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The tried-and-true phoropter is one of the most venerable devices in the profession and likely one of the first pieces of equipment you added to your practice. It may very well have predated you at the office, in fact. But are the days of spinning dials and asking the patient, “Which is better? One or two?” going to become a thing of the past? Advocates of digital refraction systems believe it’s possible.

“In general, the purpose of these devices is to make the process more expedient, more consistent and more accurate than manual refraction,” says Alan Kabat, OD, a professor at Southern College of Optometry. “Digital refraction systems can minimize not only the time a doctor spends performing this procedure but also the physical wear and tear on his or her body. Any optometrist who has done retinoscopy on 20 or 30 patients in one day can relate.”

Today’s high-tech upgrades range from digitizing the phoropter to replacing it outright, while others incorporate wavefront aberrometers to improve accuracy. Still, not all are convinced of their benefits over the standard phoropter—at least not enough to justify the price.

Here’s a look at the latest high-tech refracting systems and some dissenting opinions from those who believe the venerable phoropter suffices, especially with the opportunity cost of forgoing other upgrades to your practice’s suite of equipment when investment budgets are tight.

High-tech digital refraction systems add a ‘wow factor’ to modern optometric practices, says Kambiz Silani, OD, of Beverly Hills (pictured). Photo: Kambiz Silani, OD

Greater Accuracy?

Dr. Kabat is involved in a study using the Voice Activ Subjective Refractor, or VASR (Vmax Vision), a wavefront autorefractor that uses a concept called subjective point spread function (PSF) refraction. “From my own personal experience, I have found the device is at least as accurate as I am in attaining 20/20 vision. But according to the manufacturer, this platform can routinely deliver 20/16 or even 20/12.”

Note that most patients under age 65 see better than 20/20 and can be refracted as such with a conventional phoropter, says Mark Wilkinson, OD, a clinical professor of ophthalmology and visual sciences at the University of Iowa. “It is not hard to get them to their best acuity level with a phoropter and standard refraction techniques,” he says. “We have to remember that Snellen acuity was developed during the Civil War, and 20/20 is simply a number, not the best vision a person can attain.”

The idea behind PSF is that the best refraction target is a point as opposed to letters or images that are two-dimensional, which may fail to fully reveal the extent of astigmatism or higher-order aberrations in the eye, according to Vmax Vision. PSF uses point spread images, which automatically correct for both low- and high-order aberrations in the final prescription. The PSF target appears blurred when looking at the endpoint, rather than smaller and darker as in Snellen letters, which prevents over-minus, according to the company.

From the patient’s point of view, it is easier to discern differences using a point target than a traditional Snellen chart, making the entire process faster and creating less “refraction anxiety,” Dr. Kabat says. “The result is an easier scenario for patient and doctor, and the potential for enhanced acuity by a more precise assessment.”

David Geffen, OD, of La Jolla, Calif., has been using the PSF system for the past three years and says he has found patients with a previous 20/20 prescription now are able to read 20/15, or in some cases, 20/10 letters. “A lot of doctors just stop at 20/20. And that’s not fair. If we can get someone to 20/12, we should try,” Dr. Geffen says. The system allows a patient to see in a more refined way than standard phoropters, allowing for an increase in best-corrected acuity, he says.

By using some of the higher-tech devices, you are essentially neutralizing the normal aberrations of the eye, Dr. Geffen adds. The PSF is five times more accurate than a phoropter, he says, and digitized spectacle lenses allow a doctor to custom fit lenses to virtually to any prescription.

“We aren’t creating a wavefront lens, but rather using a point spread function to create a more accurate prescription,” says Dr. Geffen. “When you refract that way, it optimizes those aberrations, so we are giving the patients better glasses, and that’s why we are getting better vision results. It is better because we are able to refine the patient’s Rx to a much higher degree than with Snellen letters. We’re optimizing patients’ aberrations.” 

However, even though a prescription can be determined in 0.05D increments, lens manufacturing is still fabricating lenses in 0.25D increments if a wavefront lens is not used, Dr. Wilkinson says. “Also, given that we expect each 0.25D to equal one line of vision for a normally sighted person, I am not sure how a person is going to appreciate a 0.05D difference in refraction power, even if fabricated in a digital lens.”

Dr. Geffen also notes that patients set to undergo refractive or cataract surgery can now be corrected to a much higher level of precision and “doctors still using phoropters are basing their readings on older technologies” that may not fully characterize the quality of the surgical outcome.

Also, the high-tech refractors can benefit patients with reduced visual acuity from conditions such as keratoconus or macular degeneration, Dr. Geffen adds. With a keratoconic patient, a diopter or two of difference in 10 to 15 degrees of astigmatism on Snellen letters can be achieved. “But with point spread function [devices], we can bring them down two or three lines,” Dr. Geffen says. In patients with macular degeneration, if the size of the point spread is increased, the patient can see smaller differences and sometimes a line of acuity is picked up, he adds. “It’s a big deal for those patients.”

Dr. Wilkinson agrees that a phoropter should not be used for this type of patient but doesn’t believe the only way to improve their correction is via digital refraction. “A trial frame refraction is best for refining acuity in folks with less than normal vision,” he argues.

Dr. Geffen (pictured) says the PSF Refractor provides more accurate readings than the standard phoropter through its point spread function. Photo: Vmax Vision

Upgrading the Experience

Paul Harris, OD, of Southern College of Optometry, notes that the ability of these systems to dial in the patient’s habitual prescription and save it is a major plus, in addition to being able to show the patient their old Rx and their new one with just the touch of a button.

Dr. Geffen, who had carpal tunnel surgery 10 years ago—a condition he says is common in the profession—finds his new system is faster and less physically taxing. “With the phoropter, we sat there and used our computer and then we spun dials. Now all I have to do is use a mouse to refract. So, it’s easier on the doctor, and I feel the patients find it easier to tell differences than looking at the Snellen letters and being asked, ‘Which is better? One or two?’”

 “Automated phoropters offer a refreshing and modernized addition to the exam lane,” according to Kambiz Silani, OD, of Beverly Hills, Calif. “Patients have grown accustomed to seeing the same manual phoropter for decades, so embracing the updated digital refracting systems adds a coolness factor to the millennial practice. In our office, patients have responded enthusiastically toward the latest gadgets with countless positive remarks.”

While not all these technologies are considered standard of care, they are increasingly present in practitioners’ offices. Adds Dr. Geffen, “we keep adding all this high-tech equipment, so the patient goes through this huge pretest regimen where they have an OCT done, topography, visual fields and a special camera [for ultra-widefield imaging], and then they go into your exam room and you have a flat screen and all this pretty stuff and what do they see? That same thing hanging on the chair that optometrists have used for 100 years. So they respond, ‘Oh, are you still using that, doc?’ If your practice is based on adding the latest technology, it doesn’t look very cutting edge to be using the same piece of equipment you used when your 50-year-old patient was five.” 

Should You Make the Switch?

It’s not so much a decision of whether but rather when to replace the manual phoropter, Dr. Kabat argues. “Let’s face it—health care has become an exceedingly complex business over the last 20 years, with greatly increased responsibilities for data collection and medical coding.” As reimbursements from third parties have declined, doctors have been forced to accommodate more patients into their schedules to maintain profitability, he says. “To remain competitive, doctors must be able to adapt and take advantage of products that can not only help patient flow but also provide a better overall patient experience. I suppose the most important question an optometrist can ask is, ‘Do I want to continue to be successful?’” If so, upgrading to next-generation equipment is one way to help foster that.

Additionally, Dr. Kabat says doctors should consider:

• Financial constraints, i.e., how much is available to spend, in terms of upfront purchase or fixed payments.

• Office space and desired patient flow.

• Number and type of ancillary personnel. 

These variables can help to determine what type of unit is best for a given practice, whether it will be used in the exam room or an ancillary testing room, and who will primarily operate it.

Vx55 enables bluetooth communication between the head and the tablet. Photo: Visionix

Stumbling Blocks

Yet optometrists should consider the costs of these systems and whether they are the best use of investment dollars put toward the success of their practice, Dr. Wilkinson says. 

When considering whether to trade in your phoropter for a high-tech model, the most commonly cited obstacles to consider are as follows:

Costs. For Dr. Geffen, the biggest perceived con is cost. “They are expensive units and cost more than the standard phoropter.” Some doctors may view refracting equipment with a don’t-mess-with-success mindset, since they feel their phoropter does the job and they prefer to stick with what already works. Adds Dr. Kabat, “whether we admit it or not, most of us are creatures of habit and immensely dislike change.” 

Support. Some of the companies manufacturing the newer devices are small and might not offer the customer support of a company with a national footprint, should trouble arise, Dr. Geffen says. “If you’re somewhere out in a more rural location and you need help, it might be hard to get.” In his experience, his system has needed minimal service, and his practice is located near where it’s manufactured.

Design limitations. If performing retinoscopy is a standard part of an exam, the digital systems will not suffice as the only setup, Dr. Harris notes. “Most of the digital systems I’ve had contact with have a set of controls off of the instrument head itself.” These types of systems are “back saving,” he says, since a doctor doesn’t need to reach around a patient to change a lens, and some patients prefer to be across the room from the doctor during the exam. “Retinoscopy, though, requires one hand on the scope and for us to be on the visual axis of the patient. Since our visual attention is on the reflex, it can’t be on the controls of the system, so a must for such a system, if it can be used for retinoscopy, would be touch controls with haptic feedback for sphere, cylinder power and axis,” he says.  

Diminishing the doctor’s role. Additionally, optometrists may worry that the new technology will somehow be “too good,” making the role of the doctor obsolete, Dr. Kabat adds. “In essence, ODs are concerned they will be replaced by these machines. Of course, that is nonsense. These individuals confuse the process of refraction with the art of refractive prescribing. A doctor’s knowledge and experience can never be replaced by technology, but technology can greatly enhance a doctor’s ability and efficiency.”

“Optometrists are far more than ‘refractionists,’ in that what we derive is a range of lens powers, under different conditions—for example, objective and subjective—to which we apply professional judgment,” says Dr. Harris. “This is what leads us to write final prescription numbers that resemble, but were not exactly found in, any of the measurements taken of our patients’ eyes.” Optometrists, he stresses, do not “blindly transfer measurements to a script. We take into account how patients use their visual systems to find formulas that help them process visual information more efficiently and effectively, and minimize future negative changes.”

The Role of Refraction

Some of the newer refracting systems are geared toward the doctor and designed to be operated in the lane. This expedites the refraction process by incorporating automation and integration between the autorefractor, the subjective presentation and the electronic medical records, Dr. Kabat says. But techs could use other systems, such as the VASR, during pre-testing, he says.

In some offices, technicians already perform the bulk of refractions, but optometry has not embraced this practice as quickly or completely as ophthalmology, Dr. Kabat says. “As a clinical professor, I’ve been delegating refractions for nearly 25 years. And while that responsibility goes to an optometry student rather than a technician, the outcome is the same.” Someone else collects the refractive data and refines it as best as possible, then he decides what is most appropriate to prescribe. “If the data I receive seem invalid or unusual, I check it myself. This process applies to digital technologies, but the consistency of outcomes is far better, while the need for adjustment is far less.”

Unburdening doctors from the tedium of refraction can mean more time spent on medically focused eye care while still providing accurate spectacle and contact lens prescriptions for patients, Dr. Kabat says.

Others bristle at the notion. “Refraction should remain a critical component of optometric care,” says Dr. Wilkinson. If it is not, optometry will be indicating that online refractions and refractions done by anyone with an autorefractor are acceptable. We’d then move away from our roots, with refractions done by a non-optometric person.”

Whether to pass the refractive reins over to a tech remains an individual choice. “Delegating the objective pre-testing tasks to a technician allows doctors to spend more chair time with the patients to discuss and review treatment options and less time just collecting data, adds Dr. Silani. “As far as performing, it’s still common practice to be performed by the eye doctor as well as expected and appreciated by the patient.”

Will the new technology make phoropters a thing of the past? Not so fast, says Dr. Harris. For the short term, he believes the standard phoropter will remain the mainstay. Clinical staples of the refractive exam, specifically retinoscopy, can be difficult with newer systems, he says. However, “I can foresee a time when the things leaving me reticent to shift over have been addressed and the benefits begin to outweigh the standard phoropter’s use. I look forward to the day when these technologies help me change people’s lives more than I can now.”

A Menu of High-Tech Refractive Options Optometrists looking to trade in their phoropter have several choices to consider. Here’s a look at some of the refractive systems on the market, as promoted on the manufacturers’ websites and in testimonials from proponents: TRS-5100 and Epic-5100 Refraction Workstation (Marco): The Epic decreases workup time to under 10 minutes and performs the refractions in three to five, according to Marco. Practitioners control the refraction process from a small, portable keypad. The TRS-5100 is programmable, and all the lenses are moved at the touch of a button. It improves the patient’s ability to compare previous and new prescriptions. The device can configure in the traditional lane or as part of the Epic workstation. CV-5000 (Topcon): This automated phoropter offers fast lens rotation and comfort for the doctor and patient, according to Topcon. The device provides three interfaces for operation. The first option is a one-dial controller that uses a 10.4-inch color LCD touch screen. The second and third options allow you to load the controller software on a PC or the PC integrated inside the CV-5000 to be controlled by the PC mouse. The CV-5000’s automatic phoropter head also provides fast lens rotation for user and patient comfort, Topcon says. PSF Refractor, Perfectus and VASR (Vmax Vision): The PSF refractor offers a more accurate prescription derived from refraction data measured in 0.05D increments—five times more precise than a phoropter’s 0.25D increments, according to the company. The system uses a subjective PSF, and 20/12 is an achievable goal, Vmax says. The Perfectus integrates wavefront autorefraction, and the VASR is patient-driven.  “This is a small company, but pretty impressive, since they are using a very different system,” says Paul Karpecki, OD, of Lexington, Ky. “Patients simultaneously get upper and lower images that seem easier to decipher, including those individuals with cataract or keratoconus.” Adds Dr. Karpecki, the ability of these and other systems to measure night vision as well comparing their previous refraction (with Snellen letters) with a single touch of a button is valuable for the patient.  Dr. Kabat says the VASR system uses artificial intelligence software and verbal commands to guide the patient through the process. “With an alert and responsive subject, the procedure typically takes about five minutes for both eyes,” he says. “Thus far, the results we’ve obtained and the attitudes of our patients towards this new technology have been very positive.” Vx55 (Visionix): The Vx55 enables bluetooth communication between the refractor and the tablet, plus connection and transmission to other devices. “It shows an image on the tablet of a phoropter,” Dr. Karpecki says, “and you just take your finger and press the buttons.” These types of automated phoropters cut down on shoulder injuries that are common in professional optometry, he adds.  For Kambiz Silani, OD, of Beverly Hills, Calif., a Visionix advisory board member, this is his system of choice; he says it is “as easy to use as an iPad.” His practice uses the entire Visionix suite that also includes an automated lensometer, Vx40, to measure spectacle lenses and the “technician friendly” Vx120, which performs numerous diagnostic testing of anterior segment health as well as wavefront autorefraction. “As a bonus, these devices intelligently communicate with one another to make the transition smoother and more efficient for the technician, the optometrist and the patient,” says Dr. Silani. The company also offers the Vx60 digital autophoropter system, which comes with a control panel. Huvitz HDR-7000 (Coburn): This digital refractor features a slim design with wide viewing angles to improve precision, according to the company. It features fast and silent lens loading with a dual cross cylinder lens, automatic occlusion and automatic convergence, Coburn says. It includes 18 visual acuity test charts, 26 vision test charts and up to 35 user-defined unit test charts. Additionally, the device offers wireless communication and is equipped with a 21-point exam package. According to Coburn, the HDR-7000 alleviates difficulty by displaying results for easy reading for examiners and patients. Visuphor 500 (Zeiss): This subjective digital refraction system, which is modular and expandable, offers an intuitive operation through a touch-screen interface, its manufacturer states. Preconfigured workflows save physicians’ time preparing refraction tests, according to Zeiss, as settings for each test are optimally adjusted, making standard refraction tests simple and fast. Settings and workflows can also be individually configured in the freestyle mode. Patient contact with the headrest is continuously monitored and displayed on the screen.  Phoroptor VRx Digital Refraction System (Reichert): “This automated phoropter is a quiet and smooth system,” Dr. Karpecki says. It offers fast lens exchanges, motorized prisms, split cylinder lenses and a quiet operation with a touchscreen display and ergonomic keypad, according to the manufacturer. Dr. Karpecki adds the system is easy to learn and offers numerous pre-program tests. The device connects to electronic medical records systems as well as numerous models of pre-test and acuity devices from both Reichert and non-Reichert brands.