor’s note: Watch an example of the advanced eye analysis on Eyetube: http://bit.ly/waring0416.)

Within minutes of checking in, every patient is escorted to our advanced eye analysis center, where he or she is essentially put on a digital diagnostic track in which our technicians explain what each machine does. This is important, as all patients appreciate the high-tech, high-touch experience. Furthermore, they associate the

advanced eye analysis with state-of-the-art technology. All digital images are then imported into our electronic health record system while the patient is once again escorted, this time to the exam lane. While dilating, the patient reviews educational material explaining the benefits of laser-assisted lens surgery and advanced lens implant options on digital tablets.

At the outset of the exam, I explain to the patient that we will evaluate his or her overall ocular health with an advanced eye analysis that assesses the lids, lashes, lenses, nerves, vessels, and nutritional status. Once the biomicro-scopic exam is completed, the patient is taken on a digital tour of his or her eye (using a camera as analogy), paying particular attention to the two lenses and the film of the camera. I begin with a discussion of the patient’s outer lens and show his or her level of astigmatism with topographic and tomographic images, including the ectasia risk screen-ing maps for LASIK evaluations. This is followed by OCT images of the cornea.

The patient is then educated on the health of his or her internal focusing lens with a dilated Scheimpflug image of the lens correlated with the densitometry (both with the Pentacam; Oculus). This step is important in that patients can easily see the aging changes associated with lens opac-ity and the correlating light scatter.

THE PATIENT EXAM IN THE DIGITAL AGE: A TRULY VISUAL EXPERIENCEAdvanced diagnostics can help to promote patient education.

BY GEORGE O. WARING IV, MD, FACS; AND FERNANDO FARIA-CORREIA, MD

Marketed as an advanced eye analysis, this exam takes patients on a digital tour of their eyes to create a truly visual experience.

“

• Advanced eye exams should be a part of advanced eye clinics and a premium patient experience.

• Patients appreciate the high-tech, high-touch experience of an advanced eye anaylsis and associate it with state-of-the-art technology.

• Specific displays from diagnostic devices can help to clarify patient complaints or propose and explain certain surgical procedures.

AT A GLANCE

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Next, the patient is shown “how you are seeing” with a double-pass wavefront (HD Analyzer; Visiometrics), which “measures not only the amount but also the pattern of blur” (point spread function), as we explain. Although patients are generally thrilled postoperatively, images can be repeated and compared after lens replacement to demonstrate that their new clear lens has no light scatter or blur. The exam is augmented with slit-lamp video and photography as needed, as well as with macular OCTs or fundus images.

Additional diagnostics and imaging are performed for other conditions and procedures. For example, in patients with narrow angles, particularly hyperopes, we will image and measure their angles with anterior segment OCT and Scheimpflug imaging before and after lens replacement, and we can often correlate a drop in IOP with widening of the angle after lens replacement. Patients appreciate the procedure more when they can visualize why they have improved. We will perform similar imaging for patients implanted with the Visian ICL (STAAR Surgical) to measure their angles and vaults.

Use of our advanced internal lens analysis is paramount to properly educate patients with dysfunctional lens syndrome. This exam is often the first time patients have the opportunity to understand why they stopped driving at night and why their glasses no longer work despite multiple attempts. We dis-cuss the nonsurgical and surgical treatment options for these patients, including dysfunctional lens replacement (DLR). It is worth mentioning that DLR is different from clear or refrac-tive lens exchange in many ways. Most important, these lenses are not clear, as demonstrated by the objective diagnostics described above. Even though these patients may not qualify for an insurance-based lens procedure, they came to our clinic looking for surgical options to reduce their dependence on glasses. Once we show them the sources of their blur, it is easier for patients to understand that they may be better served with

a lens-based refractive procedure than with a cornea-based procedure. This is particularly true for patients older than 60 years. As with all surgical consultations, we outline all risks, benefits, and alternatives, including the relative risks associated with lens- and cornea-based procedures. However, patients like that DLR is a permanent, all-in-one solution that addresses both congenital and age-related causes of ametropia.

Advanced eye exams should be a part of advanced eye clinics and a premium patient experience. Things have changed since Herman Snellen first described the gold standard visual acuity measurement in 1862. We now have the technology to objectively measure and show patients their quality of vision with advanced diagnostics such as the HD Analyzer. These advances have enabled us to not only serve our patients with better options and outcomes but to better educate them as well.

Diagnostic Images Make Excellent Patient Education ToolsPictures can be worth thousands of words.

By Fernando Faria-Correia, MDSince I began performing refractive surgery, I have used a Scheimpflug imaging device (Pentacam HR; Oculus) and a wavefront ana-lyzer (iTrace; Tracey Technologies) on a rou-tine basis. Many patients in our clinic have dry eye disease, and use of the Keratograph 5M (Oculus) is essential for the study and

follow-up of such patients.

DIAGNOSTICS AS VISUAL AIDSNot only do I integrate these advanced digital diagnos-

tics routinely as part of my clinical examinations, but I also use these instruments to provide visual aids for patients. Generally, I select specific displays from each device that will help me to clarify the patient’s complaints or to propose and explain certain surgical procedures. The types of displays that I select depend on the patient’s age and type of com-plaint or desire.

For example, if a patient with mild to moderate myopia is interested in laser vision correction (LVC), I usually look at the four-map display and the Belin/Ambrósio enhanced ectasia display on the Pentacam to ensure that femtosecond LASIK is appropriate. Integration of clinical data with corneal tomography data is useful to analyze the patient’s suscepti-bility to ectasia after LVC.

For presbyopic and post-LASIK patients, I usually check the Scheimpflug-based lens densitometry from the Pentacam and the dysfunctional lens index (DLI) on the iTrace (Figure 1). Combining these devices is essential in

WATCH IT NOW

http://bit.ly/waring0416

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order to identify where the problem is: in the cornea or in the lens. Some patients are more suitable for refractive lens exchange with a multifocal IOL rather than LASIK because the problem is in their crystalline lens. In this type of patient, I also select the cataract preop display on the Pentacam (Figure 2), as this helps us to check the magnitude of higher-order aberrations and assess whether a toric IOL may be appropriate.

ELUCIDATE COMPLAINTSExplaining the data presented on these displays in a rou-

tine examination helps me to elucidate the patient’s visual complaints and propose an appropriate treatment. Patients respond well to the visual information. I find that patient satisfaction is enhanced when patients are able to visual-ize their problems. It also motivates patients to seek more

knowledge about their disease, par-ticularly the pathophysiologic mecha-nisms, clinical signs and symptoms, and treatment options.

Sometimes patients in the exami-nation room are reluctant to ask questions. They may feel that they are wasting the doctor’s time or are afraid of looking ridiculous or poorly informed. Having these imaging out-puts as visual support enables a more open conversation with these patients. It allows the physician to better clarify any doubts and relieve anxieties, as well as to present the best treatment or surgery options available. These interactions are helpful to establish more confidence in patients regarding the doctor and his or her team.

CONCLUSIONThe integration of advanced digital

diagnostics undoubtedly improves the level of patient care. For the physi-cian, it helps with differential diagnosis and selection of the most appropri-ate treatment option. For patients, these visual aids help to objectify their problems and understand the causes and the therapeutic modalities avail-able. The interaction between physi-cian and patient in presentation of the diagnostic images also improves patient confidence regarding the treatment or procedure proposed. These tools can also help to obtain informed consent for surgery. n

George O. Waring IV, MD, FACS n Director of Refractive Surgery and Assistant Professor of

Ophthalmology, Storm Eye Institute, Medical University of South Carolina

n Medical Director, Magill Vision Center, Mt. Pleasant, South Carolinan Member, CRST Europe Global Advisory Boardn waringg@musc.edun Financial disclosure: Consultant (Abbott Medical Optics)

Fernando Faria-Correia, MDn Refractive Surgery Department, Instituto CUF, Porto, Portugal;n Ophthalmology Department, Hospital de Braga, Braga, Portugal;n Research Associate, Rio de Janeiro Corneal Tomography and

Biomechanics Study Groupn f.faria.correia@gmail.comn Financial disclosure: None provided

Figure 1. The dysfunctional lens display demonstrates the contributions of cornea and

crystalline lens and total eye vision simulation using Snellen E. This display also illus-

trates the dysfunctional lens index score on a color scale.

Figure 2. The cataract preop display.

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OSI: ENHANCEMENT OF PATIENT UNDERSTANDING The graphic display of the Ocular Scatter Index helps explain conditions and treatments.

By Alain Saad, MD

The ability to objectively diagnose patients’ quality of vision and the state of their crystalline lens is greatly aided by the measurement of ocular scat-ter. Objective evaluation of the health of the lens allows us to determine whether we should be performing a lens- or cornea-based procedure.

Tools that allow objective evaluation of ocular scatter also generate diagnostic reports that can help to increase patients’ understanding of their pathologies and, thus, their confidence in our treatments.

I use the AcuTarget HD (AcuFocus) routinely for cataract and refractive surgery patients. The instrument uses a double-pass aberrometry approach, shining light on the retina and then measuring the transmission of this light through the tear film, cornea, and crystalline lens. The device then generates an ocular scatter index (OSI) consisting of a quantitative measurement and a qualita-tive analysis of the distribution pattern of scattered light in the eye. This information allows us to objectively assess visual function and determine the source of visual com-plaints. A high OSI may indicate issues with the quality of the tear film or the crystalline lens. Conversely, a normal OSI in a patient with visual complaints could indicate issues in the retina or optic nerve.

EDUCATING PATIENTSThe report generated by the instrument can be shared with the

patient, displaying several objective refraction images, the double-pass image, the modulation transfer function (MTF) diagram, a simulated retinal image, and the OSI numbers. The OSI numbers and retinal image are particularly useful in engendering patient understand-ing. The numbers are illustrated on a color-coded bar that indicates increasing severity in progression from green, to yellow, to red (Table 1). The color level is tremendously useful in improving patient under-standing. Patients may not understand exactly what terms such as moderate or severe mean, or the significance of an OSI of 3.5, but showing them an objective number attached to a color code trans-lates this into information they can comprehend.

The simulated image on the report represents the image that the device is sending to the retina and juxtaposes it with an image that represents what the patient is seeing. This illustrates how lens chang-es are affecting ocular transparency and, therefore, vision.

This type of diagnostic tool also facilitates excellent follow-up. Patients may initially present with an OSI of 1.9 or 2, which is not severe but may suggest the early presence of a cataract (Figure 1). The analyzer provides objective quantification of the patient’s sub-jective visual complaints and builds a base with which to compare future numbers and to aid in determining the best course of action. Detecting early cataract formation allows the surgeon to provide informed treatment and gives patients tangible evidence they can understand.

CONCLUSIONWith the presentation of images and traceable numbers from the

AcuTarget HD, patients can better understand the modalities of their condition and their chosen treatment. Their level of confidence in not only their care but also their physician is greatly improved when they truly understand what is happening with their vision and what is being done to address it. n

Alain Saad, MDn Anterior Segment and Refractive Surgery Department,

Rothschild Ophthalmology Foundation, Parisn Vice-director, CEROC, Paris n dralainsaad@gmail.comn Financial disclosure: Consultant (AcuFocus)

Figure 1. A 58-year-old female presented for refractive surgery with 20/20 vision

and a refraction of 1.50 D. The AcuTarget HD analysis revealed a high ocular scat-

ter index, indicating that cataract surgery or clear lens extraction are the most

appropriate treatments for her.

TABLE 1. COLOR-CODED OCULAR SCATTER INDEX

Color Display

Green Yellow Red

Ocular Scatter Index

< 2 2–4 > 4

Diagnosis Ocular transparency good; vision satisfactory

Ocular transparency beginning to be affected

Severe interference with ocular transparency

A B