Applying new technology without sacrificing rehearsal space

When optometrists make important decisions about adding technology to their practice, floor space is often a limiting factor. We try to equip ourselves to provide patients with the best possible care, and this often involves weighing the effect of different devices on office layout and patient flow.

Eye care professionals should do what is right for the patient. We build patient confidence and we work hard to maintain it. If a patient has a condition that we cannot diagnose with certainty – and we do not have the ability to perform the necessary further testing – we will either refer the patient only for testing or send them to a specialist for care.

Then it may turn out that the problem could have been solved within our office. And that would have saved the patient the hassle of having to travel to a new office and familiarize themselves with new staff.

As technological development continues to accelerate, more and more devices become available that we could use. The good news is that the size of devices is generally decreasing.

I’ve been in the industry for over 25 years and remember training on Zeiss’ first Humphrey Field Analyzer (HFA), which was six feet long and six feet wide, with a large bowl. While still significant, today’s HFA devices are significantly smaller (see Figure 1† In the past, lasers also required a large space. Now they are often portable and can be taken from office to office.

The introduction of wearable devices takes this trend of shrinking to a new level. In my practice I use the Heru headset with a field of view (see Figure 2), contrast sensitivity and color vision studies.

The platform is guided by a headset that can be hung on the wall. It creates its own dark environment, so no special darkroom is needed. This means that adding this powerful technology has no impact on the floor space.


Portability advantage

The portability of new diagnostic technology, such as the Heru headset with multiple vision diagnostic exams, is incredibly valuable to eye care professionals because testing on a patient can be performed anywhere in a practice.

As we navigate the COVID-19 pandemic, it gives clinicians the flexibility needed to avoid having to move a patient from room to room. The technology comes to the patient, who can be in a cleanroom with the door closed.

Another important factor is that the patient does not contaminate additional testing space. Once a room is soiled, it will remain empty until it is cleaned. It involves a more thorough, time-consuming clean than before the advent of COVID-19, and test rooms can become bottlenecks.

As practices tried to operate smoothly under new spacing and cleaning requirements, one step often was to take a more problem-oriented approach to exams.

Providers would ask if an exam really needed to be done during the visit or if it would be possible not to take the patient to a testing room.

In our practice, we also moved equipment, anticipating the tests patients would need at the same time, and tried to place those devices in the same room.

In this environment, the ability to bring instruments into a patient’s exam room is of great value. It makes it easier to conduct a wider range of screening and testing and reduces the need to stick to a reactive approach.

If the patient has a family history of glaucoma, I can have my technician perform a quick visual field using the Heru headset. I can also quickly do an unplanned screening if a patient has a headache and I want to rule out neurological factors.

Better use of resources

Waiting rooms often represent underutilized space within a practice. With the introduction of wearables that create their own test environment, the waiting room can become a test room. This also applies to the dilatation area, which is now sometimes not only a testing station but also a treatment area.

For example, in small practices, meibography can be performed in the dilatation area. If suitable for the flow, treatment of the meibomian glands can also follow in the same location using a portable or fixed camera system.

TearCare (Sight Sciences) is a wearable eyelid technology that provides heat therapy that doctors can use on patients in the dilatation area or examination room (see figure 3† Manually expressing the meibomian glands can also be done in the examination room using a slit lamp.

Staff availability is a limited resource in all practices, although it is not related to square footage. Wearables like the Heru headset free up technicians to perform valuable practice activities while in the patient’s room. In the past, a visual field test required a darkroom, and the technician was in the dark and unable to multitask.

The Heru headset platform allows patients to put on the headset and shut off their environment (see Figure 4† The platform features a virtual guide that guides patients through the tests, while real-time gaze tracking within the platform confirms that the patient’s fixation is always appropriate.

Patient-driven tests allow the technician to perform other tasks, such as updating records, entering medication into the system, or ordering contact lenses.
While the technician must still be in the room, he can still perform additional work.

Multifunctionality

Another trend is multifunctionality. A wide variety of diagnostic tests are combined in 1 device.

Optical coherence tomography (OCT) devices contain cameras, making it possible to capture an image of the retina and OCT. New OCT devices are also capable of capturing both anterior and posterior segment images, with wide-angle imaging. Other combinations include infrared autorefractive devices with camera or meibography capabilities.

For the diagnosis and monitoring of glaucoma, the Ocular Response Analyzer G3 (Reichert) measures both corneal hysteresis and corneal-compensated IOP, providing a more complete predictor of glaucoma progression than IOP alone or IOP along with corneal thickness (see Figure 5 for a similar device). In addition to the IOP, the FAT1 (Falck Medical) also measures eye abundance, ocular pulse amplitude and pulsatile power of the central retinal artery.

Multifunctionality is combined with portability. The Heru platform provides suprathreshold and full threshold visual fields, contrast sensitivity testing, and color vision screening (both Ishihara and Farnsworth D-15 comprehensive color vision testing). The company also just added a new “rapid pattern” suprathreshold visual field test that takes just 20 seconds.

When I first started using Heru for visual field testing, I used the platform on a patient with known glaucoma and did an HFA visual field on the same day. This showed me how consistent the results and the prints were. The digital platform has been shown to have a strong correlation with the gold standard HFA.1

I welcome the opportunity to test the contrast sensitivity of the platform, as patients come in who have trouble seeing at night. This is usually related to a lower macular pigment density, which I measure in the patient’s palm with the Pharmanex BioPhotonic scanner (Figure 6

This is another device that can be moved. I work with nutraceuticals quite a bit, so once I’ve identified a problem with contrast sensitivity and the BioPhotonic scanner, I can start patients on a nutraceutical and then see if their contrast sensitivity and skin carotenoid levels change.

In addition, lenses now exist to help with color vision problems. I can use the Heru platform for color vision screening to identify patients who could benefit from it.

These VR platforms are not just for a younger patient population. Heru’s device has been clinically tested on patients ages 15 to 95, and I’ve found the tests are so intuitive that just about anyone, at any age, can complete them.

Two of the first patients I tested with the platform, who were in their 60s or 70s, said they really enjoyed the interactivity.

A promising prospect

The future looks bright for wearables. I envision a scenario where the patient comes into the waiting room and a technician comes out with a portable diagnostic device, allowing the patient to remain seated without having to go into an exam room.

A range of screening tests may be performed on the patient, including visual acuity, color vision, pupillary assessment, and a rapid visual field screening. As these are uploaded to the system, the technician walks back and does an OCT screening or takes a picture of the patient’s optic nerve.

By the time the technician is in a patient’s room, he already has an overview of preliminary data that can be shared when the doctor enters the exam room.

The faster and more efficient screenings and diagnostics are, the more realistic it is to perform them in patients who do not show any problems with their vision. Early diagnosis of progressive eye disease allows optometrists to effectively treat the disease.

Portable diagnostic platforms and multifunction devices facilitate a more efficient practice workflow and enable even those with limited space to have a comprehensive range of instruments with increased diagnostic capabilities.

Reference

1. A new look at the treatment of glaucoma using Heru portable diagnostics: re:Vive Visual Field. heru. August 1, 2021. Accessed March 10, 2022. www.seeheru.com/rethinking-glaucoma-management-using-wearable-diagnostics-from-heru-revive-visual-field

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