Prism Correction

[m0002a]

Two questions regarding a patient with prism correction:

1. Generally, I recommend that patients visit an OD rather than MD (ophthalmologist) to get a refraction. But if someone has prism correction in their current lenses, would it better for them to have the new refraction done by an ophthalmologist?
2. If a patient is wearing bi-focals with prism correction and obtains a new Rx, and the patient is sort of on the border-line between add power of +2.25 or +2.50 (but the sphere/cylinder correction is the same), it is normally the case that the prism correction would remain exactly the same for both Rx's (one with 2.25 add and the other with 2.50 add)?

[Uncle Fester]

My 2 answers---

1. No. The OD will know if it needs an MD's training (but that's unlikely).

2. Some variation is common. That's why they need regular exams. Usually prism powers don't fluctuate greatly. That said the need for prism correction can come from many different scenarios and if you're filling the rx it's helpful to know why it's required.

[Uilleann]

If you're talking refractive issues, my money is almost always on the OD's refractive prowess. Remember that in almost every case, the refraction is done by the tech for the MD (who often have even less training than your average optician), and the MD just pops in quickly to double check the numbers, scan the fundus at the microscope, and sign the chart. While there certainly must exist exceptions to this, your pt will have more chair time with the actual doctor in an OD's lane.

[SharonB]

If you're talking refractive issues, my money is almost always on the OD's refractive prowess. Remember that in almost every case, the refraction is done by the tech for the MD (who often have even less training than your average optician), and the MD just pops in quickly to double check the numbers, scan the fundus at the microscope, and sign the chart. While there certainly must exist exceptions to this, your pt will have more chair time with the actual doctor in an OD's lane.

+1000

[SeaU2020]

If you're talking refractive issues, my money is almost always on the OD's refractive prowess. Remember that in almost every case, the refraction is done by the tech for the MD (who often have even less training than your average optician), and the MD just pops in quickly to double check the numbers, scan the fundus at the microscope, and sign the chart. While there certainly must exist exceptions to this, your pt will have more chair time with the actual doctor in an OD's lane.

That's exactly what all the OD's I ever worked for told me, however I have been working for an MD for 3 years now and have experienced the least Dr. Redo's with him than any OD I've worked for in the previous 22 years. There's always exceptions to the rule I see.

[Uilleann]

That's exactly what all the OD's I ever worked for told me, however I have been working for an MD for 3 years now and have experienced the least Dr. Redo's with him than any OD I've worked for in the previous 22 years. There's always exceptions to the rule I see.

You guys mush have truly exceptional techs! Glad to hear there are those few remaining diamonds in the rough!

[SeaU2020]

You guys mush have truly exceptional techs! Glad to hear there are those few remaining diamonds in the rough!

It's not the techs. It's definitely the Dr.

[drk]

Thanks for the confidence in optometry. I hope we reciprocate the confidence in your profession.

Prism correction is not exact, so don't worry about the relationship between add power/working distance and prism. (This would only apply in a near vision only application, anyway.)

Secondly, the prism correction most of the time to be worn in distance and near gaze, and an add of whatever power has no bearing on the amount.

[m0002a]

If you're talking refractive issues, my money is almost always on the OD's refractive prowess. Remember that in almost every case, the refraction is done by the tech for the MD (who often have even less training than your average optician), and the MD just pops in quickly to double check the numbers, scan the fundus at the microscope, and sign the chart. While there certainly must exist exceptions to this, your pt will have more chair time with the actual doctor in an OD's lane.

I think I made it clear that for a normal refraction, I would always recommend an OD. But I was wanting to know specifically about someone who is current wearing a lens with a prism correction, and whether an OD is still best for that.

[Uilleann]

I think I made it clear that for a normal refraction, I would always recommend an OD. But I was wanting to know specifically about someone who is current wearing a lens with a prism correction, and whether an OD is still best for that.

I must not have been clear myself. Apologies. For any refractive issues, I would [personally] always look to optometry first. Particularly for anything difficult or tricky in any way. I've done my time in ophthalmology as a tech for a number of docs over the years. What I witnessed in that setting did not leave me with an overwhelming sense of confidence in above-and-beyond refractive abilities and outcomes. Spinning and grinning sure - that wasn't generally an issue. Perhaps the very nature of each business model is part of why you saw fewer remakes. Consider that OD's are often a first line eye doctor, while MD's are more likely to be paid a visit when the wheels are coming off the bus. Further, the demographic sets can be dramatically different as well. In my experience, there was a very large shift to the geriatric population, and most had medical conditions that glasses alone would not address. Is it possible that an 85 yo pt, with secondary cataracts, ARMD, and/or glaucoma isn't as concerned about a refractive VA of 20/15 as say a 20 something engineer with -0.25 sph OU? Just thinking aloud here. Hope you find the prism answers you need.

[Jubilee]

I happily have my prism calculated by the ODs I work with, and I have seen many an OD prescribe prism that makes a dramatic difference for patients who never had prism before, regardless of eval by MD/OD.

Every office is different. I know of docs that "won't do prism" and several that consider that their specialty. Just the same as some Ophthalmology groups rely on techs for refraction, others have ODs, and a few MDs still like to do it themselves. That's the great thing about this business. So many different ways to practice..

[standarduck]

I know of docs that "won't do prism"

What an appalling attitude. Makes you wonder why people even bother training.

[ml43]

What an appalling attitude. Makes you wonder why people even bother training.

Most likely due to the fact that prism is normally just a bandaide for an underlying problem.

in general, once you prescribe prism, it only increases.

Most of the time prism can be treated/reduced with vision therapy and/or surgery.

Anyone with prescribed prism, I normally recommend they see a vision therapist in the hope their prism can be reduced or eliminated all together. It makes everyone's life easier at the end of the day.
From the refractionist, to the optician, the lab, and ultimately the patient.

[drk]

I hope no one takes your medical advice.

[ml43]

I hope no one takes your medical advice.

ouch, directed at me?

Not a fan of vision therapy?

[mervinek]

If you're talking refractive issues, my money is almost always on the OD's refractive prowess. Remember that in almost every case, the refraction is done by the tech for the MD (who often have even less training than your average optician), and the MD just pops in quickly to double check the numbers, scan the fundus at the microscope, and sign the chart. While there certainly must exist exceptions to this, your pt will have more chair time with the actual doctor in an OD's lane.

Absolutely! I agree 1000%

[NCspecs]

If you're talking refractive issues, my money is almost always on the OD's refractive prowess. Remember that in almost every case, the refraction is done by the tech for the MD (who often have even less training than your average optician), and the MD just pops in quickly to double check the numbers, scan the fundus at the microscope, and sign the chart. While there certainly must exist exceptions to this, your pt will have more chair time with the actual doctor in an OD's lane.

Yup, totally.


FWIW, My money is on DRK, ml43. Ain't his first rodeo.

[drk]

No, I am not against vision therapy.

To insert yourself into a doctor-patient relationship (when no one was probably even asking you!) is the height of unprofessionalism. That's not what everyone here is trying to do for opticianry...quite the contrary.

You'd better know what you're talking about when you make blanket statements such as you did. I don't think you do, respectfully.

Not trying to be a jerk, but if I'm writing Rxs for prism (and I do) and you fill them and tell my patient that I mismanaged them, and then you refer to a surgeon or for VT...I'm coming down on you, big time.

If you have a problem with another professional (OD, MD, optician) you should discuss it with them or their regulating board.

[ml43]

double post

[ml43]

No, I am not against vision therapy.

To insert yourself into a doctor-patient relationship (when no one was probably even asking you!) is the height of unprofessionalism. That's not what everyone here is trying to do for opticianry...quite the contrary.

You'd better know what you're talking about when you make blanket statements such as you did. I don't think you do, respectfully.

Not trying to be a jerk, but if I'm writing Rxs for prism (and I do) and you fill them and tell my patient that I mismanaged them, and then you refer to a surgeon or for VT...I'm coming down on you, big time.

If you have a problem with another professional (OD, MD, optician) you should discuss it with them or their regulating board.

forgive me, I just realized what I wrote above.

I did not mean anyone, I meant anyone with problems.

I've seen more than few people with prescribed prism, hop from doctor to doctor, and place to place to get their rx filled. so after a few years they end up with multiple rx's all with different amounts of prism. and a hand full of glasses, of which they just choose the one the works ok, many times through trial and error.

prescribing prism doesn't sound fun, and cutting it isn't either. especially if it's in more than one direction with cylinder.

[drk]

Got it!

[m0002a]

If you're talking refractive issues, my money is almost always on the OD's refractive prowess.

Several people have given support to this statement, and sans prism correction, that is what I said in my OP. In normal circumstances an OD is the preferred provider for refraction. But I don't see many even mentioning whether this is true for prism correction situations, which is what this thread is about.

In truth, many OD's don't do prism correction and will refer to other providers if one is needed or is patient has one already from a previous Rx. The same "may" be true for ophthalmologists to some extent, but I suspect a higher percent of MD's (compared to OD's) will handle patients with a prism correction.

I may have been naïve, but I was expecting some constructive assistance and advice, especially for question #2 in my OP. The question of OD vs MD for normal refractions was not question that was raised by me (as I noted in my post).

[Uncle Fester]

Several people have given support to this statement, and sans prism correction, that is what I said in my OP. In normal circumstances an OD is the preferred provider for refraction. But I don't see many even mentioning whether this is true for prism correction situations, which is what this thread is about.

and will refer to other providers if one is needed or is patient has one already from a previous Rx. The same "may" be true for ophthalmologists to some extent, but I suspect a higher percent of MD's (compared to OD's) will handle patients with a prism correction.

I may have been naive, but I was expecting some constructive assistance and advice, especially for question #2 in my OP. The question of OD vs MD for normal refractions was not question that was raised by me (as I noted in my post).

Is your blanket statement "In truth, many OD's don't do prism correction " based on your impression? I would beg to differ. My experience is most OD's would do more and not shy away from it. Their education emphasizes refractive as well as physiological issues of the eye which prism addresses. The MD is looking at much more than that and handling the referrals of medical not refractive problems from the optometrist.

Your question 2 needs to be more specific in that what type of prism are you referring to?. Slab off or another? The full rx would be helpful. The broad answer is normally the prism correction if slab off would be subtlety different (assuming lens measurements are consistent) but if not slab off some change is not unusual. The doc's will almost always error on keeping prism to its barest minimum and not "feed the beast".

Hope this helps.

[Uilleann]

I'm not sure what seems so "unnatural" about prism correction for the OP. The reality is, every ophthalmic lens we use is prism based. The addition of prism to a given SRx isn't any different than sphere or cyl in terms of power or clarity of VA's to a pt who needs it. I would further kindly suggest expanding your base of OD's from which you fill SRxs from. Over many many moons of dispensing myself, I have n-e-v-e-r seen an OD shy away from prism correction. And in complete truth, I've seen more errors and critical omissions on the written numbers from MD's than I have OD's.

At any rate, I can't see any reason why our OP should be directed NOT seek the assistance of any qualified OD (which in reality should NOT be difficult) with any prism question. Best of luck either way!

[Robert Martellaro]

In truth, many OD's don't do prism correction and will refer to other providers if one is needed or is patient has one already from a previous Rx. The same "may" be true for ophthalmologists to some extent, but I suspect a higher percent of MD's (compared to OD's) will handle patients with a prism correction.

I don't know of any ODs who'll refer out for binocular disorders, except for pathology. Even then, they'll still co-manage the case. However, most ODs, especially the young ones, don't routinely perform phoria testing! MDs don't either.

I may have been naïve, but I was expecting some constructive assistance and advice, especially for question #2 in my OP. The question of OD vs MD for normal refractions was not question that was raised by me (as I noted in my post).

Okay.

1. No.
2. Yes.

Two questions regarding a patient with prism correction:

1. Generally, I recommend that patients visit an OD rather than MD (ophthalmologist) to get a refraction. But if someone has prism correction in their current lenses, would it better for them to have the new refraction done by an ophthalmologist?
2. If a patient is wearing bi-focals with prism correction and obtains a new Rx, and the patient is sort of on the border-line between add power of +2.25 or +2.50 (but the sphere/cylinder correction is the same), it is normally the case that the prism correction would remain exactly the same for both Rx's (one with 2.25 add and the other with 2.50 add)?