Refracting Pt with corneal deformity

[big boby]

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Good Morning guys..

I'm wondering if anyone have some tips or tricks to find out the real RE for a Pt w/ Central corneal deformity either scar, irregularity or whatever.

I've been through many difference types of Auto-ref but all are giving VERY far away results.
Definitely the retinoscope is not the best choice for these cases.
So recently i used to start the Subj. Ref from Zero to get the right RE which is perfect but time consuming.

Please share me you knowledge and experience.

 

[optsuker]

RGP lens makes refracting easier/consistent, but not accurate for real life.

A couple drops of a thick gel AT, a few strong blinks, then quickly do your refraction.
Emphasis on best sphere power. Don't dwell on refining axis too long and don't be afraid to cut cyl power a little.

 

[UnicornOpt]

I'll share my own workflow one professional to another. I'm assuming you are a new graduate.

First off, I'll want to say that you should never trust an autorefractor completely for any patient.
Second, I don't agree at all with what optsuker wrote.

If the patient has pretty good uncorrected VAs like 20/60 or better, then I also will start around plano if I can't get any useful information from retinoscopy. I'll normally run MPBCVA sphere adjustment, power searching in all major meridians, cyl axis refinement, cyl power refinement with a +/- 0.50 JCC (my phoropter contains both 0.25 and 0.50 JCC), then I'll repeat the sequence another one or two times to see if can keep refining it. Remember your optics: you are trying to continuously collapse the CLC (circle of least confusion) on to their retina.

It may seem lengthy, but this is obviously not a normal routine patient. They need help, and they need your expertise the most. I can typically spend 20-30 min with them on just refraction alone, and I'll document it. But I've a very good record and so far in my 5 years at working at the hospital haven't had any rechecks or complaints, even though I tell these folks the most to be aware of adaptation and to return if they have problems.

After I get a good refraction, I normally will run a pentacam and send them out for cross-linking consultation if they are under 30 and I suspect keratoconus or progression on future pentacams. I also discuss contact lenses if they desire better vision then what they are afforded in my manifest phoropter.

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Now if the patient has very poor uncorrected VAs and I can't get them to do anything even with pinholes, then you can consider pentacam and fit with sclerals empirically.

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Final words of thoughts: please don't rush and rob your poor vision patients. I've seen too many doctors give very awkward results that I'm pretty sure are just Rx'd off an autorefractor. I even had a same day referral with distorted corneal mires given -2.00x3.00xWTR OU 20/40 BCVA that I got to 20/20 BCVA and they ended up like +2.00-6.00xWTR; I know the other doctor prescribes off the autorefractor because my autorefractor read the same thing.

Collapse that CLC with most plus sphere. There is a reason the refraction sequence is designed this way. There are no short cuts. I normally run the refraction sequence twice if I keep yielding more MPBCVA sphere results on my second sphere refinement.

 

[big boby]

I'll share my own workflow one professional to another. I'm assuming you are a new graduate.

First off, I'll want to say that you should never trust an autorefractor completely for any patient.
Second, I don't agree at all with what optsuker wrote.

If the patient has pretty good uncorrected VAs like 20/60 or better, then I also will start around plano if I can't get any useful information from retinoscopy. I'll normally run MPBCVA sphere adjustment, power searching in all major meridians, cyl axis refinement, cyl power refinement with a +/- 0.50 JCC (my phoropter contains both 0.25 and 0.50 JCC), then I'll repeat the sequence another one or two times to see if can keep refining it. Remember your optics: you are trying to continuously collapse the CLC (circle of least confusion) on to their retina.

It may seem lengthy, but this is obviously not a normal routine patient. They need help, and they need your expertise the most. I can typically spend 20-30 min with them on just refraction alone, and I'll document it. But I've a very good record and so far in my 5 years at working at the hospital haven't had any rechecks or complaints, even though I tell these folks the most to be aware of adaptation and to return if they have problems.

After I get a good refraction, I normally will run a pentacam and send them out for cross-linking consultation if they are under 30 and I suspect keratoconus or progression on future pentacams. I also discuss contact lenses if they desire better vision then what they are afforded in my manifest phoropter.

----

Now if the patient has very poor uncorrected VAs and I can't get them to do anything even with pinholes, then you can consider pentacam and fit with sclerals empirically.

----
Final words of thoughts: please don't rush and rob your poor vision patients. I've seen too many doctors give very awkward results that I'm pretty sure are just Rx'd off an autorefractor. I even had a same day referral with distorted corneal mires given -2.00x3.00xWTR OU 20/40 BCVA that I got to 20/20 BCVA and they ended up like +2.00-6.00xWTR; I know the other doctor prescribes off the autorefractor because my autorefractor read the same thing.

Collapse that CLC with most plus sphere. There is a reason the refraction sequence is designed this way. There are no short cuts. I normally run the refraction sequence twice if I keep yielding more MPBCVA sphere results on my second sphere refinement.

WOW well that's an awesome perfect full answer, I totally agree to follow the sequence and spend the full needed time with them

But now im doing my second year in the clinic I can tell you that i see them like weekly, so i was looking for more manipulations to improve the outcomes with least time.

Thank you for sharing this super amazing experience.

 

[big boby]

RGP lens makes refracting easier/consistent, but not accurate for real life.

A couple drops of a thick gel AT, a few strong blinks, then quickly do your refraction.
Emphasis on best sphere power. Don't dwell on refining axis too long and don't be afraid to cut cyl power a little.

Well yeah it is a good way but always i ended up with undercorrection and i need to refine the cyl power.

Thanks for sharing ideas

 

[UnicornOpt]

Since you're a student, may I suggest you talk with your faculty for their perspective.

 

[optsuker]

Well yeah it is a good way but always i ended up with undercorrection and i need to refine the cyl power.
Thanks for sharing ideas

My system is from the approach that I'm the one making the glasses that are going to be worn.
If I want to avoid costly re-do's AND make the patient happy MOST of the time, I cut back on the cyl.

So many of these corneas fluctuate daily (even AM vs PM) and cyl axis is what changes most.
They are happier with -2.00 cyl that fluctuates 10-20 degrees than -3.00 of cyl that was right on the nose at 10AM Tuesday, but is something else by Wednesday afternoon.

I'm not saying to give them spherical equivalent, but chasing your JCC until you're both fatigued may be a futile effort.