PRESCRIBE NEW LENS
TECHNOLOGIES FOR
OCULAR PATHOLOGICAL
CONDITIONS
Peter G. Shaw-McMinn, OD
Assistant Professor
Southern California College of Optometry
Marshall B. Ketchum University
Speaker Financial Disclosure Statement
• Peter Shaw-McMinn, OD has received honoraria from Southern California
College of Optometry, Essilor of America, NeuroVision Inc, Novartis Ciba
Vision, Ophthonix, Allergan, Transitions, The Vision Council, Association
of Practice Management Educators, AR Council, International Vision Expo,
American Optometric Association, and the Canadian Optometric
Association.
• In the past he has been on the Board of Directors MaxVisionCare;
Advisory Boards for Science Based Health, Essilor, Humana, and
International Vision Expo; executive board for Association of Practice
Management Educators; member Ciba Innovative Communities, American
Optometric Association Health Professions Committee; and past trainer
American Optometric Association Leadership Institute.
• Peter Shaw-McMinn, OD is a consulting editor for AOA News Practice
Strategies, Optometric Office, and Optometry Times. He co-authored the
books Eyecare Business: Marketing and Strategy, Diagnosis and
Management of Computer-related Vision Problems, and Eyecare Practice
Toolkit. He has contributed to books Business Aspects of Optometry,
Sports Vision and The Clinical Practice of Contact Lenses.
One of the advantages of our profession is we have the
opportunity to improve the quality of our patient’s life
on a daily basis.
1
We have the opportunity to
improve the quality of life of:
•
•
•
•
•
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Patients
Staff
Ourselves
Our professions
The Eyecare Industry
Society
Today’s Objectives
1. List and describe new lens technologies
available for you to use in the office
2. Recall the visual effects of ocular
pathology disorders.
3. Recognize the epidemiology of ocular
pathology conditions benefiting from
new lens technologies.
4. Apply the new technologies to specific
patient pathological conditions
Objectives Continued
5. Prescribe spectacle lenses to neutralize
the effects and slow progression.
6. Communicate the use of spectacle lenses
as a medical prescription for the
pathology patient’s occupational and
recreational needs.
7. Encourage patient compliance with
prescribed treatments
2
How big is the Ophthalmic Market?
Consumer Barometer
Total Vision Care Market in the U.S.
Annual Sales by Product Category – In Millions
+5.2%
12ME Dec12
$11,137.5
$10,587.2
+2.7%
$8,638.5
12ME Dec13
Total Vision Care Market:
$36,136.2 Million
+3.8% vs. 12ME Dec. 2012
$8,870.7
$36.1 Billion!
+3.9%
$5,262.1
$5,469.0
+5.9%
$3,971.5
$4,207.1
+5.5%
$3,522.7
$3,717.4
-6.9%
$2,066.5
$1,924.0
+5.8%
$766.0 $810.4
Rx Lenses
Frames
Exams
Contact Lenses
Plano
Sunglasses
Refractive
Surgery
OTC Readers
*Total Vision Care Market includes dollars spent at all retail types at any retail location on the sale of either spectacle lenses (including Rx sun), frames, contact lenses,
plano sunglasses, OTC readers, or revenue earned from refractive surgery or eye examinations. This number does not include sunglass clips and reflects the dollars spent
only by those U.S. residents 18 and older. Does not include retail dollars spent by/for contact lenses and exams for those 17 years of age and younger.
December 2013
8
Movie ticket sales hit record
February 23, 2014 LA Times
• Worldwide box-office revenue rose to record
levels in 2013, the studios’ main trade group
said Wednesday.
• Movie ticket sales climbed to $10.9 billion in
the U.S. and Canada and $35.9 billion globally
said Dan Glickman, chairman of the Motion
Picture Assn. Of America.
3
Consumer Barometer
Lens Market – Dollars
Percent of Retail Sales by Channel
Other
Optical Center in
Department Stores
12/13 absolute #
% change
$9,776.1M
$10,587.2M
$11,137.5M
6.1%
4.4%
5.9%
4.1%
5.6%
4.2%
+6.0%
10.7%
10.2%
10.4%
+8.1%
27.7%
28.1%
28.1%
+5.3%
51.2%
51.7%
51.7%
+5.2%
12ME Dec11
12ME Dec12
12ME Dec13
+5.2%
-0.8%
Mass Merchandisers /
Clubs
Chains
Independents
December 2013
Why does the movie industry seem so much
BIGGER than the ophthalmic industry?
10
11
Did you know?
• 79% of people know
that they need to use
skin protection when
exposed to the sun
• What % of people
know that they need to
protect their eyes?
4
The Answer is……….
6%
Most Recent AOA Survey
32 %
Our patients have a lot more on their
minds than worrying about the latest lens
treatment or eye drop
5
Ancient Wisdom
“The road to
success is
always under
construction”
Lily
Tomlin
Corneal scar
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Shagreen’s Corneal Degeneration
Shagreen’s Deg
Fuch’s
7
Macular Edema
Dry ARMD
8
Interaction of Light and Matter
Incident
Light
Diffuse
Reflection
Scattering and Emission
(fluorescence)
Absorption
Internal
Reflection
Specular
Reflection
Dispersion
Transmitted Light
(aberrations)
?
A lens is not a pill……
A lens is better!
The Medical Model
“General medical care relies on the history,
physical examination, and various
hereditary, social, environmental,
occupational, and recreational
considerations to generate prescriptions to
help treat and/or prevent disease.”
Susan Stenson, M.D.
Healthy Sight Counseling
9
Consumer Segments AR
Our Challenge is to convert “nofrills shoppers to Healthy Eyes
We need to teach our patients how to use lenses to prevent
disease and compensate for vision loss due to disease. !
AN EXERCISE IN
PRESCRIBING LENSES
FOR PATIENTS WITH
PATHOLOGICAL
CONDITIONS
Page 7 handout
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Case One
A 75 year old female enters with a complaint
that she cannot see as well to read or drive,
particularly at night. She enjoys playing
cards and traveling. Examination reveals va
with her clear bifocal correction of +2.00 1.00 x 90 with +2.50 add is 20/30- in each eye.
You find an increase of +.25 in each eye
improving the visual acuity a couple of
letters. Biomicroscopy is unremarkable
except for a 2+ nuclear sclerosis O.U.
accompanied by a 3+ brunescence of her
lenses. Retinal examination is unremarkable.
What may you prescribe?
Use the medical model to prescribe
lenses for ocular pathologies
1. Educate patient as to lens technology
available.
2. Use the history form to trigger patient
needs
3. ECP matches history form to possible
lens solutions
4. Doctor reinforces need and solution
5. Optician demonstrates benefit
Step 1: Educate the patient as to
what lens technology is available
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Before the visit
In the reception room
During history and pre-testing
During the doctor’s exam
In the dispensary
After the visit
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What Lens technologies are available
to us?
Advances in Lens Design
• Digital Lenses
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Wave Front Technology
Progressive Addition Lenses
Computer Lens Designs
Near Vision Lens Designs
What are Digital Lenses?
• Digital lenses are lenses manufactured by
digital surfacing.
• A computerized process that allows many
powers in the lens, better matching the
human eye.
Generating
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How is freeform done ?
• Lens surfaces are direct cut using a
variety of fly cutters, or rasters
• Single-point diamond turning
provides the precision of the cut
–
–
–
–
Lens rotates
Cutter moves from edge to center
Cutter moves in and out
“Cuts” a continuously
changing surface height
37
©2009 Jobson Medical Information LLC
What are the Benefits of Digital
Technology?
• Can improve every lens characteristic
– Uses new technology and learnings
• Can optimize both surfaces rather than one
– Increase precision and accuracy
• Faithfully replicate the patient’s Rx (0.25D, 0.12D, 0.01D)
– Considers fitting requirements
• Variable corridor length, any “B” size
– Reduces magnification effects
• Moves zone width control to back surface
– Personalized, correcting higher order aberrations
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Higher Orders & Perception
No Coma
With Coma
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Higher Order Aberrations
“Higher order” refers to the mathematical model used
to describe the effect of the aberration on an image.
Secondary Coma y
Z14 р (3 – 12 p2 + 10 p4) sin [θ]
http://wyant.opt-sci.arizona.edu/zernikes/zernikes.htm
Higher Order Aberrations
• Defined as: Any refractive error that
cannot be corrected by spherocylindrical
lens combinations
• Higher order aberrations make up
approximately 20% of the total
aberration error.
• HOA are higher in eye disease
14
Who has signiciant HOA?
Emmetropes
Myopes
All content  2007 Ophthonix, Inc. All Rights Reserved
20/20 is not Vision Optimized!
Signs of Non-Optimized Vision
Double images
Low contrast, lack of crispness
Lack of color perception
Glare sensitivity
Night driving problems
“Halos”, “star burst patterns”, “comet’s
tails” around lights at night
• Compromised far and near vision
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All content  2004 Ophthonix, Inc. All Rights Reserved
15
Conditions Affecting HOA
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Ptyergium
Kerataconus
Corneal scarring
Radial Keratotomy
LASIK
Corneal degeneration
Corneal dystrophies
Corneal infections
Corneal edema
Corneal precipitates
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•
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Contact lenses
Congenital cataracts
Cataracts
Macular edema
ARMD
Epiretinal membrane
Floaters
K-Sicca, Poor tears
Pupil size
Page 7 of handout
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Keratoconus, Pellucid Marginal Degeneration
Keratoconus
• The National Eye Institute reports that keratoconus
is the most common corneal dystrophy in the United
States, affecting approximately 1 in 2,000
Americans, but some reports place the figure as
high as 1 in 500.
• A UK study suggests that people of a South Asian
heritage are 4.4 times as likely to suffer from
keratoconus as Caucasians, and are also more
likely to be affected with the condition earlier.
• Corneal Collagen Crosslinking surgery shows
stabilization at an early age may be possible.
In the future, keratoconics will be corrected with spectacles with
non-glare, reduction of HOA, and polarized sun lenses instead of
contact lenses.
Corneal transplants
Best possible correction of vision to compensate for HOA,
glare, reflections.
17
Corneal opacities
Corneal opacities
• Corneal opacities occur when altered stromal
keratocytes either (1) fail to produce certain
chemical factors after infection, trauma, or
surgery, or (2) form underlying disease or
dystrophy.
• New collagen fibers become disorganized,
scatter light, and result in a nontransparent scar.
The location, size, texture, and depth of the
corneal opacity are all critical to the patient’s
visual potential. By definition, some degree of
irregular astigmatism is expected with any
corneal opacity
Corneal scar
Corneal scar
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Neovascularization of the cornea
Prevalence among CL wearers is 1-30%; prevalence is lower in
those who wear (rigid) gas permeable lenses than in soft CL
wearers.[14] There is an increased risk for patients who have high
myopia, dry eyes, or ocular surface disease (eg, idiopathic or
associated with other diseases, such as acne rosacea, Sjögren
syndrome, and immune dysfunction). There is also an increased
risk in those who use extended wear hydrogel CLs and in those
who use aphakic or therapeutic CLs.
Mortality/Morbidity
Symptoms can range from asymptomatic and mild to severe with
loss of vision. NV in the cornea's visual axis can threaten visual
function directly or through secondary hemorrhage,[15] scarring, or
lipid deposition.
Corneal neovascularization
EKC
• Review of 195 medical records at a tertiary
corneal practice revealed that
blepharokeratoconjunctivitis was the most
common single diagnosis at consultation,
accounting for 15% of referrals. Arch
Ophthalmol. 2005 Dec ;123 (12):166770 16344437 Cit:11
• Blepharokeratoconjunctivitis in children.
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Corneal infiltrates
Dystrophy
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CORNEAL DEGENERATION
• Non-familial, late onset
• Asymmetric, unilateral, central or
peripheral
• Changes to the tissue caused by
inflammation, age, or systemic disease.
• Characterized by a deposition of material,
a thinning of tissue, or vascularization
Louise A. Sclafani, OD, FAAO
Rare dystrophy in only 4 families
21
Corneal clouding
There are many reasons why the normal, clear
cornea may be cloudy, resulting in loss of
vision in one of both eyes:
– congenital corneal clouding
– eye trauma
– eye infections
– corneal dystrophies
– medications
Vision through fuchs
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Radial Keratotomy scars
23
Irregular astigmatism
Conditions Affecting HOA
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Ptyergium
Kerataconus
Corneal scarring
Radial Keratotomy
LASIK
Corneal degeneration
Corneal dystrophies
Corneal infections
Corneal edema
Corneal precipitates
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•
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Contact lenses
Congenital cataracts
Cataracts
Macular edema
ARMD
Epiretinal membrane
Floaters
K-Sicca, Poor tears
Pupil size
Page 9 of handout
24
Congenital anterior and
posterior polar cataract
Cortical cataract
Cortical cataract
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Conditions Affecting HOA
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Ptyergium
Kerataconus
Corneal scarring
Radial Keratotomy
LASIK
Corneal degeneration
Corneal dystrophies
Corneal infections
Corneal edema
Corneal precipitates
•
•
•
•
•
•
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Contact lenses
Congenital cataracts
Cataracts
Macular edema
ARMD
Epiretinal membrane
Floaters
K-Sicca, Poor tears
Pupil size
Page 9 of handout
Macular Edema
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Conditions Affecting HOA
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Ptyergium
Kerataconus
Corneal scarring
Radial Keratotomy
LASIK
Corneal degeneration
Corneal dystrophies
Corneal infections
Corneal edema
Corneal precipitates
•
•
•
•
•
•
•
•
•
Contact lenses
Congenital cataracts
Cataracts
Macular edema
ARMD
Epiretinal membrane
Floaters
K-sicca, Poor tears
Pupil size
Page 9 of handout
FACTS
1. 7.6 % of glasses are redos
2. 16 % of US CL wearers dropout every year
3. 35 % of patients have dry eye
4. The part of the refractive system you should you examine first is the tear film.
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Q/A: What % of glasses are redos?
Warranties and Redos
2012 Presentationby Steph De Long, Eyecare Business 7.6%
THINK ocular surface first
ACT through targeted history and examination
DO by providing the care needed to improve the patient’s quality of life
Lenses with tints and UV will reduce tear evaporation and absorption of heat from light – ex. computer users
Conditions Affecting HOA
•
•
•
•
•
•
•
•
•
•
Ptyergium
Kerataconus
Corneal scarring
Radial Keratotomy
LASIK
Corneal degeneration
Corneal dystrophies
Corneal infections
Corneal edema
Corneal precipitates
•
•
•
•
•
•
•
•
•
Contact lenses
Congenital cataracts
Cataracts
Macular edema
ARMD
Epiretinal membrane
Floaters
K-Sicca, Poor tears
Pupil size
Page 9 of handout
29
Drugs that Produce Mydriasis
• Tricyclic
Antidepressants
• Antihistamines
• Amphetamines
• Nitroglycerin
• Clonazepam
• Fluoxetine
•
•
•
•
•
•
Cimetidine
Midazolam
Alprazolam
Topiramate
Sildenafil
Beta blockers
National Registry of Drug Induced Ocular
Side Effect
• Frederick T. Fraunfelder,M.D.; Casey Eye
Institute (www.eyeregisty.com)
• Collect data on possible drug–induced ocular
side effects
• Registry lists over 300 potential mydriatic
agents
• Nearly all categories of systemically
administered drugs have the potential to
cause adverse ocular reactions
Most result in more Higher Order Aberrations!
30
What if we
could measure
and correct
HOA?
iiTrace Aberrometer
November 13th 2008 First photos of
planets outside our solar system
25 light years away
130 light years away
130,000,000,000,000 miles away!
1,235 Planets Outside Our Solar System!
31
iTrace aberrometer is:
•
•
•
•
•
Auto-Refractometer (Multi-Zone)
Keratometer
Aberrometer (High Order Aberrations)
Corneal Topographer (3D included)
Pupillometer (Photopic to Scotopic – 2 to 8 mm)
The iTrace Can:
•
•
•
•
•
Determine Lens and Corneal Aberration Sources
Auto-refraction for different pupil sizes
Demonstrate early cataract changes
Measure Near and Far (Accommodation Volume)
Measure Binocular Open Field (natural Man Ref)
Normal Eye
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UCVA vs BCVA
Horizontal Cyl
Sphere
Variations in
mapping
accommodative
power in the
normal
crystalline lens
Vertical Cyl
Coma
1/3 of patients
show change
in cyl and
coma
i.Profilerplus
Step 1
3-in-1 measurement device
 Autorefractor
 Atlas 9000 Corneal Topographer
 Wavefront Aberrometer
The entire measurement process takes approximately one
minute
33
Toward a balanced prescription
+
=
A wavefront-guided Rx can employ the best of wavefront and manifest
refraction: the prescription is refined based on the wavefront information,
while preserving binocular balance and prismatic corrections
A-DT
100
i.Scription® software: calculate i.Scription®
•
Once the subjective
refraction results are input,
the i.Scription software
calculates the refined Rx
•
i.Scription is written to .01
diopters
•
This level of precision
requires freeform
surfacing
Page 101
i.Scription is available on all ZEISS
customized lenses
Progressives
Single Vision
ZEISS Progressive Individual 2
ZEISS Individual SV
ZEISS Progressive Choice
Plus V
ZEISS 3D SV
ZEISS Progressive Choice
Plus
ZEISS Progressive Choice
Computer
ZEISS OfficeLens
All ZEISS customized lenses are fabricated using
patented* ZEISS back-surface technology
* U.S. Patent 6,089,713
34
Subjective refractor by VMax
ec
Night Driving Clinical
• Subjects underwent
reaction testing on
simulated night driving
course.
• Three different objects
need to be detected and
correctly identified.
• Reaction time is measured
for each condition.
35
Night Driving Clinical Results
• iZon Wavefront-Guided Lenses produced a
significantly improved ability to identify
pedestrians by an average of 300 milliseconds
(0.3 second), or 25 feet @ 55 mph, over
conventional lenses.
Night Driving Clinical Results
• As additional perspective, 0.3 second at 55
mph…
– About 2 car lengths.
– Distance across a typical intersection.
– The reaction time improvement of the
Federally mandated third taillight.
“These lenses will not only give you
high definition vision, but they
may save a life someday…possibly
your own or your loved ones!”
36
Lenses that correct HOA
•
•
•
•
•
Varilux S Series
Physio W3+
Comfort W2+
i.Scription Zeiss lenses
Encepsion by Vmax
i.Scription® by ZEISS
Progressive Addition Lenses
that correct for HOA
• Patients with varying refractive error
– Post RK patients
– Diabetic patients
– Macular edema
• Presbyopes with disorders reducing contrast
– Cataracts
– Corneal conditions
– Glaucoma
• Patients with poor v.a. (requiring +4.00 add)
THE W.A.V.E.
TECHNOLOGY™
ADVANTAGE
W.A.V.E. Technology revolutionized PAL design in 2006
STEP 1: Identify aberrations
• All lenses have distortions
which reduce sharpness of vision
37
THE W.A.V.E.
TECHNOLOGY™
ADVANTAGE
W.A.V.E. Technology revolutionized PAL design in 2006
STEP 2: Reduce aberrations
• All lenses have distortions
which reduce sharpness of vision
• Patented WAVE Technology
allows lenses to control
distortion more precisely!
Unique DEFINITY™ Design
•
DUAL ADD® lenses feature a
reduction in power below the
reading zone
•
Provides less unwanted astigmatism
on the lower portion of the optic
with less variation of power across
the lens
•
Minimizes distortion for a flattened,
more natural field of vision
GROUND VIEW ADVANTAGE™
Good for patients with balance or walking problems
or presbyopes playing sports
DUAL ADD Progressive Optic
®
A design innovation
available for the first time
in a spectacle lens
• Different progressive
designs are placed on the
front and back surface
• Unwanted astigmatism
can be distributed in
different patterns over
each surface
•
38
A Breakthrough Design
Front
Back
Minimal overlap means the astigmatism doesn’t add up
The 1:1 rule doesn’t apply
When You Increase Add Power
single surface progressive
Unwanted Astigmatism (D)
DUAL ADD®
2.55D
2.13D
1.77D
+2.00
+2.50
You can increase
add power and
decrease distortion
+2.50
Measured Add Power (D)
Varilux® Ipseo® New Edition
Head mover
Eye mover
39
The E/H Ratio dictates the way
Varilux Ipseo is designed…
Why is there swim in progressive lenses?
40
Features of Nanopix™ Technology
Each optical element manages
the curve effect on the front and
power effect on the back
The result: a ray of light can pass
through each optical element
without unwanted deviation
Features of Nanopix™ Technology
When combined, the
optical elements work
together throughout the
lens for continuity.
Digital
DigitalProgressive
Progressive
41
How is binocularity achieved today?
But 2 different prescriptions cause different aberrations patterns, and an unbalanced binocular vision. Fact: over 95% of the population has a different Rx between their eyes. SynchronEyes Technology
For the first time in
progressive design,
SynchronEyes
Technology uses the Rx
from the left eye and
right eye to
simultaneously
calculate the lenses as
a pair.
SynchronEyesTM, a revolution in lens design
Digital Progressive
42
The Perfect Progressive Lens
• Correction of HOA in PAL design
• Changes BC on front of lens for every power
change
• Corrects for aniseikonia induced anisometropia
• Add on both sides of lens
• Unwanted astigmatism in vertical direction
• Customized to head and eye movement
• Correct optic axis, pantoscopic tilt, panoramic
tilt, vertex distance
• Correction for patient’s specific HOA
How long were PALs available before
more were ordered than bifocals?
Single Vision
Progressive
Bi/trifocal
49%
2011
25% PAL vs
21% Bifocal
26%
25%
12 Months Ending December 2006
Source: Jobson Optical Research/VisionWatch
50 years!
Difference in income per patient for
Premium PAL indoor and sun lenses:
$450 vs 90 = $360
$600 vs 90 = $510
$1050 vs 90 = $970
(assuming patient got only clear
bifocal lenses)
43
Income prescribing one additional
pair of Premium PALs a day:
$510 x 20 x12 = $124,400
Income prescribing one additional
pair of Premium PAL clear and
sun lenses a day:
$970 x 20 x 12 = $232,800!
Prescribing hint:
• Prescribe progressives in sunglass
lenses first
• After the patient adapts to the lenses in
about two weeks, order in clear lenses
• Use Varilux S Series, if you wish to
order clear lenses first
Easy Focus
Design
Live Optics has identified design solutions to the
visual demands of modern life.
Typical Day 1994
Field of Vision
Distance Vision
Intermediate Vision
Near Vision
driving
TV
reading
reading
reading
reading
Time of Day
Typical Day 2010
Field of Vision
Distance Vision
Intermediate Vision
Near Vision
driving
GPS
text
PC
cell call
reading
remote
Time of Day
44
Digital Eye Strain
An emerging health risk
Nearly 70% of American adults experience some form of digital eye
strain due to prolonged use of electronic devices.
Digital Eye Strain… surpassing carpal tunnel syndrome and tendinitis.
133
Essilor® Anti-Fatigue™
September 2005: Launch in UK of Essilor®
Anti-Fatigue™, developed from an idea
expanded by Bernard Maitenaz, former
CEO, and today Honorary Chairman, of the
group.
Essilor has designed the first lens capable
of reducing the effects of visual fatigue
for wearers aged 20-45.
45
Studies by Zeiss have shown the same to be
true about their new Zeiss Digital Lens.
WHO BENEFITS MOST FROM SV
LENS WITH A LOW NEAR ADD ?
• Patients between the age of 20 and 45 (prepresbyopic age)
• Patients that spend more than 3 hours a day
working at close range e.g. reading, computer
work etc
• Patients that complain about experiencing visual
fatigue whether they wear prescription spectacles
or not
46
Cylinder and HOA increases with accommodation
Essilor Anti-FatigueTM
Announced EyeZen lenses will soon be available
VERTICAL ASPHERIC DESIGN TECHNOLOGY
The activated vertical aspheric area helps wearers deal with
focusing and refocusing all day long.
Sync supports in all directions and provides additional vertical
support for the dynamic visual demands at various distances.
47
VERTICAL ASPHERIC DESIGN TECHNOLOGY
Hoya has created a new category in single vision lenses:
Vertical Aspheric Sync combines a radial aspheric front surface
design with an activated vertical aspheric back surface.
Sync provides all the benefits of aspheric design plus additional
support for today’s dynamic visual demands at various distances.
The combined activated support area supports focusing and
refocusing in all directions and at all distances.
•Reduces eye strain and fatigue for relaxed vision all day
long
•Comfortable vision and easy adaptation
For all corrections
While there are 2 addition strengths with
Sync, the vast majority of patients benefit
most from the Sync 8 – or +0.88
correction. Sync 5 applies +0.55 diopter of
total plus power
Theses lenses can be made in i.Scription, correcting HOAs
2003
• Daily computer users in US: 175 million
– 5,000 for every OD in the US
• Daily computer-using kids in US: 61
million
– 2,000 for every OD in the US
48
Consumer Barometer
Currently Wearing Computer Eyewear at All
Percentage of American Adults
Total
5.0%
5.1%
5.2%
12ME Dec11
12ME Dec12
12ME Dec13
Male
4.8%
5.2%
5.1%
Female
5.2%
5.1%
5.3%
18 to 34
35 to 44
45 to 54
55+
2.1%
2.1%
2.0%
3.6%
3.6%
3.7%
6.1%
6.4%
6.6%
7.7%
7.8%
7.7%
December 2013
145
Computer Lens Designs
Variable Focus Lenses
VS
% Intermediate Lens
Variable Focus 1.75 +2.25 sphere
+0.50
+1.37
+1.50
+2.25+2.00
49
Essilor ComputerTM Design
3 Areas of Vision
Add Powers:
1.00
1.50
2.00
2.50
FV

NV
• 60% of the reading power is
delivered at the fitting cross
+1.00
+0.50
+0.25
TACT 40 BKS and EP40 for Intermediate Vision Emphasis:
40% of the near Rx at the fitting point
Recommended for wearers using glasses primarily
at the desktop computer
TACT 60 BKS and EP60 for Near Vision Emphasis:
60% of the near Rx at the fitting point
Recommended for wearers using glasses primarily
for reading and laptop computers
50
Computer/office Lenses
– Recommended for computer and office
work
– Patients engaged in prolonged near and
intermediate viewing
– First time presbyopes
– Single vision wearers
– CVS sufferers
– Monovision
– LASIK pts
What can you do with spectacles when
refracting surface (tear film) varies?
Treat the symptoms:
Photophobia
tints, sun lenses
Glare
AR, polarized lenses, minimize HOA
Watch for co-morbidity compounding
Bruce Onofrey
51
Co-morbidity compounding
It is common that anterior segment diseases
contribute to other conditions causing symptoms.
•
•
•
•
Computer fatigue + dry eye = Symptoms
Binocular vision problems + OSD = Sx
Accommodative disorders + Blepharitis = Sx
Reduced acuity from any disease may = Sx
Prescribe computer lenses or anti-fatigue lenses
Technological Improvement in
Lens Materials
•
•
•
•
•
Polycarbonate
Hi-index
Trivex
Polarized
Transitions
Duty to Warn
• Since 1988, the eyecare professional is
responsible for informing patients that
one lens material exceeds all others in
impact resistance.
• The intent is to help the consumer make
an informed decision about which lens
material to choose; and protect us from
liability.
52
Polycarbonate or Trivex
•
•
•
•
•
•
•
Monocular Patients
Patients with poorer vision in one eye
Patients with progressive eye disease
High risk activity patients
Children
Epileptics
Narcolepsy
Patient Profile
Who should wear Thin&Lite 1.74?
Patients looking for extreme thinness and
flatness
Patients desiring the latest technology and
best AR with Crizal Avancé
Mid to High Rx patients looking for best
cosmetics
Fashion conscious patients who are up-to-date
with the latest trends
Contact Lens wearers
Good for high progressive myopes and following
retinal detachment surgery increase in myopia
Polarized Lenses
•
•
•
•
•
Polarized film is cast within the lens itself
1.8 mm standard thickness
1.7 mm for polycarbonate
available in aspheric
hi-index 1.67
•Macular degeneration
•Cataracts
•Corneal conditions
53
Glare Reduction •
•
Light striking a flat, shiny surface becomes polarized as it strikes a horizontal surface Polarized lenses are filters that absorb light with horizontal polarization, so glare is greatly reduced
Raising The Bar on Polarized Lens Technology
Photochromics
Available in gray and brown in:
•
•
•
•
•
1.50 standard
Polycarbonate
1.67 hi index
Trivex
Polarized
•
•
•
•
•
Single vision
FT 28, 35
Trifocals
Progressives
Driving glasses*
Prescribing Hint: Prescribe for all
children’s glasses – “they’re cool”
Variable polarization, the next first
162
54
Transitions® Vantage™ lens technology
Conventional photochromic molecules
darken in random patterns
Transitions Vantage lens molecules
darken + horizontally align to
create polarization
163
Blue-blocking
Lenses
• Block short blue wavelengths of light
which:
– Decreases scattering effect
– Protects retina
Over 98% of the UV is absorbed by the lens after age 18
Blue-blocking Lenses
BluTech by Signet Armorlite
Coppertone Polarized Lenses by Vision-Ease
Crizal Prevencia No-Glare lenses by Essilor
Hoya Recharge by Hoya Vision Care
Nikon SeeCoat Blue AR
iBlue Coat by PFO Global
Retinal Bliss Tech DES by Quantum
Innovations
Unity w BluTech by VSP Optics
55
Light: harmful vs. beneficial
• Harmful Light
– UV light damages the front‐side of the eyes and is a major risk factor for many eye diseases, including cataract.
– Blue‐Violet light (415nm‐455nm) is harmful to retinal cells and is a risk factor for the onset of age‐related macular degeneration (AMD).
• Beneficial Light
– Blue‐Turquoise light (465nm‐495nm) plays an essential role in regulating the sleep/wake cycle, memory, cognitive performance, and other contributing factors to general wellness.
– The remaining Low Energy Visible light spectrum is essential for color perception, acuity, etc.
Deflects harmful Blue‐Violet light by 20%
Blue Tech, Hoya Recharge
56
Scattering of light molecules in the
atmosphere is proportional to 1/λ4
• The way light scatters off molecules in the
atmosphere explains why the sky is blue and
why the sun looks red at sunrise and sunset. In a
nutshell, it's because the molecules scatter light
at the blue end of the visible spectrum much
more than light at the red end of the visible
spectrum. This is because the scattering of light
(i.e., the probability that light will interact with
molecules when it passes through the
atmosphere) is inversely proportional to the
wavelength to the fourth power.
Multilamellar Bodies (MLBs)
57
UV Protection
• Decreases scattering which improves
contrast
• Protects lens of eye
• Protects retina in those below age 18
Lid Neoplasms
Protection from Sun light
58
Pterygia and Pinguicula
Photo of Nelly
All Types of Reflections
59
Match the region to the % of
lenses dispensed with AR
 European Union
 100%
 Canada
 50+%
 Japan
 99%
 United States
 63%
 Korea
 29%
AR Lenses around the World
Canada
63%
Japan
United States
Europe
29%
50+%
100%
Korea
99%
Brazil
27%
Photo/Graphic Courtesy of Essilor of America
Variability of AR prescribing among practices 60
AR = Always Rx

See better
 10% More light 
Look better
 Eliminates glare on reaches the eye
front of lenses
▪ Clearer crisper vision
▪ Let true beauty of eyes show
 No annoying or distracting reflections
 Eliminates under‐eye ▪ Safer driving
 Less eyestrain
▪ Better productivity
shadows ▪ Avoid looking older/tired
See Better, Be Safer
Non-AR lenses
AR lenses
61
See better, less eyestrain
Non-AR SUN lenses
AR SUN lenses
 Reflectance Formula:
 Ir = (n1 – n / n2 + n) 2
 Substitute for the cornea:
 I r = (1.336 –1 / 1.336 +1) 2 = 0.02 or 2%.
 For index 1.67:
 Ir = (1.67 – n / 1.67 + n) 2 = 0.63 or 6.3% per surface
2 (surfaces) x 6.3% loss = 12.6%
total light
lost and distracting reflections!
 As material index increases, so does the amount of transmission lost to reflection…
 CR‐39  Poly
 1.67
 1.74
 Diamond = 7.94 %*
= 10.26 %
= 12.32 %
= 14.58 %
= 34.40 %
62
Obstacles Solutions
63
Eye‐Sun Protection Factor™ (E‐SPF)
Crizal Sapphire UV™
Crizal Avancé UV™
Crizal Alizé UV™
Crizal Easy UV™
Crizal SunShield™
Sunwear Protection
Everyday Protection
“This has a SPF of 50+ for your eyes!”
E‐SPF is a new global index developed by Essilor, endorsed by independent third parties, measuring the lens' UV protection excluding direct eye exposure from around the lens. E‐SPF of 25 means the wearer is 25 times more protected than without any lens. With clear 1.5 plastic, E‐SPF of 10.
Prescribing hint:
• “Do you want lenses with glare or
without glare?”
• “We now have new non-glare
technology that improves night vision
and makes lenses nearly invisible.”
• “These new lenses are the easiest to
keep clean. Not even a post-it note
will stick to them.”
Product
Retail
Cost
Profit
Value AR
$50
$25
$25
Premium AR
$110
$50
$60
Incremental Profit
40 jobs per week
10% AR Sales (4)
20% AR Sales (8)
80% AR Sales (32)
Basic 50% of all
sales
$50
$100
$400
Premium 50% of all
sales
$120
$240
$960
Total Profit per
week
$170
$340
$1360
Profit per year
$8,840
$17,680
$70,720
64
Product
Retail
Cost
Profit
Value AR
$50
$25
$25
Premium AR
$125
$50
$75
Incremental Profit
160 jobs per week
10% AR sales
(16)
30% AR Sales (48)
60% AR Sales (96)
Value 50% of sales
$200
$600
$1,200
Premium 50% of
sales
$600
$1,800
$3,600
Profit per week
$800
$2,400
$4,800
Profit per year
$41,600
$124,800
$249,600
®
Crizal Lenses
with
Do your lenses ever fog up causing temporary blindness?
19
4
Outside
Activities
•
•
•
•
•
•
•
Riding Bikes
Playing Tennis
Skiing
Hunting
Jogging
Horseback Riding
Sunglasses
19
5
65
The Restaurant and Food
Industry Seem to be
EXTREMELY Susceptible
to foggy
•
•
•
•
lenses
Washing Dishes
Freezers
Butchers
Chefs
19
6
Safety
• Fork Lift
Drivers
• Food
Industry
 Blast
Freezers
• Paper Mills
• Steel Mills
• Paint Booths
• Train
Engineers
• Public Safety
Officers
• Wrap Style
Safety
Frames
• Masks
19
7
ACTIVATOR™
KIT BOX
BOTTLE
INSTRUCTIONS
FOR USE
MICROFIBER
CLOTH
One drop on lens lasts a week and also cleans lens
19
8
66
Eyelid position disorders
Require more light
trichiasis
Blepharitis
Best possible correction of vision to compensate for fluctuating tear film
Blepharitis Treatment Guidelines Published
by: American Academy of Ophthalmology 2008
Summary
• Eyelid hygiene is indicated initially and may need to be
continued life-long.
• For patients with staphylococcal blepharitis, a topical
antibiotic is prescribed.
• For patients with severe conjunctival infection, marginal
keratitis, or phlyctenules, topical corticosteroids may be
helpful.
• For patients with posterior blepharitis whose chronic
symptoms and signs are not adequately controlled with
eyelid hygiene, oral tetracyclines are given.
• Artificial tears may improve symptoms.
Bottom Line: Think of lenses in treating chronic
anterior segment disease symptoms!
67
Treatment Protocol – Dry Eye
•
•
•
•
•
Restasis
Lacriserts
Azasite ?
Autologous Serum
Compounding medications
– Vitamin A
– Cyclosporin increases %’s
• Punctal Plugs
• New artificial tears – esp non preserved
Lenses to relieve photophobia and reduce evaporation of tears
Pterygia and Pinguicula
Photo of Nelly
68
GPC
Giant Papillary Conjunctivits
HYDROGEL
LENS
GPC
RGP LENS
GPC
Silicone hydrogels
Morphology GPC
resembles
RGP
Zone 2
Allergic conjunctivitis
Best possible correction to compensate for large pupils, irregular tear film
69
Anterior Uveitis
Lenses that provide best possible correction for HOA, glare, scattering
Symptoms (Vision problem) of patients
with Anterior Segment Disorders
•
•
•
•
•
•
Clouded, blurred or dim vision
Increasing difficulty with vision at night
Sensitivity to light and glare
Seeing "halos" around lights
Fading or yellowing of colors
Double vision in a single eye
Our challenge is to relieve these vision
problems and prevent progression
What Lens technologies are available
to us?
70
Steps to Using a medical model to
prescribe spectacle lenses
1. Educate patient as to lens technology
available.
2. Use the history form to trigger
patient needs
3. ECP matches history form to possible
lens solutions
4. Doctor reinforces need and solution
5. Optician demonstrates benefit
Step 2: Use the History form to indicate
a patient need for an intervention
• What are the patient’s perceived needs?
– Entering Complaint
• What is the patient’s needs from your point of
view?
– Patient and Family medical history
Patient Medical History and
Medications
• High cholesterol
• Depression
• Arthritis, aches and
pains
• Insomnia
• Diabetes
• Heart Disease
•
•
•
•
•
•
•
Allergies
Birth control
Infectious disease
Skin conditions
Erectile Dysfunction
Hypertension
Antiarrhythmia drugs
Page 10-11 of handout
71
Amiodarone
• Amiodarone belongs to a class of drugs called VaughanWilliams Class III antiarrhythmic agent. It is used in the
treatment of a wide range of cardiac tachyarrhythmias.
• Corneal micro-deposits (Corneal verticillata, also called
vortex keratopathy) are almost universally present (over
90%) in individuals taking amiodarone for at least 6
months. These deposits typically do not cause any
symptoms. About 1 in 10 individuals may complain of a
blueish halo. Optic neuropathy occurs in 1-2% of people
and is not dosage dependent. Bilateral optic disk swelling
and mild and reversible visual field defects can also occur.
• Less common
– blurred vision or blue-green halos seen around objects; sensitivity
of eyes to light
• Symptoms: the corneal changes are rarely of any
visual significance.
• Signs:
– Symmetric, bilateral, whorl-like pattern of powdery,
white, yellow or brown corneal epithelial deposits
– Appears in a vortex fashion in the inferocentral cornea
and swirls outwards sparing the limbus
• Occurs in Fabry's disease and in patients being
treated with a variety of drugs including
amiodarone, chloroquine, amodiaquine, meperidine,
indomethacin, chlorpromazine and tamoxifen.
72
Photosensitizing Agents
• Certain substances can increase sensitivity to light
and the reactions it induces, often at low exposure
levels
• Chromophores: molecules that absorb light energy
• A photosensitizing (or phototoxic) reaction occurs
when the chromophore remits the light energy and
initiates potentially harmful changes in other
molecules
• Some systemic medications are photosensitizers and
exacerbate the damaging effects of UVR on ocular
structures and vision
Photosensitizing Drugs
Cardiac Antiarrythmia
(Amiadorone)
Antihypertensive
Agents (Diuretics)
Antidepressants
Antipsychotics
Isotretinoin
HIV/AIDS Agents
Cancer Drugs
Erectile Dysfunction
Agents
Nonsteroidal Antiinflammatory Drugs
Psoralens
Oral Contraceptives
Tetracycline
Verteporfin
Herbal products
Protection from sunlight, lenses that correct vision the best
73
Medications Implicated in Causing Cataracts
• Statins (atorvastatin,
simvastatin, privastatin,
lovastatin
• Antidepressants
• Non-steroidal Antiinflammatory drugs
(aspirin, ibuprofen,
meclofen)
• Tranquilizers
• Oral Diabetic agents
• Allopurinol
•
•
•
•
Antihistamines
Oral contraceptives
Sulfa drugs
Antibiotics
(fluoroquinolones)
• Anti-malarials
(mefloquine)
• Anti-fungals
(terbinafine)
• Isoretinoin
Medication Usage On The Rise
• $179.2 billion spent on prescription drugs 2003
– Up from $40.3 billion in 1990
• In 2002
– 61% under age 65 incurred
a prescription drug expense
– 91% among those 65 and older
• Approximately 90% of patients presenting
for eye examination take some form of systemic
medication, herbal or nutritional product
– Advertising > increases awareness > demand for
medications and OTC products
Family Medical History of previous
medical conditions and/or eye conditions
•
•
•
•
•
Cataracts
Macular degeneration
Glaucoma
Iritis
Retinitis pigmentosa
No one wants to lose their vision. We must
counsel them on how to maintain and improve it.
74
Occupations requiring time in sunshine,
night driving, near work
•
•
•
•
Professional drivers
Long commuters
Construction workers
Computer use
Recreation requiring time in
sunshine, night vision
•
•
•
•
•
•
Golf
Tennis
Hunting and shooting
Baseball
Fishing
Swimming
History Form Questions
• “How many hours a day do you use a computer at work
and home?”
• “How long before your eyes get tired or irritated?”
• “Do you ever have problems with glare interfering with
your vision?”
• “Do you have problems with glare when driving at
night?”
• “Do your eyes ever feel dry and irritated?”
• “Do you have allergies?”
• “Do you notice reflections on the lenses of your glasses?”
• “Are your glasses easy to keep clean?”
• “Is there ever a time when your glasses fog up?”
75
Steps to Using a medical model to
prescribe spectacle lenses
1. Educate patient as to lens technology
available.
2. Use the history form to trigger patient
needs
3. ECP matches history form to
possible lens solutions
4. Doctor reinforces need and solution
5. Optician demonstrates benefit
Step 3: Match lens technology to the patient’s
medical need (Page 11 of handout)
Ways to Improve Contrast
•
•
•
•
•
Decrease scattering
Non-glare lenses
Brown/yellow tints
Polarization
Correct HOAs
76
AN EXERCISE IN
PRESCRIBING LENSES
FOR PATIENTS WITH
PATHOLOGICAL
CONDITIONS
Case One
A 75 year old female enters with a complaint that
she cannot see as well to read or drive,
particularly at night. She enjoys playing cards
and traveling. Examination reveals va with her
clear bifocal correction of +2.00 -1.00 x 90 with
+2.50 add is 20/30- in each eye. You find an
increase of +.25 in each eye improving the visual
acuity a couple of letters. Biomicroscopy is
unremarkable except for a 2+ nuclear sclerosis
O.U. accompanied by a 3+ brunescence of her
lenses. Retinal examination is unremarkable.
What may you prescribe?
77
Lens Options
Progressive
Non-glare
Polycarbonate
Single Vision Scratchresistant
Bifocal
Aspheric
Hi-index
Trifocal
Polarized
UV 400
Cr-39
HOA
Tint
Photochromic
_____________ _____________ ____________
75 year old cataract patient
• AR to provide more light to retina
• UV to decrease scattering and improve
contrast & decrease cataract formation
• Premium Progressive +3.00 add for
playing cards and reading
• Polarized sun Rx with AR on back to
decrease cataract formation and reduce
glare, brown #2
Our patient, JC is a 70 year-old Caucasian male who
enters with no complaint. He takes a "water pill" for
Hypertension and recently stopped smoking. Past
medical history is otherwise unremarkable except his
last eye doctor said he has eye degeneration. He
plays golf three times a week and gambles at a casino
twice a week. He noted on the history form he has
trouble with glare when night driving. VA with a
correction of +1.50 -1.50 x 90 in each eye is 20/50-.
This improves to 20/40 with an additional +.50 -.25
x90. Biomicroscopy shows 1+ nuclear sclerosis O.U.
Retinal exam shows dry ARMD O.U. All else is
within expected limits.
78
Lens Options
Progressive
Non-glare
Polycarbonate
Single Vision Scratchresistant
Bifocal
Aspheric
Hi-index
Trifocal
Polarized
UV 400
Cr-39
HOA
Tint
Photochromic
_____________ _____________ ____________
72 year old male with ARMD
• Polycarbonate Polarized with SunShield AR,
Brown #3 sunglasses to decrease glare and sun
sensitivity from ARMD and diuretic meds.
Also to decrease progression of ARMD and
cats.
• Premium Polycarbonate Progressive lens with
+3.50 add for gambling and reading with AR &
UV
• Possibly non-polarized Transitions Fairway
Lens (Definity). polycarbonate, with AR on
back, sun lens for golf
• Nutraceuticals, healthy diet
Case Three
A 65 year old female enters with vague visual
complaints. Her husband of 45 years died
suddenly last year. She is taking 60 mg of
Paxil daily, medication for her stomach and
vitamins. She uses the computer several hours
a day. Examination reveals no improvement
over her present acuity of 20/25 through
+3.00 - 1.25 x 45 O.D., +3.00 -1.25 x 135 O.S.
Pupil responses are sluggish. Biomicroscopy is
unremarkable except for a 1+ nuclear sclerosis.
Retinal exam is normal. All testing shows
normal findings. What may you prescribe?
79
What are her needs?
• Find new soul-mate
• Look attractive to
prospective males
• Protect her eye from
damaging light
• Maintain eye contact
• Perform well at computer
Lens Options
Progressive
Non-glare
Polycarbonate
Single Vision Scratchresistant
Bifocal
Aspheric
Hi-index
Trifocal
Polarized
UV 400
Cr-39
HOA
Tint
Contact lenses
_____________ _____________ ____________
65 year-old widow on Paxil
• Premium hi-index progressive lens with
UV, AR, and high index to provide good
cosmesis
• Contact lenses
• Brown #3 aspheric hi-index polarized sun
lenses w Sunshield to provide protection
from increased risk due to dilated pupils
• Computer lenses with AR, with rose tint
• Lots of Compassion and a follow-up call
80
Case Four
A 48 year old black male enters with the complaint of
blurred near vision. His father went blind from some
eye disease where he had to take drops all the time. He
is taking medication for high blood pressure which is
under control. He has been told he has diabetes but is
controlling it with diet. Examination shows -.50 .25 x
180 refractive error O.U. with 20/20 visual acuities.
Biomicroscopy shows deep angles O.U. and is
unremarkable. Retinal examination shows deep
excavated cupping .6mm x .5mm O.U. Intraocular
tensions are 22 O.U. Visual fields shows an early nasal
step in the right eye. What may you prescribe?
Lens Options
Progressive
Non-glare
Polycarbonate
Single Vision Scratchresistant
Bifocal
Aspheric
Hi-index
Trifocal
Polarized
UV 400
Cr-39
HOA
Tint
Photochromic
_____________ _____________ ____________
48 year old Glaucoma Patient
• Prostaglandin one drop at night
• Grey #3 or #4 polarized, polycarbonate
with sunshield sun lenses to reduce risk of
cats from future use of beta blocker and
miotic, diabetes, and hypertension meds.
Possibly single vision.
• Polycarbonate HOA correcting Progressive
with AR and UV to offer best visual acuity
and protection from indoor UV and
improve contrast acuity.
81
The power of the white coat
Relate patient needs to
exam findings during the
exam.
Educate the patient on the
proposed treatment
throughout the exam
Present the needs and
solutions in the case
presentation
“I will advise my patients fully and
honestly of all which may serve to
restore, maintain, or enhance their
vision and general health”
Interaction of Light and Matter
Incident
Light
Diffuse
Reflection
Scattering and Emission
(fluorescence)
Absorption
Internal
Reflection
Specular
Reflection
Dispersion
Transmitted Light
(aberrations)
82
Prescribe NEW Lens Technologies for
Ocular Pathological Conditions!
Thank You for Your Attention!
Peter Shaw-McMinn, O.D.
shawmc1@me.com
83