I recently chatted with an old friend, a fellow 30-plus year practitioner. Despite our varied experiences, we came to the same conclusion: spectacle prescription checks and remakes were some of the most frustrating and challenging situations encountered in practice. They are a constant reminder that refraction is more of an art than you might think.
Often, it can be challenging to reconcile a patient’s subjective and objective findings to get the right prescription, despite the help of newer technology such as autorefractors. Some might assume that the refraction in the phoroptor is the refraction you should prescribe, but this philosophy might be the driving force behind many of the glass checks and spectacle remakes you see in your office.
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| Handheld flippers at +0.50/-0.50 show the patient a proposed prescription. |
Most seasoned clinicians have found some good answers—as much for our sanity as for economic survival—including some that go against the grain of traditional refraction. Abandoning the “white-knuckle” phoropter refraction experience, with its litany of choices and rapid changes in quarter-diopter steps, has helped put patients at ease and increased their confidence.
Here are 12 strategies to help you avoid glass checks and spectacle remakes—some of which might challenge your traditional approach to refraction.
Do you agree or disagree? We welcome your comments. Write to ROeditorial@jobson.com with your thoughts on the strategies below.
1. Treat the Patient, Not the Refraction
Everyone in the medical field is aware of the step-wise approach to therapy: start with the simplest option and move forward from there. The same might be said of refraction, so carefully weigh patients’ difficulties with adaptation to their new prescriptions.
While each practitioner has his or her own approach, I have found that adding more than one diopter of plus at near, or +0.75 at distance, unless there is a significant binocular disruption that high plus will solve, can be problematic. Your best retinoscopy, autorefraction and subjective measurement may all indicate a diopter or more of change, but in my experience your chances for prescribing success diminish as you make spherical changes that don’t follow the above rule. Assure that your distance prescription improves visual performance over the prior prescription.
Also consider if the patient needs a prescription change to meet motor vehicle standards and job requirements. Although we have to prescribe with patients’ adaptation in mind, it is mandatory to update prescriptions in a manner that allows qualification for state vision standards. We have an implied duty to warn patients who would not pass a state motor vehicle examination. Be sure to know your state’s regulation on this. For example, in New Jersey it is a violation of patient confidentiality to report vision exam results without consent. This may vary tremendously in other states.
| Glass Checks: A Team Effort Glass checks are an excellent opportunity to collaborate closely with your opticians. In fact, their expertise can often resolve glass check issues without crowding your already busy schedule. Patient Education Whether it’s difficulty adjusting to new progressive lenses, improper measurements, or a frame selection issue, opticians are a crucial first step in getting to the heart of the patient’s problem. “Education is a key factor, and discussing why one frame is better than another is critical. Weight, shape and size play a major role,” says Ross Cappuzzo, MBA, president of Millennium Eye Care in West Freehold, NJ. Difficulty adjusting to new progressive lenses, for example, is one of the main reasons Mr. Cappuzzo sees patients for glass checks. To help them better understand the changes and the role their frame selection plays, Mr. Cappuzzo uses the example of today’s entertainment advancements. “Using terms like digital and focal improvement can help patients understand,” he says. “I like to compare today’s digital lenses with the advances in HD digital TVs. The technology once worn (or viewed, as in the case of the new TVs) is dramatic” compared with what we have today. Turning Trouble Into Success Although you and your opticians may provide great patient education about lens changes and frame choices, some patients will inevitably return unsatisfied. And when that happens, the best solution is the same for all glass checks: exceptional customer service. Anything can be fixed, and ensuring patients they are understood and that solutions are available will go a long way to securing them as future customers. Mr. Cappuzzo strongly recommends all practices have a glass check protocol on hand to help make this happen. “Having a glass check protocol office policy in place that everyone in the practice understands is the key,” Mr. Cappuzzo says. “It’s a written policy of how we are to treat the customer and handle the glass check. We treat each glass check as an opportunity to demonstrate our skill level in the field of optics.” The first step in the protocol is ensuring the patient is directed to the right person—the optician. They can get to the bottom of the patient’s issues and either solve them with proper education, expert frame adjustments or simply some much-needed reassurance. But the protocol also reminds staff not to tell patients “‘try to get used to the glasses.’ They can always decide to do that themselves.” Instead, staff should listen to the patient’s complaint and respond accordingly—and always remember to document the encounter. Even when the patient needs to—or insists on—seeing you, the optician’s documented glass check can make the appointment run a lot smoother when you are finally face-to-face with the patient. |
2. “Soften” Your Cylinder Axis and Power
We find that a very common cause of glass checks and remakes is when subjective cylinder axis and powers are prescribed without compromise. But a small change can help; I seldom change a cylinder axis by more than 20 degrees, even if it improves acuity. Spatial distortion increases as the cylinder axis is changed, especially in cylinders above +1.00D. Higher cylinder powers tend to make axis changes more difficult, so be conservative in changing cylinder axes if powers are high, and test to ensure that vision is improved.
3. Don’t Overtest
The new prescription depends as much on the old one and history as it does on findings. Patient fatigue can be a significant problem in the classic subjective refraction, especially for some senior and systemically ill patients. Although subjective refraction takes little more than five minutes, the burden of accuracy you place on the patient can quickly become overwhelming and intimidating. I advocate for a brief event, with only a few demonstrations on each eye. Quickly go to a trial frame or flippers if results are in doubt. Leave the white-knuckle refractions back in training.
I have found that the most indecisive patients on subjective refraction tend to have more difficulty with changes in their prescription. At the same time, hypercritical patients are more likely to return with issues as well. Again, target the change to the patient’s needs, and be cautious in changing if test results are vague. For example, a patient with no complaints and 20/25 acuity with a spherical prescription may actually get 20/20 by adding -0.50 of cylinder. But, patients have variable responses to the Jackson Cross Cylinder method of determining axis, with repeated contradictions. This would be a great case to defer cylinder prescription.
4. Test With Trial Lenses Like Crazy
What a great technique. Establish binocularity and best-corrected acuity as is customary, then use trial lenses, preferably held over the habitual eyewear, in a waiting area or outdoors.
Lighting is a big issue, especially glare, and trying lenses in different lighting can solidify—or reject—your exam room results. Simulate habitual lighting whenever possible, especially for reading and computer work. That additional +0.75 that was so strongly accepted in the exam room may blur license plates and street signs.
Trial lenses with Halberg Clips (Keeler Instruments) allow you to demonstrate a new prescription over the habitual glasses without the strain of holding the lenses in place. Trial frames can sometimes be cumbersome and time consuming—small changes are often easily demonstrated with flippers and Halberg Clips.
5. Remember: Hyperopia is a Different Animal
How often have you had a hyperopic patient who was completely asymptomatic with an uncorrected distance acuity of 20/50? It happens to me almost every day. Pupil size, accommodation and visual demands all play a role in mandating less plus, or none, compared to our intuition. Better said, don’t push plus on asymptomatic patients.
I believe that we tend to prescribe glasses for too many people based solely on classic refraction principles, with the resultant glass checks for patients who might struggle with adaptation.
Uncorrected hyperopic patients notoriously reject plus for distance. Trial frame a plus prescription that does not exceed a spherical equivalent of +0.75 for best adaptation and acceptance, but only if the patient is symptomatic and might be in danger of failing a motor vehicle vision exam.
6. Prepare for Progressive Design Changes
Digital progressives, with increasing patient customization, are greatly affecting our patient’s comfort. However, the transition from an older design to a newer one is not always smooth.
Counseling, in advance of purchase, can make a huge difference in acceptance of the new glasses. I discuss an expected adaptation period of 10 to 14 days and emphasize the positive aspects. Being able to view distance, intermediate and near without having to remove or change eyewear is a real plus. The newer design may offer a wider, less distorted area for intermediate vision, for example. The perception of distortion will diminish as the patient’s success grows.
This is a great time to consult with a professional optician. He or she may have a better perspective on which progressive design produces the best results when converting from an older or lower-quality version.
Do your best to find the lens that produces less peripheral distortion, or perhaps offers an occupation-specific benefit.
7. Take into Account a Patient’s Personality and Past History
This can be intuitive for some, but quite difficult for others. More precise patients can be resentful when we prescribe a change—even a small one—if they were asymptomatic. Adaptive difficulties will be attributed to the tiny prescription change, not the real culprit such as changing progressive design, frame size or base curve.
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| Halberg clips offer convenient demonstration of prescription options by holding the desired trial lenses in place. |
Demonstrating the prescription change via a trial frame, Halberg Clips or flippers can help tremendously in the patient’s decision.
A patient’s history of prior adaptation difficulties will sensitize you to be cautious on large changes in progressive design, frame or prescription.
Some patients have chronic difficulties in adapting to new glasses, and it is often appropriate to limit any changes in any aspect of the lenses. Often, difficult patients appreciate the improvement with incremental changes, and advising the patient on these issues demonstrates your thought process and will make for a more adaptable patient.
8. Respect Non-Habitual Wear
A patient who wears the prescription intermittently may have a harder time adapting to the changes.
Let’s say the patient agreed to your +0.75 prescription last year. Driving is the only time the prescription is used, and we’ve fallen from 20/20 to 20/30 at this year’s exam—would you give a +1.75? Regardless of the patient’s subjective response during the exam, this particular one diopter increase is a formula for a remake. The quarter-diopter per line of vision change is a good principle to start with, but it does not always correspond to the reality of the prescription acceptance or rejection.
9. Help Select the Right Frames
Proper frame selection is a key component in avoiding remakes. Modern spectacle prescribers are seldom involved in this process, and the disconnection sometimes leads to poor frame choices. Frame size and shape influence the nature of the fabricated lenses, and often can create visual discomfort. Did the patient have a fashionable, smaller eye size in the previous glasses? This might lead to disconcerting distortion if the patient chooses an aviator style for prescription sunglasses. Did the first-time progressive lens wearer select a frame that requires a short corridor design? This limits vision and creates maladaptation.
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| Halberg clips minimize fatigue for both patient and doctor. |
You shouldn’t tell the patient to avoid changing frames, just to be sensitive to this issue in frame selection. A brief note on the prescription can give the optician extra sensitivity. I’ll typically say, “Please note small habitual frame size when selecting new frame.”
Communicate with the fabricating optician about any frame change issues. We comment on the prescriptions themselves with suggestions such as “minimize frame dimensions, as able,” or “note computer monitor position in selecting progressive design.” These simple comments have resulted in better communication that can dramatically limit remakes.
10. Consider a Patient’s Working Distance
Modern computer workstations have created a challenge to spectacle prescribers. Variations in patient posture, monitor height, desk design and distance to screen can lead to extremely different lens designs and powers for patients with the identical prescription.
A patient may need a +2.25 add for a test distance of 16”, but the reality of an eye-level computer monitor at 27” will produce a rejected prescription unless you take the work distance into consideration.
A separate “computer” prescription, customized for a patient’s workstation features, is tremendously helpful if patients are willing to purchase a dedicated pair of glasses for this purpose.
Clinical Pearls
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11. Focus on Patient Education
No matter what your approach to refraction may be, patient education is a must. It is important to demonstrate prescription changes to patients and let them decide if they perceive a benefit from the changes.
Explain the adaptation period necessary with some prescriptions, especially PALs for new presbyopes. This will ensure each patient leaves your office with a prescription he or she has agreed to, as well as an understanding of how you reached that decision together.
12. Remember: Perfection Can Be Subjective, Too
Refraction involves a physical measurement of a biological system. Just like any laboratory test or medical imaging, there can be variation and vague results. Accepting this will help you aim for a result that is perfect for your patient, even if it’s not perfect from an objective testing standpoint.
This is the essence of optometric practice in terms of vision correction. No matter what modality is used, patient expectations must be shaped in order to promote better acceptance of the new prescription.
Avoiding glass checks and changes obviously benefits both the patient and your practice, but it can be harder than you think. Just as we are careful not to overmedicate drops and oral medications, we should take the same approach with eyeglass powers, axes, adds and lens designs. Although this may challenge some tenets of the traditional philosophy of refraction, most patients will appreciate conservative changes and will be less likely to return with complaints.
Dr. Potter is chief of Optometry and Contact Lens Services at Millennium Eye Care in West Freehold, NJ. Millennium is a multi-subspecialty optometry/ophthalmology practice, where Dr. Potter has practiced for 29 years.
