Every few years technologies come along that are game changers. In some instances, we can still make do with traditional ways of doing things, but in other cases such instruments and technology become ‘must have’ items. Alan Saks reflects on the rapid pace of change and takes a peek into the future.
I still recall the first autorefractors in the early 1980s. They tended to induce accommodation and results varied wildly. Although we had one at optometry school – it was the size of a small desk and weighed a ton – we relied on our trusty Hamblin streak retinoscopes. When automated visual fields came along, they soon became widely adopted and are now ubiquitous. In the 90s and beyond, nonmydriatic fundus cameras became the ‘must have’ item.
During this period of rapid evolution – fuelled by integrated circuits, advanced imaging, computers, and software – we also purchased a topographer. It was an Australian developed Medmont E-300, which became a worldwide success and continues to evolve. We used it to set up the first orthokeratology (OK) practice in NZ during the early noughties. I found it invaluable with ectasia, grafts, and custom designing corneal rigid gas permeable lenses. Although widely used by expert contact lens (CL) practitioners and cataract and refractive surgeons, it still astounds me how many optometric practices still don’t have one. That said, in the early days of topographers, I shunned them and relied on my old-school Bausch and Lomb keratometer, sodium fluorescein (NaFl), a Burton Lamp, and trial lenses. But once I had my Medmont I never looked back.
ROLL ON THE NOUGHTIES
In the early noughties, I first became aware of the Oculus Pentacam at a conference in South Africa. It’s a superb instrument, that uses rotating Scheimpflug imaging, with many resultant functions. I greatly desired one over the next decade or so but could never convince my colleagues to take the expensive plunge. Unlike a placido disc topographer, that relies on reflections off the tear film/cornea interface and interpretation thereof, the Pentacam provides corneal shape information that is not affected by a variable tear film. Ophthalmologists used this to improve biometry in intraocular lens selection and refractive surgery screening and treatment, and some adopted Pentacam early on. In optometry it took many more years for Pentacam to become a desired tool, mostly among speciality CL practitioners. They find it invaluable in scleral lenses, irregular cornea fitting/monitoring, OK, and myopia management. This sea change was largely due to enhanced software and added functionality like AXL Wave and the Cornea Scleral Profile (CSP) report.
Pentacam, along with another highly desired instrument, the Eye Surface Profiler (ESP), is a core instrument in sclerals and in prescribing ScanFitPRO contact lenses, combining elevation specific technology with developments in topographical scanning and proprietary algorithms. WAVE and CSP are also adapted to fitting other proprietary designs.
Despite the high cost, practitioners who’ve invested in such technologies swear by the benefits. These include efficiency, accuracy, superb results, and the ability to avoid or minimise multiple trial lenses in getting to the final lens. Those in the know, and users of such technology, explain how it pays for itself. Some have already upgraded to newer versions of these instruments. They also speak of how impressed their patients are and how referrals follow, while professional and patient satisfaction increases.
Just over a decade ago, an optical coherence tomographer (OCT) was still a rare sight in an optometric practice. Early adopters were typically retinal specialists, but today an OCT is an almost indispensable tool. It’s no longer a speciality tool but one that’s commonly found in many practices – ranging from large corporates to small independents. Again, many have upgraded to higher resolution instruments with faster acquisition, more advanced algorithms, larger normative databases, and a smaller footprint, as we see with many evolving imaging systems.
The advent of anterior segment (AS-OCT) was a boon to anterior segment specialists and CL practitioners, while widefield and ultra-widefield fundus photography is also high on wish lists, if not already in practice.
NEXT GENERATION DESIRES
The latest development that early adopters are hankering after is the Australian Cylite HP-OCT. HP stands for hyperparallel, which has redefined OCT using a micro-lens array that splits the 840nm laser light-source into 1008 individual ‘beamlets’ to capture sharper, faster, wider field images, resulting in more accurate scans and data.
The Cylite and Pentacam both deliver valuable posterior corneal elevation and pachymetry maps and can also be used to assess on-eye scleral lens fitting characteristics and measure axial length. The Pentacam AXL includes a Hartmann-Shack aberrometer, which potentially allows for aberrationcontrolled lenses to be made. The Cylite, of course, provides posterior segment OCT imaging as well, potentially replacing three separate instruments.
Which would you choose?
All the aforementioned technologies have greatly enhanced the patient pathway with earlier diagnosis, better management and more effective outcomes, health, and safety.
EXTRA! EXTRA! HEAR ALL ABOUT IT
You can hear about much of this technology in lectures, and experience it firsthand in workshops and at exhibitors’ stands at the forthcoming 19th International Cornea and Contact Lens Congress (ICCLC), themed ‘The Matrix’ at QT Surfers Paradise, 23–25 August 2024.
Register ASAP at icclc2024.com.au so you don’t miss out, as spaces are limited.
The biennial ICCLC is always a not-to-bemissed event. It includes top-shelf local and international speakers, a great program of lectures and workshops with much fun to be had. It’s a highlight of the CPD calendar.
Alan Saks is a retired optometrist. He is the Chief Executive Officer of the Cornea & Contact Lens Society of Australia and a regular contributor to mivision.
