Wet Refractions

[Lachrymator]

Hey everyone, I'd like to start by saying I'm new to optiboard, and this is my first thread here.

Over the last 5-6 years I've worked with probably half a dozen O.D.'s in our clinic, and of course each one has their own style. But one thing I've always wondered about is the art of the wet refraction.

Some of our doctors will see the patient for about 15 min, refract them, dilate them, and release them to us (the opticians) so we can go over their insurance and show them our frames. Their spectacle Rx is finalized and we know exactly what we're working with (prescription-wise). We make our sale, and send the patient back in the exam room for the retinal portion of the exam.

Some other doctors will see the patient, refract, dilate, etc. But after our sale, they will perform a wet refraction (while the patient is dilated) to get a better feel for the true shape of the patient's eye. Of course they don't write their Rx that way. They pick something in between the first refraction and the wet refraction. When I've asked these doctors, they say it's how they were trained and that it's an "art".

The other doctors (who don't do this) question "why would you perform a wet refraction since the patient doesn't walk around dilated?"

I asked this to one of our doctors performing wet refractions, and he picked up a patient's chart and showed me what he did. The patient was like a +1.75, but after dilation it was closer to +3.50 (these numbers are just ballpark, i can't remember what they actually were). He explained that the patients are using their focusing muscles, straining their eyes to make out what they can on the "dry" refraction, and that this gives him a better idea of what they really need and should be wearing. Of course he probably wrote their Rx for +2.00 or +2.25, but his claim was that their Rx would allow them to relax and cause less strain.

In our office we used to have 3-4 doctors per week, and when a job had to be redone because of non-adapt issues I would hear the doctor complain that it was b/c the other doctor didn't do a wet refraction. Whether or not it had anything to do with it is beyond me, but this subject has always been confusing to me. Why would some optometry schools train O.D.'s to do something another school wouldn't do? Especially if it's as important as these docs say it is.

Thanks for reading,
Lac

[Andrew Weiss]

While we wait for the ODs to respond . . .

One OD I worked with did wet refractions, mostly on children. What she told me was that she'd do it if she noticed evidence of muscle spasming, which, in her opinion, compromised the accuracy of the dry refraction. Again, the same argument as what your OD told you: the patient's muscles are working too hard, straining, and re-refracting with the eyes in a more relaxed state improved the accuracy of the final Rx. Note: we had very few redos with her Rxs.

I'm really interested to her from folks like drk, Ory, DrNEyeCare, orangezero, Snowmonster and all the rest. We have some great ODs on this board and I anticipate an interesting dialogue. :bbg:

[pauly47]

Latent Hyperopes are a nightmare! Hate 'em, hate 'em hate 'em! Wet refractions show the true prescription but too much plus will make the patient. Sure in school they always talked about rx'ing the most plus a patient can tolerate, but in reality it's different. Give what they can see with comfortably.
Generally I will only Rx some additional latent plus if binocularity problems exist, but that's just one guys opinion...

[fjpod]

Sometimes we do a wet refraction on older folks too because lens changes and small pupils obscure the quality of the retinascopic reflex. These circumstances also make auro-refractions go haywire, for example, a patient may show +1.00 -2.75 x 85 on the autorefractor (dry), but wet they will show +1.25 -.50 x 90. If their habitual Rx was +.75 -.50 x 90, and they are not having major complaints about the way they see, I am certainly not going to Rx the dry autorefraction.

It's a little different on every patient...

[Lachrymator]

Latent Hyperopes are a nightmare! Hate 'em, hate 'em hate 'em! Wet refractions show the true prescription but too much plus will make the patient. Sure in school they always talked about rx'ing the most plus a patient can tolerate, but in reality it's different. Give what they can see with comfortably.
Generally I will only Rx some additional latent plus if binocularity problems exist, but that's just one guys opinion...

Interesting. The ODs in our office that do wet refractions always do them to each patient. I don't know how much they change when they write the final Rx, but I do know that the ones doing wets are having fewer redos.


I like the convenience of taking a dry refraction and never having to look back at the patient's chart or taking the extra time in the exam room. But if there's more to it than meets the eye (no pun intended :p) it seems like it should be done.

[eyestrain]

I find it odd that the other doctors (who don't perform wets) tell me they were never trained to do them. They just simply state that their school didn't teach that, and ask me why it would be necessary.

Yikes. I wonder where (or when) they went to school.

For me, I do wet refractions mostly on children, and a few adults, who I suspect have latent hyperopia. I don't do them too often, maybe not as often as I should. And the Rx I write really depends on each patient and their complaints and the difference I find between the manifest and wet refractions. I rarely give the full plus. The most I do is -0.50 from the wet refraction. I don't really have any remake problems, FWIW.

[Lachrymator]

Yikes. I wonder where (or when) they went to school.

For me, I do wet refractions mostly on children, and a few adults, who I suspect have latent hyperopia. I don't do them too often, maybe not as often as I should. And the Rx I write really depends on each patient and their complaints and the difference I find between the manifest and wet refractions. I rarely give the full plus. The most I do is -0.50 from the wet refraction. I don't really have any remake problems, FWIW.

The two OD's off the top of my head that don't do it are newer grads, and the ones performing wets are older doctors who have been in practice for 10-20 yrs.

[eyestrain]

The two OD's off the top of my head that don't do it are newer grads, and the ones performing wets are older doctors who have been in practice for 10-20 yrs.

Really? That's weird. As of two years ago they were still teaching wet refractions in my school.

[Barry Santini]

Latent Hyperopes are a nightmare! Hate 'em, hate 'em hate 'em! Wet refractions show the true prescription but too much plus will make the patient. Sure in school they always talked about rx'ing the most plus a patient can tolerate, but in reality it's different. Give what they can see with comfortably.
Generally I will only Rx some additional latent plus if binocularity problems exist, but that's just one guys opinion...

IMHO, Its not a *true* refraction if it's not representative of the total refractive state of their eye outside of the darkened, exam room.

Barry

[Ory]

Young myopes love minus. I'll often redo sphere after dilation to make sure I don't overminus.

Hyperopes of all ages overaccommodate when refracted so there's always some plus hidden unless they're fully presbyopic.

Typically I redo sphere on those dilated but rarely change the Rx. In Waterloo they were very emphatic about pushing plus so as to avoid overminusing. Basically you refract to an endpoint, then increase plus to first blur noted. Omitting that last step but then comparing wet and dry probably would give about the same results.

[drk]

IMHO, Its not a *true* refraction if it's not representative of the total refractive state of their eye outside of the darkened, exam room.

Barry

First of all, your meaning of "true refraction" is the spectacle prescription needed for consistent, real-world visual performance.

But here's the deal: visual performance, as you know and expound, is "dynamic".

(Now, I hate the word "dynamic" because instead of clearing things up, it confuses. How about "variable" instead of "fixed"?)

Distance visual performance is generally fixed, despite all the mumbo-jumbo to the contrary. But the average Joe does, say, only about 50% or less of their day in fixed distance condition. Most of the time the eye is accommodating.

Cycloplegic refraction's best definition is "the lens power necessary to optimize vision in a totally non-accommodated state". That's important information to have as a precriber in some cases. Some cases have otherwise unexplainable poor visual performance which is due to accommodative spasm.

Now this sounds way more complicated than it is. The general goal of vision correction is to give clear distance vision and effortless near vision. Mostly this will require the patient to be non-accommodating at distance so they have as much accommodation available as possible.


(N.B. As to the oldsters, it's always way easier to refract when dilated for a plethora of reasons. But that's not really a "cycloplegic" refraction, per se.)

[Fezz]

I must admit, I had a whole other picture in my mind!

I was picturing poolside phoroptors, underwater slit lamp evals, and swimsuits!

You folks are boring!!!

;):cheers::cheers::cheers::bbg:

[Barry Santini]

First of all, your meaning of "true refraction" is the spectacle prescription needed for consistent, real-world visual performance.

But here's the deal: visual performance, as you know and expound, is "dynamic".

(Now, I hate the word "dynamic" because instead of clearing things up, it confuses. How about "variable" instead of "fixed"?)

Distance visual performance is generally fixed, despite all the mumbo-jumbo to the contrary. But the average Joe does, say, only about 50% or less of their day in fixed distance condition. Most of the time the eye is accommodating.

Cycloplegic refraction's best definition is "the lens power necessary to optimize vision in a totally non-accommodated state". That's important information to have as a precriber in some cases. Some cases have otherwise unexplainable poor visual performance which is due to accommodative spasm.

Now this sounds way more complicated than it is. The general goal of vision correction is to give clear distance vision and effortless near vision. Mostly this will require the patient to be non-accommodating at distance so they have as much accommodation available as possible.


(N.B. As to the oldsters, it's always way easier to refract when dilated for a plethora of reasons. But that's not really a "cycloplegic" refraction, per se.)

drk:

You are correct: That is what I want from a True refraction.

And I'll agree to using Variable - it is a better term.

Now, how can be get more representative Rxs from these "variable" clients?

Barry

[chip anderson]

I can remember back in the day, when O.D.'s couldn't legally dilate, most OMD's would tell me that the ability to do dillated Rx's was one of the main things that kept the OMD's results head and shoulders above the O.D.'s.

I have known OMD's that did all Rx's undillation with poor results.
Others that did all un-dillated with good results, some that always dillated on origional visit and only occasionally on later annual visits.

Chip

[fjpod]

The purpose of dilation varies. Sometimes it's to help get a better refraction, sometimes it's done to establish a baseline, sometimes just to look for pathology.

You can't just say a wet refraction ALWAYS gives you a better (or worse) Rx. It's another piece of the puzzle. Sometimes you need it. Sometimes you don't. Anyone who says they ALWAYS do it or NEVER do it is a liar. (or they may not be DPA certified).

The endpoint of a refraction, dry or wet, is not the final Rx.

[Lachrymator]

The purpose of dilation varies. Sometimes it's to help get a better refraction, sometimes it's done to establish a baseline, sometimes just to look for pathology.

You can't just say a wet refraction ALWAYS gives you a better (or worse) Rx. It's another piece of the puzzle. Sometimes you need it. Sometimes you don't. Anyone who says they ALWAYS do it or NEVER do it is a liar. (or they may not be DPA certified).

The endpoint of a refraction, dry or wet, is not the final Rx.

Yea that makes sense. We have a few doctors who always ask the tech to do an AR after dilation before going in for the retinal part of the exam. I'm sure they only do a wet refraction if there's a big difference on the wet AR, but the other few doctors only check the retina and never touch the phoropter after dilation or ask for a wet AR. That always puzzled me.

[Barry Santini]

The endpoint of a refraction, dry or wet, is not the final Rx.

I so completely agree with this statement. But, seen from the dispensing side of the desk, its impossible to discern the intent/reasoning behind the adjustments that are made by the Dr. to get to the Rx we see.

barry

[Ory]

The other issue to remember is that 0.5% tropicamide will still leave a young adult with 0.5D of accommodation, and that varies a lot. I don't know of anyone who routinely uses 1.0% cyclopentolate to dilate - dilation for up to 24 hours is just mean, and you'd need to wait 30+ minutes for full effect. So even these so-called "wet" refractions have some variability.

And Fezz, think of the average client you have. Would you want to see him/her in a bathing suit?

[drk]

drk:


Now, how can be get more representative Rxs from these "variable" clients?

Barry

Well, you nailed it.

The key would be refracting patients say, three times over a week and then averaging the results.

Not practical, I guess, but that's what we are doing with remakes, in a way.

[orangezero]

I swear I remember reading in Borish that when they did studies years and years ago they found about 50% of children were more hyperopic after cycloplegia, 25% were the same, and 25% became more myopic. Do not remember which medications were used. Interesting, eh?

Certainly focusing is affected with tropicamide, but the affect is variable due to the amount that absorbed, iris pigmentations, and other factors.

This brings up a whole host of issues that I'm sure would get someone shot, especially on this board.

Generally, if a kid is extremely hyeropic I'm not just finding out about it at the very end of the exam 40 minutes after instilling cyclopentolate. These other clues are what the older ODs were able to use, along with some retinoscopy skills, to solve these patients problems even without the use of cyclopentolate or other drugs.

We had a professor in school who would always get upset with students talking about these "damp" refractions (ie paramyd, tropicamide, and the like). "Wet" refractions really are supposed to completely (as much as possible) suspend the accommodating system of the patient. Semantics perhaps, but I think he has a point. When I think of "wet" refractions as having some type of real meaning I think of pediatrics or amblyopia when it is a medically necissary procedure used as a tool to determine treatment.

I also can't imagine too many using cyclopentolate on everyone, although to hear some of my patients talk about their last dilation perhaps one of my neighbor offices is...

[Lachrymator]

I also can't imagine too many using cyclopentolate on everyone, although to hear some of my patients talk about their last dilation perhaps one of my neighbor offices is...

Just 0.5% tropicamide here. :bbg:

[DocInChina]

We had switched over to autorefractors (the last few years of my optometric career) but when I found an unusual or questionable finding I pulled out my spot retinoscope and scoped the patient behind the phoroptor. Personally, I see little reason to do a wet refraction. It is possible to scope and see what direction the Rx is heading (latent hyperopes, accomodative spasm) as well as tease out the Rx for young children by slowing increasing the plus, let them adjust and then scope again. Once I teased out the maximum plus that I could scope I brought the patient back to the most comfortable Rx (added minus) and made note on the record of my maximum scoped findings for future reference.

[IndianaOD]

The Humphriss technique is very effective IMHO. It does a nice job of pulling out extra plus.

1% cyclo is mean when used on borderline cases! =)

[fjpod]

I so completely agree with this statement. But, seen from the dispensing side of the desk, its impossible to discern the intent/reasoning behind the adjustments that are made by the Dr. to get to the Rx we see.

barry

Honestly, I don't think it is any one thing. While patients responses can be variable, a good refractionist will pick up on that and make adjustments. While a wet refraction can give additional info, it rarely is the final Rx.
The prescriber has to:
1. Listen to the patients chief complaint, wants and needs. Look at their gait.
2. Collect all the data...entering acuity through the habitual Rx, unaided acuity (especially if you are trying to force plus on a 47 yr old who has never worn glasses before), auto-refraction, retinoscopy, keratometry, manifest refraction, phorias, (ductions in some cases), wet if necessary due to inconsistency or uncertainty.
3. Weigh all the data and prescribe.
4. Explain to the patient the benefits and limitations of the Rx.

I honestly don't agree that it is the patients' variability that causes errors. A good refractionist can tell when this is happening and work around it.

The only way to stop errors where the patient is seeing poorly, and a change in the Rx by the prescriber fixes the problem (remember, sometimes it doesn't), is to make the prescriber eat the plastic and glass he wastes. He/she will learn quickly. For those times where it doesn't fix the problem, if the prescriber took the time to explain the limitations of the Rx in relation to the patients expectations that would solve the rest. This may sound childish, but if you make the prescriber pay for mistakes which can be solved by an Rx change, 90% of the problems would go away. If you hit him for double the cost of the materials, he would learn to eliminate the other 10% also. Now before you go applauding my comments, one can make similar statements about the way some opticians conduct themselves when it comes to sales.

I've always felt, and still do, that in practices where the prescriber does not have a dispensary, you will get the worst Rxs...whether they use wet refractions, auto-refractors, streak retinascopes...whether they are ODs or OMDs...doesn't matter. They rush through it, or delegate it, and don't consider it important because it doesn't produce income. Garbage in, garbage out. It shouldn't be this way, but unfortunately, in sometimes it is. They don't feel the wrath of the patient nearly as much as the dispenser. ODs employed by opticians tend to be pretty good after a year or two, because they catch grief from the owner. Self-employed ODs with a dispensary learn real quickly too. Honestly, I feel sorry for the independant optician out there, without a doctor in the house, being at the mercy of the "outside Rx".

The above statements are not offered up as a rationale for or against optician/technician refracting. It's just my view of the optical world as I see it today.

[Fezz]

All of this dilation talk has me yearning for a re-birth of Rev-Eyes/reversing drops!