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Is it time to retire your retinoscope?
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Everywhere I turn the dictum is the same: Do more with less. In almost every occupational endeavor, the push for greater productivity, shorter timelines, better quality and fewer personnel prevails. Unfortunately, eye care is no different.
With cost constraints of managed care, along with exponential growth in practice technology and the increased standards of care, the prospect of providing comprehensive eye care seems ever more daunting.
Though I don't profess to understand the engineering behind automated instruments, I clearly understand the role they play in my practice. Each instrument, in its own way, allows my staff to "profile" patients - efficiently, comprehensively, and oftentimes, more accurately.
However, implementing new technology is not always easy. For instance, years ago our visual field technician expressed grave concerns over any instrument replacing the Goldmann perimeter. Now, there is no going back.
On the other hand, certain instruments are more easily adopted. Our staff recognized corneal topography as a valuable adjunct that expanded the services offered, and readily implemented this instrument. And, of course, no tears were shed when our office information system replaced manual insurance claim submissions.
Despite the general acceptance of office automation by most optometric practices, there is one instrument whose role remains nebulous: the autorefractor. Perhaps the most disconcerting aspect of autorefraction is that the technology threatens two of our core disciplines: retinoscopy and subjective refraction.
I have found autorefractors to be quick, easy to use, accurate and well received by most patients. That being said, have I retired my retinoscope and performed my last refraction? Hardly. In fact, though a valuable adjunct, the autorefractor has its limitations.
For instance, consider the utility of retinoscopy. What other instrument can approximate refractive error, assess accommodative function, detect irregular astigmatism and reveal media opacities? And then there's the psychology of a subjective refraction. We all care for patients who find refractions anxiety-provoking at best. Though enthralled with the prospect of a computer measuring their prescription, many have their doubts regarding its accuracy. For these individuals, there is security in knowing you are "refining" the results.
Additionally, what about prescription (in)tolerance? Only through a subjective refraction can one determine how "sensitive" a patient is with respect to small prescription changes. Arguably, this is a valuable piece of information when counseling patients interested in bifocal contact lenses or in refractive surgery.
Finally, there's the issue of binocular function. To date, subjective refraction with phoria testing and nearpoint analysis remains the standard for evaluating binocular status. Indeed, it's essential to automate while eliminating antiquated procedures of data collection. However, it is equally important to complement - rather than replace - certain time-honored procedures with new technologies.