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Thread: I Have a Challenging Patient

  1. #1
    Ghost in the OptiMachine Quince's Avatar
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    I Have a Challenging Patient

    Let me start off by saying, she is not a burden.

    This patient is one I inherited from a previous optician who is taking some time off due to burning out- normal case for me with this company. Patient had an extremely disruptive concussion 5-6 years ago and has been struggling with frames/ Rx since. She travels across state lines to work with a Dr that will take her dilemma seriously and has literally been laughed out of other offices before finding the current combo of her Dr plus my optical.

    We are in a position where she is in on a regular basis with a new Rx to try and new issues to face between comfort and visual acuity. In some ways, some of her symptoms remind me of a diabetic patient, where she will literally measure a different Rx from day to day, in quite drastic amounts.

    She is willing to try ANYTHING to find something that will consistently work for her. We have yet to solve that puzzle. With a higher minus and a petite fit, we have narrowed frames down to a Jr Ray Ban. Anything new we try, it goes in that frame to help eliminate other factors that may disrupt the testing of a new Rx.

    Currently, we have a very unique Rx on order- her cyl has shifted to a half measurement (-1.62) and I told her we would try. Meanwhile, I ordered her a replacement frame for her current one because the spring hinge broke and the plastic is cracked on the temple end. So the frame comes in and I have her come in to swap the lenses over. I do so annnnnnnnd -she can't see as clearly. Same lenses, same frame, but she can feel the difference. Adjustment is perfect, I triple check that axises are perfect and I have her try them.

    She came back in today, and she is in pain. Her eyes are straining and she is uncomfortable. She has reverted to her previous Rx in hopes of comfort because the current Rx is now feeling too strong. Just in case, it's a fit issue, we try swapping her lenses into another of the same frame (she has, like three pairs, all with varying Rxs) and I do the same to make sure the Rx is in there perfectly.

    After trying them on again, she is in tears. She still doesn't feel like it's the same Rx that came out of the broken frame and I am at a loss. She has allllll of my sympathy as I've been working with her for the past 6 months now. I know how sensitive she is- she can feel the change in Rx strength due to bevel placement- I know it is her brain and not her eyes being difficult, and she does too. She feels like she is wasting our time and is completely overwhelmed by the frustration of a previously 'okay' Rx not feeling okay anymore.




    I'm not actually expecting anyone to have insight on why this isn't working- but really felt the need to express my frustration in not being able to help her. I'm doing everything in my power (soooo wish her Dr was accessible to me) and she knows we are doing our best and that we have never made her feel bad for her situation. She has even brought me flowers before! An absolute sweetheart, with a medical condition that won't let her see clearly and comfortably.

    I'm going to sleep on it and keep my fingers crossed for her that tomorrow will be a good day, but can't help but feel a weight on my heart that she is in this position.

    Rant over~
    Have I told you today how much I hate poly?

  2. #2
    Master OptiBoarder
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    The POW measurements are identical?

    Also, has she been autorefracted? If so, and the measurements are the same day to day, you are dealing with a neurogenic issue, probably localized to the occipital lobe (if we're talking a classic frontal impact concussion), and not an ocular nor an optical issue. At that point the only thing that can be done is referral to a neuro-opthalmologist (but they tend to be as rare as hens teeth outside of an academic medical center), and hope they can some up with something on MRI or PET to figure out if it is structural damage or a neuro-optho functional issue.

    That's the best I can come up with.
    Last edited by Lelarep; 06-26-2021 at 03:10 AM.

  3. #3
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    Have you tried tinted lenses? Certain colours could have a beneficial effect for her, since the issue is purely psychological

  4. #4
    What's up? drk's Avatar
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    There is no such thing as variable refraction without stuff like dry eye or diabetes. Any other variation is from testing and/or responses. If you chase this refractive error, you are never going to help her.

    Get a dilated refraction (which reduces depth of focus) confirmed by retinoscopy (to rule out any craziness on her part). Look at the corneal surface via fluorescein or keratometry mires or topography to make sure you have a reasonable (not perfect) refracting surface.

    Then do what you can do to be consistent and accurate in the dispensary.

    Then she has to do her part. Spectacle adaptation is TOTALLY the responsibiity of the wearer. You can't do it for her. You can't underprescribe/overprescribe/fit high/fit low etc. in a case like this. You have to play it straight up. Keep her habitual glasses so she will comply.


    Now, what if you feel she's done her part, but cannot adapt? Then you have absolutely nowhere to go; this is an idiosyncratic patient. More minus? Less cyl? Axes towards 90 or 180? Different base curve? Different material? A light filter? All this is pot-shot quasi psychological stuff.

    I get it: TBI patients are in trouble. But they have to know that it's not "fixable". They have to PAY to get it right (time and materials).

    I second Robert's tint suggestion: there's a lot of mumbo-jumbo with tints that I think is crap, but the placebo effect is very powerful in these cases and they could care less if it is.

  5. #5
    What's up? drk's Avatar
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    P.S. Her fragmenting her care is...sub-optimal.

  6. #6
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    Quote Originally Posted by Robert_S View Post
    Have you tried tinted lenses? Certain colours could have a beneficial effect for her, since the issue is purely psychological
    I had a concussion patient that had severe migraines following a car accident. I know this is different but maybe this will help.... we did a FL-41 tint and it was so successful she actually was crying. Idk... worth a shot.

  7. #7
    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    I've said before that someone in the optical field recommending tints for a seemingly hopeless cause is like a chiropractor challenging an orthopedist a hundred years ago. It too, took a while to gain acceptance.

    And in this case it may very well prove ineffective but why not offer some hope and if nothing else, eliminate it being the answer.



    At my request my wife got me this book by Ian Jordan on prescribed tints a while back and I found it really interesting:

    https://tinyurl.com/57ze3sm4

  8. #8
    Ghost in the OptiMachine Quince's Avatar
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    Thanks everyone for the outside perspective. I needed fresh grey matter to help me take a step back.

    My turning point now, is do I want to get in contact with her doctor instead of just following direction? I'm about to take a leave and don't know how well anyone else in the company will want to invest in her progress until I'm back.

    I am a believer in tints and haven't thought to bring that factor in. She currently has a blue-blocker AR (not the same, I know, but that does slightly change color perception) but wonder what her Doc's thoughts would be on FL-41.

    I usually have an easier time trying to clarify expectations of new RXs, especially when there are underlying health issues, but the fact that change causes her physical pain and discomfort gets to me...

    Once again, thanks for the insight and I'll update if we make some solid progress.

    Wish me luck!
    Have I told you today how much I hate poly?

  9. #9
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    Quote Originally Posted by Uncle Fester View Post
    I've said before that someone in the optical field recommending tints for a seemingly hopeless cause is like a chiropractor challenging an orthopedist a hundred years ago. It too, took a while to gain acceptance.

    And in this case it may very well prove ineffective but why not offer some hope and if nothing else, eliminate it being the answer.



    At my request my wife got me this book by Ian Jordan on prescribed tints a while back and I found it really interesting:

    https://tinyurl.com/57ze3sm4
    Off topic, but chiropractic gained acceptance after they shed their pseudo-scientific origins. It wasn't just time and acceptance. It was getting rid of the junk theories and shifting toward medical and scientific tested theories. The people who practice "straight chiropractic" are still considered quacks by the medical world, and rightly so.

  10. #10
    OptiBoard Professional KrystleClear's Avatar
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    We have had patients with Lyme disease have similar issues with what they perceive as a constantly changing prescription, but the doctor says it shouldn't be changing and doesn't entertain it. You kind of feel helpless as the optician. One asked about glasses that have fluid in the lens that allows the wearer to adjust the power, because she was so frustrated.It seems like you have been very accommodating and are doing all you can at this point. Has she seen a neuro-ophthalmologist? If a patient like this saw the ophthalmologist I work for, I would imagine he would be sending her to neuro-ophthalmology. It would stand to reason that with what she is spending on doctor visits out of state and new lenses that the time and expense of at least seeking the opinion of a neuro-ophthalmologist may be worth it. It's so hard when you don't have the exam notes and medical history available to see if possibly there is anything else causing it or at least contributing to it. I would expect our doc would recommend she try preservative free artificial tears just to see if maybe, just maybe, she is experiencing increased dry eye? It's amazing how many complaints are actually just dry eye related. Kudos to you though for being caring and understanding.
    Krystle

  11. #11
    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    Quote Originally Posted by KrystleClear View Post
    Has she seen a neuro-ophthalmologist?
    Great suggestion.

    I think the doctor involved is an OD practicing Vision Therapy.

  12. #12
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    Maybe this is common knowledge to you all in the US, but it blew my mind when I learned that dry eye can have an effect of up to +/-0.50 on the Rx

  13. #13
    What's up? drk's Avatar
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    Not necessarily causing a true refractive shift of +/- 0.50, but making the refraction endpoints variable/soft such that the margin for error sometimes increases to +/- 0.50 or more.

  14. #14
    Eyes eastward... Uilleann's Avatar
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    Has this pt had an MRI? What does her neurologist have to say regarding their care? These seem like huge and critically important pieces to a complex puzzle.

  15. #15
    OptiBoard Professional IIxIPariahIxII's Avatar
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    If she's seeing a neuro, I would have her look into the NeuroLens. I have motion tracking issues due to concussions from way back when, and NeuroLens may be able to give her something more finetuned to help. They're expensive as all get out. And I don't know if it would be ideal if her needs are changing daily.

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