Why you can’t separate refraction from pathology

The views expressed here belong to the author. They do not necessarily represent the views of Optometry Times or UBM Medica.

I’ve been thinking a lot about technology lately and how it’s going to-um, scratch that-how it already is impacting eye care.

In particular, I’ve had refraction on my mind. Maybe it’s that company in New York City that sends those young, earnest eye missionaries with the sleek portable equipment out to your airy, loft office in their cool little cars to refract you in the blink of an eye so you barely have to look up from your computer screen as you launch your second startup in the past three years.

Related: Blink in-home vision test worries ODs

Or that Web-based refraction tool that touts itself as an “alternative” to Stone Age eye doctors who interrogate you senseless with a barrage of “Which is better, one, or two?” before getting all up in your grill with those horrible drops and blinding lights that make you totes late for your afternoon latte with your friends at the corner coffeehouse.

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The operating assumption it seems, is that refraction can somehow be separated from the “eye health” exam, everybody will see great, and we can just call it a day.

Next: Not so fast

Not so fast

As that wise old sage Coach Corso on ESPN would say: “Not so fast, my friend!”

But first, let me say up front that I love technology. My office is packed with it, including a wavefront aberrometer which daily saves my bacon, combined with an automated phoropter that my tech uses to refract the majority of our patients. I rarely have to touch his results-and our remake rate is lower than ever.

I also think there’s a time and place for remote exams (they’re especially good for initial evaluation and triage), and let’s be honest, not everybody needs “the works” every time.

I recently assessed both an iris nevus and a subconjunctival hemorrhage via pictures sent through friends’ text messages. And as if that weren’t enough, within the past two months, I’ve also diagnosed both a sixth nerve palsy and a partial third nerve palsy in a relative of mine using FaceTime.

Improvising a subjective Parks-Bielschowsky three-step test on an iPhone isn’t easy, but it is possible. I am extremely flexible, in mind if not body, and no Luddite.

Next: Can't separate pathology from refraction

Can’t separate pathology from refraction

But I also recall my days as a resident and then an assistant director at a diagnostic and referral center way back in the last century. I was supposed to be focusing on ocular disease, but I quickly learned that I couldn’t separate pathology from refraction any more than I could a definitive diagnosis from an “old fashioned” face-to-face exam.

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We had more than a few patients of all ages referred to us for “unexplained vision loss” that pinholed and then refracted to 20/20. Have you ever tried explaining to a referring optometrist or ophthalmologist that the patient he thought had some exotic, occult neurological disorder actually was a latent hyperope who also needed a diopter more cylinder? I not only learned a lot about disease during those three years, but I developed diplomacy skills on the level of a U.S. Secretary of State.

I’ve been told there was an old neuro-ophthalmogist somewhere who said, “It’s amazing the number of cases of ‘optic neuritis’ that can be ‘cured’ with a meticulous refraction.”

Next: Beat 'em and join 'em

Beat ‘em and join ‘em

While some young, healthy patients with mild-to-moderate refractive error might be able to obtain a decent glasses Rx by bypassing your office, there’s going to be a far greater number of patients who won’t. There will be false positives, false negatives, blurry vision-and hence, opportunity.

In fact, it may be possible to both “beat ‘em and join ‘em.” One tactic might be to align yourself with mobile health (mHealth) companies (unofficially and from a distance, if you prefer) rather than trashing them in public statements. There you’ll stand in the breach, with a nonjudgmental smile on your face and your arms open wide, prepared to catch the patients consumers who fall through the cracks.

Jetpacks and hover cars notwithstanding, “classic” comprehensive eye exams will always be needed and never go completely out of style.

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But make no mistake-these technologies will get better and more accurate and give birth to little baby “disruptors” that nobody’s even dreamed up yet. Current trends as well as the proposed rules for Meaningful Use Stage 3 make it clear that “patient engagement” in their own health via apps and wearables is here to stay, for better and for worse.

My point is, don’t just stand around railing against the disruptors and being known primarily for what you’re against. That tactic alone will be regarded as old-school professional protectionism by a growing demographic of patients for whom managing their lives online is as natural as breathing.

Instead, be the disruptor. Did I mention that my tech does the majority of my refractions, my patients still see great, and the world hasn’t stopped spinning?

That’s what I’m talking about.