What's New in the Exam Lane?

A look at the latest autorefractors, slit lamps, phoropters and tonometers on the market.

While manufacturers find a way to reinvent and upgrade high-tech devices year after year, the standard building blocks of an ophthalmic exam lane don't always get treated to the same kinds of annual luxury makeovers. Is updating a phoropter a little bit like reinventing the wheel? Larry Patterson, MD, of Crossville, Tenn., seems to think so.

“These are things that have been around 50 to 100 years, so most of the refinements have already happened.” A challenge for manufacturers but golden ticket for ophthalmologists? Buying a decent quality product the first time around means not having to invest in a replacement for quite awhile. Dr. Patterson says that much of the exam equipment he bought 23 years ago is still in use, thanks to listening to his teachers in residency who advised him to buy top of the line equipment on the front end.

A. James Khodabakhsh, MD, of Beverly Hills, agrees. “I routinely try to buy the ‘best’ exam equipment so I don't have to replace it often. I truly believe that smart money spent up front can save you money in the long run.”

He says even the most “up-to-date” surgeons he knows have been using the same slit lamps for over 20 years. “The reality is that even newer slit lamps are based on decades old technology. They might look better, but the core functionality is the same.”

While every company wants to be credited for making long-lasting products, quality inevitably means less frequent sales. Still, manufacturers constantly update their systems, so that whether an ophthalmologist is starting an exam lane from scratch or finally getting around to replacing devices bought during the Reagan administration, there's something new to buy. Here, we'll outline some of the latest.

Autorefractors

While portable autorefractors debuted in the mid 1990s, handheld devices have become particularly popular for pediatric ophthalmologists and those that spend time at community vision screenings. However, the diagnostic industry has seen a turn toward multi-use systems. The combined-device powerhouses save space in the exam room and provide a greater range of diagnostic services without having to invest in large amounts of equipment. Autorefractors in particular are almost always featured as part of a combined system. Dr. Khodabakhsh notes that the newest autorefractors have higher precision at all ranges.

Marco's ARK-530A autorefractor/keratometer uses Zonal Ring Image Method and sensitive CCD. The device has fully automated alignment, tracking and focusing so the measurements are repeatable. The machine includes some nice user-friendly features like a motorized chin-rest, multiple USB ports for connecting to EMR systems, and an auto printer paper cutter. The ARK-530A can also connect with any Marco refraction systems.

Even newer from Marco is the OPD Scan III, a combined autorefraction/keratometry, pupillometry, corneal topography, optical path difference and wavefront analyzing system. Wavefront analysis has become a much-desired feature for the technology's ability to assess both lower-order and higher-order aberrations. The OPD-Scan III runs all 10 tests in 10 seconds, according to the manufacturer, and offers a full 9.0-mm measurement area and EMR integration.

Topcon's KR-8000PA autorefractor/keratometer/topographer includes a computerized color corneal mapping system and 10 placido rings for corneal mapping measurements up to 10-mm. The device uses rotary prism technology for refraction measurements and offers auto tracking.

Slit Lamps

Modern slit lamps have the potential to offer simultaneous video and still photography, providing high quality external and anterior segment photography to aid in monitoring, classifying and documenting disorders of the eye. This allows clinicians to create permanent impressions of an exam, explains Alice Epitropoulos, MD, of Columbus, Ohio. Though some practices choose to buy separate components, many now purchase slit lamp and camera sets. Slit lamp bracket adapters are also available for attaching a consumer digital camera.

HAI Labs recently released the CL-1000eva, an endothelium-viewing attachment that adds specular microscopy for endothelial cell counting and analysis by using the slit lamp's light source. While the viewfinding is manual, the mini non-contact microscope automatically captures and analyzes the view of the endothelium.

Examining young patients with traditionally sized equipment can be difficult. For pediatric ophthalmologists, and those that frequently run off-site clinics or non-ambulatory patient visits, Keeler developed the PSL Classic portable slit lamp. With 10x and 16x magnification, the PSL allows illumination control down to zero. Red-free, blue and neutral density filters are included, as well as slits from 0.15-mm to 1.6-mm wide, a 12-mm circle and a 1-mm square. The lamp also has back-up power facilities, convenient for remote clinics.

Phoropters

Despite the fact that phoropters have been around since the 19th century, they still remain a solid component of an ophthalmic exam lane. Marco tweaked the classic design with the company's new RT-700 Illuminated Refractor. The device has a fully synchronized axis and cross-cylinder system and white prism, accessory and cross-cylinder scales for easier recognition in low lighting. The illumination is infinitely adjustable for sphere, cylinder and axis measurements.

Computerized phoropters, like Reichert's Auto Phoropter RS, give the device a millennial upgrade. The auto refraction system uses software that can be interfaced with various brands of autorefractor/keratometers and lens-meters. Controlled by keyboard, the Auto Phoropter RS can also be configured to EMR systems to transfer the patient's refraction starting point. Dr. Khodabakhsh, who has the device in his satellite offices, says the technology makes refractions much faster.

Though phoropters are the conventional way of measuring refractive errors, Dr. Epitropoulos predicts that the strategy could change in the future. “Wavefront measurements can give sharper vision and may eventually replace conventional prescriptions,” she says.

Tonometers

Because of the increasing number of LASIK patients and the procedure's effect on corneal thickness, CCT compensation has become a helpful feature for obtaining accurate IOP readings. Canon recently announced development of the TX-20P, a fully automatic non-contact tonometer that boasts a built-in pachymeter. An updated version of Canon's TX-F, the new model simultaneously measures corneal thickness and intraocular pressure before recalculating the corrected IOP based on CCT. The feature increases the possibility of accurately diagnosing glaucoma.

While at one time non-contact tonometers were not considered as accurate as traditional tonometers, the financial allure of reducing the need for anesthetic drops and single-use probes and tips has encouraged non-contact developments. Earlier this year, Keeler released a desktop iteration of its portable Pulsair intelliPuff tonometer. Using similar technology to the handheld device, the Pulsair Non-Contact Desktop has integrated software that analyzes all readings and eliminates anomalies before producing a final display.

Reichert also updated their non-contact device with the 7 Auto Tonometer. A USB port allows the device to connect to EMR systems for data transfer. The measurement process is fully automated, including alignment of the cornea.

Finding DICOM-Compliance

When investing money in an expensive new exam device, it's crucial to find one that meets DICOM (Digital Imaging and Communications in Medicine) and Integrating the Healthcare Enterprise (IHE) standard. The problem, says Alan P. Golota, CEO of Ophthalmic Tools, an IHE and DICOM interoperability consulting company, is that many manufacturers falsely claim to meet the standards by describing a product as “DICOM-compatible.”

The most important tip to remember when purchasing a new device, explains Mr. Golota, is to request a DICOM Conformance statement and an IHE Compliance (Interoperability) statement from the vendor and to look up the equipment in the IHE product registry (available at product-registry.ihe.net/PR). If the vendor doesn't have this information on hand, the purchase should be a no-go.

Physicians can look forward to improvements in medical decision-making, patient care and cost through the use of interoperable data exchange, facilitated by strict adherence to international standards. “The days of medical instrument manufactures' proprietary, instrument-specific, ‘data silos’ of patients' medical information are over,” adds Mr. Golota.

IHE EyeCare, supported by the AAO, has made significant strides in the application of DICOM/HL7, addressing ophthalmology-specific uses such as image management, workflow, charge posting and structured ‘displayable reports’ for image interpretation.

Because of the long lifespan of many traditional ophthalmic devices and the justified hesitancy for practices to invest in unnecessary technical upgrades, IHE EyeCare created the AMI (Acquisition Modality Importer). Understanding the significant investment in legacy digital instrumentation made by an ophthalmologist, the IHE EyeCare Technical & Planning Committees developed protocol for converting non-DICOM instruments' data output to a DICOM-conformant data structure for interoperability. “All of the ophthalmic legacy instruments that I have encountered in the field can be integrated into a DICOM and IHE-compliant image management system,” he says.

Mr. Golota insists, “The use and widespread acceptance of DICOM, HL7 and more specifically, IHE Interoperability Protocol will be one of the greatest achievements in medicine, research and clinical trials in the first half of the 21st century.” OM