Many patients may believe online refraction would suffice for a comprehensive eye exam. But we have all seen too many cases of malignant melanomas with 20/20 vision, systemic diseases, retinal tears and glaucomatous nerves this technology would miss. Still, if convenience is what our patients want, we need to adjust our practice management to ensure patients get the care they need in our offices. These two steps can help:

1. Educate

Every patient needs to understand the importance of a comprehensive eye examination and refraction. We must convey how we can diagnose everything from diabetes to cancers via a comprehensive eye exam—something a refraction alone can’t determine.

2. Enhance

ODs need to incorporate more advanced technology, making it impossible for online services to compete with our accuracy. For example, patients need to know that you use an advanced or electronic phoropter, all of which are ergonomically beneficial and impressive to patients.

One way to differentiate ourselves might be through the eventual use of robotics in clinical practice. For example, a recent research paper suggests the da Vinci robot, with modified software, could perform vitrectomy procedures. Other subtle changes to the software could lead to its use in intraocular procedures, causing less tremors than surgeons, according to an ARVO poster. But ODs don’t need to wait for these advances to incorporate robotics into their practice today. Two new technologies that have robotics at their core and are much more optometry focused have hit the market recently: Nexy, a robotic retinal imaging system (Konan Medical) and the VASR autorefractor by VMax Vision.

Nexy is a fully automated, small footprint retinal or fundus imaging machine. The patient puts their head onto the band at the top and the operator presses a green “go” button. Automatically, the robot guides 3-axis positioning for each eye, capturing polarization-clarified images. The information is sent wirelessly to the electronic health record or a reading center, often for diabetes screening. 

The VASR (voice-activated subjective refraction) autorefractor was equally or more accurate to that of manual refraction in 97% of cases in an OD-led clinical study. It included 50 patients who were examined by the VASR autorefactor, with a masked investigator using a standard autorefractor followed by a traditional subjective refinement using a manual phoropter including binocular balance and all the usual steps of subjective refraction. 

The phoropter measurements were conducted by clinicians with decades of combined experience, while the VASR subjective measurements were conducted by an optometry student with little to none. Results revealed there was no statistically significant difference between the VASR and the manual phoropter refractions. What was most impressive was that 14% of patients had better acuity with the VASR system (>1 line Snellen compared with the phoropter refraction), 3% of subjects had worse acuity with VASR (>1 line Snellen worse refraction) and 83% had less than 1 line Snellen line difference compared with a clinician’s traditional refraction.

The VASR autorefraction system uses wavefront aberrometry, and the subjective refraction component uses proprietary point-spread-function (PSF) technology. The VASR exam is voice-guided during the entire refraction, and it incorporates artificial intelligence to optimize refraction outcomes. The only time the manual phoropter in the hands of a clinician beat VASR was in being about 20 to 30 seconds quicker to complete the refraction compared with a fully voice-activated system that took the patient from start to finish.


As these advances make clear, robotics are already affecting eye care. They belong in the hands of the eye care practitioner and may one day make our clinical practice—and the lives of our patients—easier. They can increase our efficiency and accuracy and leave online refraction systems in the dust.

Dr. Karpecki is a consultant/advisor to Konan Medical and Vmax.