I still spend a fair amount of time on refraction. Yes, we have a very accurate auto-refractor* but there’s no excuse for not spending a few minutes doing best sphere (BVS) and cross cyl to see if that 6/5 can turn into a 6/4.

I don’t get many rechecks because of my approach.  I have a short room so it’s very easy to over plus.  Instead of showing a +0.25DS sphere when doing BVS, I use a +0.50DS sphere.  If you are starting pre-reg or even moving to a new practice, ask about room balance! I know a couple of optoms who add -0.25DS to their end result because they know that their room is short (the problem tends to stem from the distance the projector mount comes into the room from the back wall – this isn’t a problem with the old style charts and mirrors).

I do my refraction then look at the old Rx and, if need be, I modify the new Rx and explain to the patient that there’s a large difference between the old and new prescriptions so I’ve not given them the full change because it may be difficult for them to get used to.  This is more for cyls than spheres but it applies to both.

For example, if you test someone who is in their late fifties and had their last test 15 years ago, you might not want to hit them with a +1.50DS change in their reading add, all at once.  If you do, be very clear about working distance and adaptation and prepare yourself for that patient coming back to complain their specs are “too strong”.

Another example is someone with a cyl who has a large change in their axis.  A large change, to me, is 10 degrees for >+1.00DC and 5 degrees for >+2.00DC.  You can modify your prescribed Rx to a half-way point, explaining to the patient why you are changing the prescription.  If you are uncomfortable doing this, you’ll need to warn your patient about adaptation. When you modify the Rx, remember to check and record VA with what you’re prescribing.

Taking a couple of minutes to modify the Rx and explain the change to the patient will help you avoid remakes/rechecks and will keep your patient happy.  Also make it clear if pathology is affecting vision – this is something that I’ll move onto now.

I tested an elderly man a few months ago who was difficult.  Now, I’ve sometimes called patients “difficult” because of their pathology or their resistance to blur but maintained that they were lovely people. Now, this man was just difficult.  He didn’t seem to like the fact that I was a woman (which is not something I can do anything about) and he had a very abrasive manner.  He had a nuclear cataract in one eye that had caused a small myopic shift.  His vision in that eye could not be corrected above 6/7.5.  When I told him he was now a little short sighted in that eye (having been +0.50DS previously), he argued with me.

“That’s NOT my experience!” he said.

When I tried again to explain.  He shook his head. “No, that’s not my experience. I don’t think I’m short sighted, that means something else. I can see fine at distance!”

Anyway, he decided to get new varifocals (I prayed that he wouldn’t).  When he left the store, I just knew he’d be back.  He had questioned every single thing I’d said to him and he’d done it in a very dismissive way.  I’d told him about the cataract and said that was the reason he wasn’t seeing as well in that eye.  He’d huffed a bit about that so I assumed he’d been listening.

So, a few weeks later, he’s back for a recheck.  The small change in his distance Rx had apparently ruined his holiday as he couldn’t see with his new specs and blah blah blah.  He’d had to wear his old specs and blamed me for getting his prescription wrong.  That’s the thing, though, I didn’t.  The Rx he had in his new specs improved his vision significantly.  The blur he was describing was the cataract – apparently he hadn’t been listening to that bit after all.

Anyway, I did another refraction.  I found the same Rx again and I showed him what he was seeing with his old specs versus the knew ones.

“But you can make my vision better – just give me a stronger distance prescription!” he exclaimed, getting agitated.

I told him that I’d checked the prescription.

“Have you?!” he challenged me.

I was getting annoyed at this point. “Yes, remember I showed you the lens and asked if it was better, worse or just the same? And you said worse. Then I showed you another and you said it was worse again? Then we looked at the dots?”

He was getting flustered, knowing he couldn’t argue that point. “I’ve paid a lot for these varifocals and I expected to see better with them!”

As I said before, this was a few months ago so I can’t remember what happened in the end. Either that or I’ve blocked it out.

I’m not used to being treated like an idiot so this experience has stayed with me.  When you are dealing with the public, you need to be able to brush off the bad and focus on the good – it’s difficult but I’m getting better at it.  There’s nothing you can do in a situation like this bar be professional and courteous. I’m glad that 99.6% of my patients are lovely people**.

* An auto-refractor that I completely ignore for non-presbyopes, unless I’ve cycloed them.

** This is actually a pretty accurate statistic because, out of the 1000 patients I’ve seen in that last 8 or so months, only 4 have treated me poorly and it’s telling that 3/4 of them were elderly men.

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