During my penultimate year at uni, I tested a student who was unrefractable.  He was in the year below me and he couldn’t tell the difference between +1.00DS and -1.00DS.  He was 6/6 at +10.00DS and 6/6 at -10.00DS (fixed chart, if you are wondering).  At the end of the clinic, I was frazzled and thinking about qualifying in a profession that didn’t involve other people.  My supervisor took me aside and said, with a smile, that she was glad I’d had that particular patient as, being well known at uni as a perfectionist, I had to realise that sometimes you can’t get it 100% right.  You just had to do your best and use your common sense (hint hint, focimeter their current specs or use your ret result).

You learn to check vision at each stage in the refraction and stop giving a patient plus just because they’ve said the chart looks “the same” for the last few dioptres.  In reality, it should look better then the same then worse.  There’s only +0.50DS difference between better and worse, in my experience, so if your patient is stuck on “the same” for a while, check their vision – nine times out of ten, you’ve overplussed them and their VA will have reduced.

Sometimes you’ll need to think critically about what you are being told.  You will come across patients who answer “yes” to every single question.

Flashing lights? Yes. When? When I’m in bed at night, before I go to sleep.

Floaters? Yes. When? When I turn out the downstairs light.

Double vision? Yes. When? When I’m trying to read and not wearing my reading glasses.

Family history of glaucoma? Yes. Who? My mother/father but they had an operation to have the glaucoma removed…

Children are particularly bad for answering “yes” to everything but, on questioning (using the LOFTSEA approach), you’ll be able to separate true headaches from made-up ones.  The made-up ones only happen on Tuesdays and affect a one cubic centimetre area of the head for exactly 10 seconds.

There’s also a bit of external filtering that needs to happen.  Like the 12 year old, S, whose father had grudgingly brought him in for an eye test.  The father had never felt the need to get an eye test and he was sure S was making up his visual problems.

“His pal’s just got a pair of glasses and now he’s saying that he can’t see the board at school,” was the dismissive answer from his father when I asked S if he was having any problems with his vision.

In the room, away from his dad, S was more talkative.  He’d been gradually moved down to the front of the class but he was still having to copy his neighbour’s work because he couldn’t read the teacher’s writing.  It was embarrassing to S – both not being able to see the board and being accused of malingering by his family.

It just happened that his friend had got a new pair of specs recently* and that had prompted S to ask if he could go for an eye test.   No-one else in the family had specs – none of them had had an eye test before so this was, in itself, quite brave.

After a thorough history and symptoms, I suspected S was a little short sighted.  We moved onto vision and he was CF R&L, 6/60 binocularly.

I did ret and got approx -3.50DS R&L.  When I removed the working distance lenses, S was amazed. He could see the second bottom line (6/6 on my chart) and he was smiling for the first time since he walked into the practice.  A few minutes later, he was reading 6/5.  His eyes were perfectly healthy and I explained that being short sighted meant his eyes were a bit too powerful and that the glasses had lenses in them to take away some of the power when he was looking through them.

When we walked out of the room, S went back to being quiet and the smile slipped from his lips.

His dad had bounded up to him. “Nothing wrong with you, eh?”

I asked my optical assistant to help S look at the frames while I had a word with his dad.  I took the man into my room and sat him in the patient’s chair.

“S could barely see that top letter,” I pointed to the 6/60.  “He’s quite short sighted which means his distance vision isn’t that good but he’s fine with reading things up close.  Today, with the lenses I’ve prescribed, he can see the bottom line.”

“I can’t see the last three lines.”

“Then I think you might need an eye test.”

We glazed S’s specs then and there so he had them for school the next day.


* S had tried his friend’s specs on and they didn’t make his vision any better, which is not surprising since his friend was +6.00DS R&L (I also tested him).