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The latest tool for photo-refractive comanagement


When a colleague or a patient utters the phrase “intelligent design” (ID), it is challenging for me to not roll my eyes as far back as some patients’ contact lenses get lost up there. Honestly, if we really think about it, the design of the ocular system is far from intelligent.

When a colleague or a patient utters the phrase “intelligent design” (ID), it is challenging for me to not roll my eyes as far back as some patients’ contact lenses get lost up there. If we really think about it, the design of the ocular system is far from intelligent.

In fact, I was just explaining to a patient (who was lamenting his inability to see 20/10) about the proximity of rods and cones when I was detoured by the fact that the axons of these nuclei actually are backward. Moreover, why is the visual system so far in the back of the brain and away from the eyes? That is like putting a handicapped parking spot in the back of a building. Don’t even get me started on the crystalline lens-I mean really, four decades in and the lens is retiring! However, there is an ID worthy of notoriety in the ophthalmic field, and that is the iDesign Dx from Abbott Medical Optics.

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The evolution of refractive surgery

As primary care providers to the ophthalmic system, we are tasked with educating our patients with their best options. Over the last two decades, the landscape for the treatment of an emmetropic patient has grown. In fact, I don’t think it would be hard to argue that refractive surgery is as safe as contact lenses and safer than cataract surgery. Born from the ashes of a photo-refractive procedure that is still efficacious and safe, laser assisted in-situ keratomileusis (LASIK) is now synonymous with refractive surgery.

In true Darwinian fashion, LASIK has replaced radial keratotomy (RK) or photo refractive keratectomy (PRK), much like a DVR to a VHS recorder or a cassette player for a digital audio player. Managing patients with LASIK has been reduced to making sure your patient has his artificial tears or is taking his Restasis (cyclosporine, Allergan). Yet, much like the media-related advancements we have seen in our lifetimes, there are still some potential glitches. Although we don’t see a spinning wheel when we are managing a LASIK patient, we can encounter the occasional diffuse lamellar keratitis (DLK), striae in the flap, epithelial cell down growth, and Loch Ness Monster of complications: the infection.

Those who bring us this photo-refractive surgery technology do not just rest at this level of excellence. Did Apple stop at iPhone 3? Did George Lucas stop at Star Wars Episode 2? No! The iDesign Dx is like 3M, it is just making the surgical procedure better.

Next: iDesign Dx


iDesign Dx

The iDesign Dx is a diagnostic tool that can capture five optical measurements in one three-second scan, including:

Wavefront aberrometry

New-technology topography




Although AMO’s WaveScan WaveFront has made measuring and treating high-order aberrations (HOA) a common occurrence, this highly advanced and intelligent diagnostic tool will offer five times greater resolution, encompassing over 1,250 data points from a 7.0-mm pupil, according to the company. Even with a smaller pupil of only 5.0 mm, the system will capture over 600 data points. The device will also have a broader dynamic range, able to image wavefronts from –16.00 D to +12.00 D of sphere, up to 8.00 D of cylinder, and up to 8 µms of RMS HOAs.

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By comparison, the current system measures up to 1.3 µms of RMS error, according to the company. In addition to obtaining more information, the higher-resolution aberrometer provides much better spot quality, resulting in a more accurate representation of the true wavefront. The benefits of enhanced or high-definition wavefront aberrometry are parallel to a HD television or a retinal screen on a computer. Having a clearer image of the aberrations will enable accurate representations of the wavefront from eyes with severe aberrations from previous RK, corneal scars, or laser surgery with decentered ablations or other problems.

Next: How this tool aids comanagement


How this tool aids comanagement

The iDesign Dx is not just a diagnostic tool for a surgery center; in fact, this is the evolution of crossover devices for clinic and surgery. Having a diagnostic tool that can capture five measurements in one click will serve only to provide us with more information in seconds. Making intelligent decisions for our patients can occur only when we have good information. The device can also help to streamline patients in a practice that is limited in space and time. In a recent study of 71 eyes from 36 patients, a comparison of manifest refraction to the high order autofractometry was found to be within 0.25 D sphere and 0.10 D cylinder.

Now, which is better there-one or two? I’d say they are pretty close to exactly the same. Having the pupil size and topography can also be an asset in fitting contact lenses without having to use multiple diagnostic tools. Moreover, I use the consistency of the HOAs and topography collectively to see if my patient has corneal edema or is experiencing dry eye-pretty intelligent!

Photo-refractive surgery for many is now as commonplace as going to the Internet to read this article. However, when new intelligent devices such as iDesign Dx are combined with the laser to create a new level of treatment, this feels new all over again. So the next time a patient is asking for 20/10, I may have to bite my intelligent design comments and offer iDesign DX Wavescan Platform.

Dr. Bloomenstein serves as a consultant to AMO.

Click here to check out the latest comanagement advice

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