Wavefront Analysis and Clinical Applications

Wavefront Analysis and Clinical Applications

Robert A. Ryan, OD, FAAOAssociate Professor, Flaum Eye Institute

FINANCIAL DISCLOSURES

Served as an unpaid consultant/advisor to the Ovitz team during their Luminate Rochester campaign

WAVEFRONT GUIDED CONTACT LENSESOPTIMIZING ABERRATION CORRECTION

HOW IMPORTANT ARE LOWER ORDER ABERRATIONS?

WHICH HIGHER ORDER ABERRATIONS (HOA’s)

ARE IMPORTANT?

CAN WE CORRECT FOR HOA’s WITH CONTACT LENSES?



Sphere, cylinder and prism are examples of LOA’s

In a ‘normal’ eye, LOA’s account for 80-90% of refractive status

LOA correction impacts high contrast visual acuity

LOA’s are key when the pupil is < 6mm


Share of Total Soft CLs

Sphere

Toric

Bifocal

77%

18%

Toric soft lens fits are under-represented relative to

prevalence of astigmatism in population

Level of Astigmatism in Population

>2.50D

1.25-

1.50D

1.75-

2.00D

<0.75D

0.75-

1.00D

2.25-

2.50D

55%39%

Oct 2005, HPRHolden 1975

HOW IMPORTANT ARE LOWER ORDER ABERRATIONS?CORRECTING LOW LEVELS OF ASTIGMATISM

-2.00 -0.75 x 180 w/ -2.25sph

-2.00 -0.75 x 180 toric scl

OPTIONS FOR DETERMINING HOA’s

• Zywave by Bausch and Lomb

• iTrace Visual Analyzer by Tracey

• Visionix VX130 by Luneau Technology

• iProfiler by Carl Zeiss Meditec (LADARWave no longer available)

• WaveLight Allegro Analyzer by ALCON Laboratories

• OPD Scan II by Nidek, Inc

• COAS (Complete Ophthalmic Analysis System) by AMO Wavefront Sciences

• Maxwell Optical Wavefront Aberrometer by Ziemer Ophthalmic Systems

• Optiwave Refractive Analysis (ORA) by WaveTec Vision (intraoperative)

• KR-1W Wavefront analyzer by Topcon Medical

• xWave by Ovitz7

xWAVE ABERROMETER SYSTEM by OVITZ

Lightweight unit detachable from carriage for portability

Complete ocular HOA profile

Proprietary HOA lens design

Direct submission to lab for lens fabrication

Subscription model – easy entry to wavefront assessment

WHICH HOA’s ARE IMPORTANT?

Sachdev, etal J Cat & Ref Surg 30(8):2004

N = 40 EYES

20 w/o OPACITIES

(10 = NS, 10 = CS)

MEAN BVA 6/9 CS

MEAN VA 6/15 NS

B&L ZYWAVE SCANS

CORTICAL CATARACT = INCREASE COMA/TETRAFOIL

NUCLEAR CATARACT = INCREASE SPH AB/TETRAFOIL

SOFT CONTACT LENS CONSIDERATIONS

Kollbaum, etal Optom & Vis Sci 2013 90(9):924-936

On eye CL deformation and precorneal tear lens

alters SA

Hammer, etal Optom & Vis Sci 1994 71(8):522-528

Generated model to predict induced SA of CL

based upon BC and Rx

Numerous studies

State importance of CL surface hydration upon

parameter stability and optical performance 13

IMPORTANCE OF PUPIL SIZE

14

Point Spread Function of wavefront over varied pupil size

CASE 1 - KERATOCONUS

• JT 20 YOAM H/O KCN OU, anxiety, depression, OSA, seizures

•04/20/2017 underwent epi-on CXL OU for KCN

•06/12/2017 presented for 2nd opinion, while in process for

scleral RGP CL OU elsewhere

•Recommend continuing process with current provider

15

CASE 1 - KERATOCONUS

• JT 20 YOAM H/O KCN OU, anxiety, depression, OSA, seizures

•01/29/2018 returned voicing inability to tolerate RGP CL OU

•Ophthalmic challenges resulted in IEP, unable to attend HS FT

•Attempted KeraSoft fitting, punctal occlusion, BVA 20/40 OU

•MR OD -2.50 -3.25 x075 20/50+, OS -4.00 -2.50 x105 20/70

•03/05/2020 initiated Valley Contax Ares prolate design OU

16

JT20 YOAM

CASE 2 - KERATOECTASIA

•LB 62 YOCF H/O LASIK OU 2001 in Niagara Falls, CAN

•Dx Keratoectasia in 2006, managed by spectacle correction

•10/08/2014 Pach OD .509, OS .493

MR OD +4.00 -4.75 x075 20/25--, OS +5.00 -8.00 x130

20/70

•CXL OU 10/08/2015 in Toronto, CAN

•Fit with KeraSoft IC OS CVA 20/40, no lens OD 20/40

•Refit into Biofinity Toric XR OS CVA 20/40+

23



•11/16/2020 visit for annual exam, noted NS1 OU

MR OD +3.25 -2.50 x070 20/25

OS +3.50 -8.00 x130 20/100

24

LB62 YOCF

LB62 YOCF

LB62 YOCF



•Refit into scleral rigid gas permeable contact lens OU

•Valley Contax Ares Oblate design OU

30

LB62 YOCF

IMPACT OF PUPIL SIZE AND REFRACTIVE ERRORLB 62 YOCF

36

5.3mm pupil w/o sim Rx 5.3mm pupil w/ sim Rx

IMPACT OF PUPIL SIZE AND REFRACTIVE ERRORLB 62 YOCF

37




•Valley Contax Ares Oblate design OU

•Over refraction OD Pl -2.25 x165 20/20, OS Pl sph 20/20

•Reports “vision is wonderful”

38

CASE 3 – POST-LASIK FLARE

• DP 26 YOCM H/O Zyoptix LASIK Femto OU on 05/03/2016

•Pre-op MR OD -4.00 -1.25 x125 20/15

OS -3.50 -0.75 x047 20/15

• 06/11/2020 VA sc OD 20/15--, OS 20/15-

•Post-op MR OD -0.25 sph 20/15

OS -0.25 sph 20/15

• Reports flare after dark, works as sheriff

39

DP26 YOCM

CASE 4 – PSEUDOPHAKIC COMPLAINTS

• CM 69 YOCF H/O Cat Ext w/ B&L Envista IOL OU

•09/05/2019 OD MX60E +22.0D target Plano

•One week post op MR OD -0.75 -0.50 x050 20/20

•09/19/2019 OS MX60E +20.5D target Plano (adj for myopic

outcome OD)

•07/09/2020 YAG cap OD, offered PPV for dense floaters OD

•03/01/2021 MR OD +0.25 -1.00 x090 20/20

OS PL -0.75 x050 20/20 44

CM69 YOCF

CASE 5 – PSEUDOPHAKIC ENGINEER• MB 56 YOCM H/O Cataract Extraction OU

07/15/16 OS B&L AO60 +7.0D target -1.00

08/01/16 OD B&L AO60 +5.0D target -1.00 (adjusted)

•Post-op (1W) MR OS -2.00 sph 20/15

•Post-op (1W) MR OD -1.00 sph 20/20

•05/03/17 YAG capsulotomy OD for ‘very thick PCO’

•Post-op MR OD Pl -1.25 x065 20/20

•Poor tolerance of anisometropia51

CASE 5 – PSEUDOPHAKIC ENGINEER• MB 56 YOCM H/O Pseudophakia, anisometropia

08/01/17 IOLx OS B&L AO60 +5.0D target Plano

12/27/17 YAG capsulotomy OS

•03/18/21 Vasc OD 20/20-, OS 20/25+

MR OD +0.25 -1.00 x080 20/15

MR OS -0.25 -0.50 x140 20/15

•Happy now? Not a chance! Attempted CL correction of RE,

brimonidine, presently ordering spectacles in 0.25D

increments to determine desired refractive outcome 52

MB56 YOCM

IMPACT OF PUPIL SIZE AND REFRACTIVE ERRORMB 56 YOCM

59


IMPACT OF PUPIL SIZE AND REFRACTIVE ERRORMB 56 YOCM

60




80-90%, accurate cyl correction

WHICH HIGHER ORDER ABERRATIONS (HOA’s)

ARE IMPORTANT?

Coma and SA > .25 rms (pupil dependent)

CAN WE CORRECT FOR HOA’s WITH CONTACT LENSES?

The future is here!!!

SUMMARY & CONCLUSIONS•Accurate correction of lower order aberrations will satisfy the

visual demands for the majority of patients

•Posterior corneal curvature, crystalline lens shape/clarity and

pupil size are key components of the visual wavefront

•For subjective complaints in the presence of good Snellen

acuity and absence of apparent pathology suspect HOA’s

•Coma and spherical aberration most common HOA’s noted

•HOA CL correction requires consistent centration, orientation,

minimal movement and excellent surface characterisitics 62

Thank you for your kind attention!

[email protected]

Wavefront Analysis and Clinical Applications

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