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?
WAVEFRONT GUIDED CONTACT LENSESOPTIMIZING ABERRATION CORRECTION
HOW IMPORTANT ARE LOWER ORDER ABERRATIONS?
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
HOW IMPORTANT ARE LOWER ORDER ABERRATIONS?
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
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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
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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
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JT20 YOAM
JT20 YOAM
JT20 YOAM
JT20 YOAM
JT20 YOAM
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+
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CASE 2 - KERATOECTASIA
•LB 62 YOCF H/O LASIK OU 2001 in Niagara Falls, CAN
•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
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LB62 YOCF
LB62 YOCF
LB62 YOCF
LB62 YOCF
LB62 YOCF
LB62 YOCF
CASE 2 - KERATOECTASIA
•LB 62 YOCF H/O LASIK OU 2001 in Niagara Falls, CAN
•Refit into scleral rigid gas permeable contact lens OU
•Valley Contax Ares Oblate design OU
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LB62 YOCF
LB62 YOCF
LB62 YOCF
LB62 YOCF
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
3.0mm pupil w/o sim Rx 3.0mm pupil w/ sim Rx
CASE 2 - KERATOECTASIA
•LB 62 YOCF H/O LASIK OU 2001 in Niagara Falls, CAN
•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
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DP26 YOCM
DP26 YOCM
DP26 YOCM
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
CM69 YOCF
CM69 YOCF
CM69 YOCF
CM69 YOCF
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
MB56 YOCM
MB56 YOCM
MB56 YOCM
MB56 YOCM
MB56 YOCM
IMPACT OF PUPIL SIZE AND REFRACTIVE ERRORMB 56 YOCM
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5.3mm pupil w/o sim Rx 5.3mm pupil w/ sim Rx
IMPACT OF PUPIL SIZE AND REFRACTIVE ERRORMB 56 YOCM
60
3.0mm pupil w/o sim Rx 3.0mm pupil w/ sim Rx
WAVEFRONT GUIDED CONTACT LENSESOPTIMIZING ABERRATION CORRECTION
HOW IMPORTANT ARE LOWER ORDER ABERRATIONS?
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!
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