An Erudition on Tradition Giving Traction to Modern Refraction

End of alliteration.  I promise.  Just couldn’t resist playing with a topic expounded nicely in this month’s Optometric Management (OM), begging the question as to whether modern refraction faces a Fiddler on the Roof in terms of conducting refractions the way we always have because of tradition.

But wait a minute, you ask.  What’s Dr. Lou Catania doing as the lead author on an OM article that opens by paraphrasing a scene from the mythical town of Anatevka?  I don’t know.  Actually, I think I do know.  Lou adopted Dr. Irv Borish as his mentor for refraction, and Irv’s family was from a town just like Anatevka.  Lou Catania teaming up with Irv Borish on refraction about 20 years ago was the optometric version of Christof Koch teaming up with Francis Crick on consciousness.  For Lou to get into refraction seemed to be career suicide after making his mark in anterior segment disease.  Yet he has done very well in bridging refraction with adaptive optics.  I hold Lou in high regard.

The OM article elaborates on a shorter version that Dr. Catania authored for Primary Care Optometry News last year, one that was met with some controversy over the delegation of refraction in a response by Drs. Harris and Thal.  Dr. Catania laid the groundwork for delegating the data gathering portion of refraction in a 1998 article he co-authored with Dr. Borish in the Journal of the American Optometric Association entitled Traditional versus computer-aided refraction: “which is better”?  Dr. David Goss captured the flavor of some of this in a mini-review in the Indiana Journal of Optometry in 2005.  He cites a chapter that I wrote on intelligent use of autorefraction, incorporating some of the interpretive use of retinoscopy.  Since co-authoring my textbook on Clinical Pearls in Refractive Care, we now use an additional autorefractor that provides a direct open view binocular measurement of accommodation.
Now if you Google “Lou Catania and Irv Borish – Refraction”, you’ll come up with a very interesting insider newsletter that Lou writes to Marco Reps, whose job it is to sell automated refraction equipment with emphasis on delegation.  In this issue he writes: “You observe the doctor spending an inordinate amount of time measuring phorias on a 60 year old.  We all know that phorias on a 60 year old are meaningless.  But that wasted time is also telling you something about that doc’s approach to refraction.”  Wow!  That’s quite a statement.  After reading that I’m trying to figure out how someone who has such great insights about the role of the brain in vision, neuroplasticity, and neuroadaptation (see here) can be so dismissive of the significance of binocular vision in adulthood.  I hope to convince him that his view on phorias is an aberration of the highest order, and that concerns for binocular vision at any age are not merely vestiges of tradition.



8 thoughts on “An Erudition on Tradition Giving Traction to Modern Refraction

  1. Dear Dr. Press,

    Sometimes the new and popular is really a ‘disimprovement’. Adopting new technology that is worse does harm. Plastic headlights
    are not really better over their lifespan in automobiles are they??

    Here’s just one eye test example: projectochart polaroid vision testing (old school) wins vs television wall screen (new school). In a projected letters method you can easily perform stereo distance vision tests that quickly yield stereopsis, suppression, and binocular simultaneous perception vision results. I think we still can agree that one minute of arc stereopsis is the near zenith of binocular depth perception.
    So far, only binocular testing using Worth Four Tests and prism disassociated vernier fixation disparity get even close to good polaroid projected testing. (LED, plasma or any flat panel screens.) I know that polaroid binocular testing on these types of screens could be done but I have yet to see any of these ‘improved screens’ offer any useful polarization or shutter testing. They are fun and fast, but yield a lower quality exam when it comes to binocular coordination. Do you agree about this?

    Dr. Tom Baugh
    Denison, TX

  2. Dear Lenny,

    Your commentary triggered a number of thoughts

    One is the Peter’s Principle. It is obvious that Dr Catonia is beyond his expertise in understanding the dynamic between refraction, binocular function and a patient’s quality of life.

    A second point is an obvious conflict in interest. An important question is whether these insights are based on the potential to improve care or simply income.

    Dr Catonia has made significant contributions to optometry and eye care. I do not SEE this new chapter as a positive addition to his legacy. Technology is an important part of our evolution but we should not throw the baby out with the bath water.


    PS A comprehensive glaucoma screening on all children is more ludicrous than assessing phorias in a 60 year because the latter group may even have a binocular problem

  3. Thanks for the comments, Richard. It’s always interesting to follow the career path of an OD who goes over to the industry side as a paid consultant. There is often a compromise between autonomy and pushing the corporate agenda. I do believe that on balance Dr. Catania has the potential to contribute more positively to the challenge of interfacing the technology of refraction with visual performance. The contributions of adaptive optics have, to this point, almost entirely overlooked the fact that most people function with two eyes, and its relevance to refraction at any age.

  4. Hi Len,
    While browsing for something, I stumbled on your July 28th VISIONHELP BLOG. It made me realize what I never liked about you. You’re always right!!! Seriously, I agree with all of your (and your respondents) comments, except perhaps your innuendo about my going over to “the dark side” (industry) in my twilight years. I agree that I was wrong in my comments about phorias in 60 YO’s, but that is not a good reflection of the work I am trying to do (for next to nothing financially, I might add) for the new technologies that Marco is trying to introduce to optometry and, in which I have done considerable clinical research and fully believe (as did Irv) are in the best interest of optometry. My written comments to Marco reps should weighed in the context of my effort to “unscientifically” explain to them how to reach certain types of ODs (I think you know what I mean). And you know how I can get too enthusiastic sometimes and that is what you (and one of your respondants) may be reading as a sellout. I assure you, it ain’t. In any case, please be assured that I have not “lost sight” of the essence of vision even though I may be fighting to move beyond some refractive “traditions.”
    Take care my friend and keep up your great work,

    • Thanks for your comments, Lou, and though I’m not always right it does seem that way. 😉 But seriously, I want to highlight what I said in the center of that blog: I hold you in high regard. I didn’t use the phrase “the dark side” in referring to industry, and I have no clue what you’re paid by Marco, only that you represent them as a consultant given the literature I receive as a Marco client. Much as I admire Marco for the products they have produced, I admire you for the clinical applications you’ve innovated with and for them. It was precisely in that vein that I was disappointed to read your comments to Marco reps. I know you’re trying to explain your thoughts to them unscientifically, but the thoughts still hold. In or out of context, it reads that doing phorias on a 60 year old is a waste of time and that, my friend, is a sellout. Read it again: “We all know that phorias on a 60 year old are meaningless. But that wasted time is also telling you something about that doc’s approach to refraction.”

      I’m glad you cited Irv Borish, because I’m not so sure he would have been convinced that those comments were in the best interests of Optometry, even in context. I’ll cite a key article in this regard, in which Borish worries about our profession abandoning its roots:
      “The reason, he says, is that as optometrists scope of practice expanded, it became necessary to introduce more tests and procedures into the exam. To do these and still incorporate all the traditional aspects of optometry would be too expensive and time consuming.”

      So Lou, my challenge to you is to help reposition binocular vision in the regard with which it should be held by our profession (and others). To prove that we haven’t shifted the scope of our profession as opposed to having expanded it. I don’t know of anyone else who has the cachet that you do when it comes to seeing the big picture. While the drive toward adaptive optics and the best monocular sight that an individual can have cortically through each eye is admirable, let’s not lose sight of all the reasons why two eyes are better than one, and our job as professionals to safeguard that. I have confidence that your reps will be able to appreciate that. Perhaps Marco can be at the forefront of a marketable device that helps measure that readily, in a way that can be incorporated into refractive and therapeutic approaches to binocular vision. Always great to hear from you, and please stay in touch.

      • Good response, Len. I realize that trying to mix practical realities of our profession (i.e. ODs not addressing binocular vision appropriately) could justifiably produce clinical sensitivities and I caused that with my “flip” comment. But be assured that I do respect the science of binocular vision (and yes, it is incorporated in Marco’s Epic refractor) and I will continue to defend and promote its importance in vision care. But notwithstanding our beliefs, as my “Fiddler” metaphor (from Reiview journal article) suggested, let’s not forget how “shaky” some of our colleagues can be with their appreciation for a good refraction.
        In any case, I wish you and your family a happy and healthy New Year and I hope to see you sometime soon.

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