When I ask patients which tests they dislike most, visual field (VF) testing, IOP measurements and, believe it or not, refraction are the top three. A simple plan to improve your patient’s positive experience—and boost your practice success—might be to increase education and upgrade your technology for these tests.  

Visual fields. New algorithms such as SITA Fast could help patients complete the test sooner. Although SITA Standard is more precise than SITA Fast at lower VF sensitivities, this difference is unlikely to affect the monitoring of change or deterioration.1 

Fully objective VF testing with the ObjectiveField analyzer (Konan Medical) shows equal accuracy to the standard subjective testing.2,3 The tool depicts statistically independent clusters of visual stimuli at multiple locations in the patient’s visual field.4 The resulting pupillary responses from each visual stimuli provides a map of VF function. 

IOP measurements. It’s no secret that patients hate the air-puff test. Today, clinicians can use new tools such as the iCare ic100 tonometer and the Ocular Response Analyzer (ORA, Reichert) instead. The iCare ic100 uses rebound technology to measure IOP, while the ORA measures hysteresis, corneal-compensated IOP and Goldman tonometry. 

Refraction. New patient-friendly systems have grown in the last decade, ranging from digital refractors to point-spread function (PSF) refractors (VMax), the latter of which uses a different stimuli that is easier for patients to differentiate.5 

These systems allow you to show the patient their previous refraction and the new one to help them decide on a new pair of spectacles.

Three Tests ODs Don’t Like

There are also clinically important tests clinicians and staff struggle with: 

The swinging flashlight test. Although extremely valuable to rule out a brain tumor and other life-threatening neurological conditions, pupillary testing challenges even the most seasoned clinician. One solution is Eyekinetix (Konan Medical), a 40-second objective test that provides an accurate assessment of pupillary function, including RAPD measurements.

Phoria testing. Approximately 1% to 3% of all glasses have prism in them, yet both clinicians and patients often struggle with the necessary testing for prism, such as the Maddox Rod and Von Graefe phoropter tests.6,7 The neuroLens is a new automated device that takes one to three minutes to provide a comprehensive assessment of the patient’s eye alignment and synchronization. It then provides the precise amount of prism recommended, which can be used to create a contoured prism that, in my opinion, far exceeds the success of previous prism options.  

AMD testing. Examination with a 90D lens and evaluating fundus photos for small drusen and pigmentary changes isn’t easy. A cross-sectional study of 644 adults revealed that doctors missed AMD about 25% of the time.8 A new objective test that may help with the early identification of AMD is dark adaptometry (AdaptDx, Maculogix).9 In addition, a new device for measuring carotenoids that can assist in testing and monitoring for AMD is the BioPhotonic scanner (Pharmanex). Research suggests this objective hand scanner is a more accurate corollary to macular pigment than the current subjective macular testing methods.10

We know what patients dislike and what isn’t providing us with accurate clinical information.  Armed with this knowledge and new technologies, we can make changes to enhance our practice and provide patients a better experience.

Note: Dr. Karpecki consults for companies with products and services relevant to this topic.


1. Saunders LJ, Russell RA, Crabb DP. Standard or Fast? - Differences in precision between SITA Standard and SITA Fast testing algorithms and their utility for detecting visual field deterioration. Invest Ophthalmol Vis Sci. 2014;55:3010. 

2. Maddess T, Kolic M, Essex RW, James AC. High versus low density multifocal pupillographic objective perimetry in glaucoma. Clin Exp Ophthal. 2012;21:571-78.

3. Carle CF, James AC, Kolic M, et. al. High resolution multifocal pupillographic objective perimetry in glaucoma. Invest Ophthalmol Vis Sci. 2011;52:604-10.

4. Maddess T, Bedford S, Goh XL, James AC. Multifocal pupillographic visual field testing in glaucoma. Clin Exp Ophthalmol. 2009;30:678-86.

5. Geffen D. Your phoropter on steroids. Rev Optom. 2017;154(9):30-38.

6. Vision Council. VisionWatch–The Vision Council Member Benefit Report. 2016.

7. Cantó-Cerdán M, Cacho-Martínez P, García-Muñoz A. Measuring the heterophoria: Agreement between two methods in non-presbyopic and presbyopic patients. J Optom. 2018;11(3):153-59.

8. Neely DC, Bray KJ, Huisingh CE, et al. Prevalence of undiagnosed age-related macular degeneration in primary eye care. JAMA Ophthalmol. 2017;135(6):570-5.

9. Jackson GR, Scott IU, Kim IK, et al. Diagnostic sensitivity and specificity of dark adaptometry for detection of age-related macular degeneration. Invest Ophthalmol Vis Sci. 2014;55(3):1427-31.

10. Conrady CD, Bell JE, Besch BM, et al. Interrelationships between macular, skin, and serum carotenoids. Invest Ophthalmol Vis Sci. 2016;57:3628.