Over-plus ing (i know, the spelling, the horror)

[becc971]

okay. So our optometrists have been adding plus to a lot of our RX's, in the theory that it will help the patients eyes "relax." Our remake report is through the ROOF right now, most of which are because they are 1/2 to a full diopter of more plus. patient is given a +4.00 RX, and comes back from seeing the doctor for a 2nd time with a +3 - a +3.50. They don't like it, clearly, and neither do we, or our lab, or the techs, or anybody haha. has anyone else been experiencing this issue? one of our student doctors told me this extra plus thing is something they're teaching in school?? any thoughts from anyone? bueller?

[braheem24]

pushing plus has always been the norm, how long is the exam room?

Does this happen with everyone? Presbyopes more then others?

[becc971]

from chair to eyechart probably 10ish?

[harry888]

In my sixteen foot exam room I always need to add and extra 0.25 of minus.

Every exam room is different. Previous room was 14 feet without mirrors and nothing needed to be compenstated.

Harry

[wmcdonald]

pushing plus has always been the norm, how long is the exam room?

Does this happen with everyone? Presbyopes more then others?

Braheem,
Maximum Plus for Maximum Visual Acuity (MPMVA) is the norm. Adding minus causes the eye to accommodate, which we do not want. Adding excessive plus will do nothing but blur the image. I hope this is helpful

[Barry Santini]

Braheem,
Maximum Plus for Maximum Visual Acuity (MPMVA) is the norm. Adding minus causes the eye to accommodate, which we do not want. Adding excessive plus will do nothing but blur the image. I hope this is helpful

Dr Warren:

IMHExperience, this ol' maxim is:

Simplistic
Inaccurate
and often just plain wrong

[fjpod]

There is nothing wrong with accomodating a little. Most people in the world are low hyperopes and they accomodate a little all the time without symptoms. There is no rule that says the final Rx has to be the most plus you found in the manifest refraction. You must consider the habitual, the patient's entering symptoms, the aided and unaided VA before writing the final Rx.

How experienced are your optometrists???

[wmcdonald]

Dr Warren:

IMHExperience, this ol' maxim is:

Simplistic
Inaccurate
and often just plain wrong

I am sure it is Barry. You should have completed the course! Seriously, it is simplistic, but not at all inaccurate. You can find complete information in Clinical Refraction by Borish if you wish to review the material. Keep in mind however, as fjpod indicates, there is much to consider beyond just the end point in the manifest.

[OHPNTZ]

There is nothing wrong with accomodating a little. Most people in the world are low hyperopes and they accomodate a little all the time without symptoms. There is no rule that says the final Rx has to be the most plus you found in the manifest refraction. You must consider the habitual, the patient's entering symptoms, the aided and unaided VA before writing the final Rx.

How experienced are your optometrists???

Hey, you forgot cover test, phoria, accomodative amplitude, etc...

Just had a great example 6 weeks ago. 15 yr old comes in for exam. Last year other OD determined rx at about +1.75. During refraction, and binocular balance, she was all over the place. Decided to do a wet refraction...which revealed +5.75. She wanted contacts, which made life easier. When she returned tried +4.00...she hated it. I even tried dilating her, and sending her home with the +4.00. Didn't work. Started her at +2.00, and brought her back once a week, increasing by +0.50 to +0.75 per week. 1 month later, she is comfortably wearing +4.50. So there you go...some people do not adapt well, whereas I have had others who have no problem with near a full wet refraction (backed off 0.50 to 0.75 D).

[anthonyf1509]

In a short amount of time (3+ yrs), I'd say habitual and patients expectations are biggest factors.
I do routinely find our own OD (25+ yrs) who does the most thorough exam and is very knowledgeable, to go to high on the plus side. But this is only in comparison. It's not so much it's wrong, as it is just not what's going to be right. And there is no law against lowering an add or altering an Rx where needed. Especially when discussing with doc.

To OP, yes we had a short lived issue similar to yours, but communication goes a long way. Also, my fellow optiboarders helped and a trial fre set is a must.

[becc971]

pushing plus has always been the norm, how long is the exam room?

Does this happen with everyone? Presbyopes more then others?

sorry i didn't see that part of the question. yes with presbyopes more than others.

[becc971]

I'm strongly considering bringing one of the trial frames down here from the exam room.and using it before we even make the glasses. Thats how high our remakes have been lately. It really is a huge concern because it makes us look incompetent when we have to say go home, try them. then they come back 1 - 3 times to get it right. One of our optometrists more than the other one, but the other one is very receptive to our input. When we told him it was an issue, he listened. It just plain doesn't work! and now we just have angry patients wanting refunds.

p.s. totally calling out my manager and our lab guy because they put me up to being the one to start this thread thats right mikey, callin you out!!

[Diopterman]

I'm strongly considering bringing one of the trial frames down here from the exam room.and using it before we even make the glasses. Thats how high our remakes have been lately.

I strongly believe that EVERY optician should have their own trial lens set and trial frame. If you do not have your own, definitely use the office set if available. It has saved me many, many, maaaannnnnnyyyy remakes!*



*Please note: I am not advocating playing Junior Optometrist! Make sure that your owners, Dr.'s, are okay with you using the set to guage patient accepting the new rx! Also, I would assume that in some states and circumstances that using a trial frame and set may imply that you are playing doctor and could be legally frowned upon! Practice opticianry at your own risk!

[Uncle Fester]

You must consider the habitual, the patient's entering symptoms, the aided and unaided VA before writing the final Rx.

Pardon my ignorance showing.

Am I correct in taking habitual by its common definition meaning the habit of past powers worn?

I don't recall my doc's using the term.

[optilady1]

In my experience, anyone over a +1.50 can have a hard time adapting to any extra plus. Working with MD's, with techs doing the refractions, it has been a real frustration on my part to deal with people who can do a refraction, but have no knowledge of how a person uses that refraction outside of 14 ft pitch black exam room.

Most of the times, when I am discussing new rx's with patients, I talk extensively about the change, how it can be difficult to adapt and the need to give it a good two weeks to see if they can get used to it.

Unfortunately, there isn't too much we as opticians can do about the refractionist.

[Barry Santini]

Pardon my ignorance showing.

Am I correct in taking habitual by its common definition meaning the habit of past powers worn?

I don't recall my doc's using the term.

Habitual, as in "what they're used to." Adding a change (A "delta") here can (negatively) influence acuity, utility or perspective. Eyewear satisfaction is a very multi-layered thing.

B

[obxeyeguy]

from chair to eyechart probably 10ish?

There is the problem, spending too much time with them.

There is nothing wrong with accomodating a little. Most people in the world are low hyperopes and they accomodate a little all the time without symptoms. There is no rule that says the final Rx has to be the most plus you found in the manifest refraction. You must consider the habitual, the patient's entering symptoms, the aided and unaided VA before writing the final Rx.

How experienced are your optometrists???

That's why I always said it's an art, not so much a science.

I also trial frame or loose lens them over existing Rx out of the "perfect little world" exam room.

[becc971]

There is the problem, spending too much time with them.

we lowly opticians don't get to hang out in the exam rooms much hey man all i'm good for is picking out pretty glasses frames! as it is i'll probably have to james bond a trial frame set from out back somewhere

[Robert Martellaro]

There is nothing wrong with accomodating a little. Most people in the world are low hyperopes and they accomodate a little all the time without symptoms. There is no rule that says the final Rx has to be the most plus you found in the manifest refraction. You must consider the habitual, the patient's entering symptoms, the aided and unaided VA before writing the final Rx.

How experienced are your optometrists???

Maybe this is a practice that has less experience prescribing and fitting eyeglasses for emerging presbyopic mild hyperopes, one of the more challenging and demanding groups, with healthy eyes, that we work with. God bless the prescribers in my area who rarely give me this kind of grief.

[fjpod]

Pardon my ignorance showing.

Am I correct in taking habitual by its common definition meaning the habit of past powers worn?

I don't recall my doc's using the term.

Yes, exactly.

If the patient has never been wearing a DV Rx and they come in and manifest +1.50, you're not going to give them +1.50 first time out of the box, because they will not adapt...even if it is single vision. If however, they are used to wearing +1.00 for distance and they manifest +1.50, you might give them +1.25 if they have symptoms with the +1.00.

There's really more to it like age, physical condition, working distance, temperment, gait...

I still blame the OD. Even without a trial frame, they should know how to gauge how much change a patient can tolerate. There's an expression in the business..."the only way you are going to learn how to prescribe is to eat some glass (plastic)". IOW, make the prescriber pay for the mistakes.

[Fezz]

I'm just a temple bender, but I have found that most patients eat minus and reject plus?

I love to trial frame patients in "The Real World" if I fear that they are over plussed!

The trial frame and lenses are your friend!

I say that if your docs don't want to listen, so be it. It is their bottom line and patient satisfaction that is suffering. Maybe one day they will wise up and be a little less myopic on the subject!

[braheem24]

myopic

[becc971]

I'm just a temple bender, but I have found that most patients eat minus and reject plus?

I love to trial frame patients in "The Real World" if I fear that they are over plussed!

The trial frame and lenses are your friend!

I say that if your docs don't want to listen, so be it. It is their bottom line and patient satisfaction that is suffering. Maybe one day they will wise up and be a little less myopic on the subject!

bahahaha ... myopic :)

i think part of the problem is they're also employed by the larger entity, so they don't really see the bottom line? i agree with the eating minus rejecting plus idea ... i'm a prime example they refract my left eye and if they don't stop it themselves i will sit there and let them make it more and more minus all day long!!

its mostly presbyopes with the issue ... they don't seem to want to try them in baby steps like giving them half of the power now, and stepping it up every 6 months or so which would be preferable. instead they're like "hey, i'm going to throw all of this at you right meow and you're going to have to like it mm'kay??" they would rather blame the patient than their RX !

[Jarhead Daddy]

"Subjective"refraction matters. I agree that most patients eat minus and reject plus. Ourextremely professional O.D. has discussed this with us in morning meetings(huge asset). The most common Rx remake seems to be first time PAL wearers who havenever worn glasses before. They usually refract with a little +, but have been accommodatingfor it their entire lives. The solution is for the O.D. to communicate with thepatient and do a bit of "lifestyle dispensing". Don't demand amechanical 20/20. Shoot for 20/happy. Set a reasonable expectation. Take babysteps when necessary, and make sure that the O.D., the optician, and thepatient are all on board with a plan of attack. Props to our Optometrist. Hebelieves in communication and 20/happy. He is not snobby. He listens to thepatients and the opticians. We work together. It makes for a very pleasant workenvironment.