Refracting like an OD and not an optometry student

I work at VA Las Vegas for my 2nd rotation where I have 30 minutes to finish a complete exam with dilation with no technician help. On top of this the staff doctor has to check my work (which I mess up on all the time). So I have found I definitely can’t refract like I used to in order to finish on time! Many of these I learned from my staff docs, hope they help!

This post is for anyone who still refracts like they taught you in refraction 101 (and not how real practicing OD’s do it). The key is to save time but still be accurate. Another key is to give the patient easy choices. Patients are afraid they are giving the wrong answers and it can be stressful for them, if you always remember their point of view it will make the refraction go smoother.

When checking initial VA’s. I like to isolate a vertical line of letters to figure out where they are approximately. That way they aren’t allow to read the entire chart top-to-bottom that some patients like to do when given the chance but also gives them the ability to show me their acuity from 20/40 to 20/20 for instance without having to scroll around to show them a lot of different lines. From there you can continue to check different lines yourself but this is a good start.

Starting: Best way is dialing in the habitual Rx into the phoropter. If you can’t, start with auto-refraction or retinoscopy. Never start from zero if you can help it.

Options: Make sure to educate them that saying “no difference” or “same” or “I can’t tell” is a fine response, some patients won’t realize this and you won’t realize they don’t know this until you are spinning round and round on JCC because they think one of the choices is the right choice between 1 and 2 when there is no difference.

Fog: Unless I am suspicious they are incredibly over-minused, I don’t fog more than 2-3 clicks. I then go BVA from there. Also, I like to start refracting with a line they can read easily. I don’t refract showing the complete chart but just isolate horizontal lines of 20/40 or 20/20 most of the time. As a patient, it is more stressful to see letters you can’t read further down the chart.

JCC: This goes back to giving patient easy choices. For axis refinement, if their axis is 180, I don’t start my JCC at 180 because it forces them to differentiate between choices which may be very similar (hence “not easy” choices). This can be frustrating for them and you when they bounce all over the place. I start at around 170 and then check if they lead me back to 180 (an easy choice if they truly like their habitual of 180), if they do I move to 10 and see if they move me back to 180. If so, I am done with axis refinement.

For someone who I am checking if they have cyl at all, I start with -0.50 cyl and see if they reject it at 180,90, 135, 45.

Talk slowly but move quickly. If you speak calmly they won’t feel rushed – because if they feel rushed they won’t feel like they are getting the right Rx. Be very complimentary as in “you are doing great.” Having two hands on the phoropter dials can save a little time with JCC.

Bonus round! When I think a patient will read 20/20 or even 20/25 but don’t want them to stress if they can’t do it. I like to say “okay, bonus points if you can read these letters, they are VERY small.” If they can get my bonus points which is the 20/20 line, I say “wow, great work, those were real small!”If they read 20/20, I like to say “you just read 20/20, and as you know that’s basically the limits of human vision!”

This is also good for the picky patient who can read 20/20 or even 20/15 but always has to throw in “but it wasn’t that clear” (who also has cataracts by the way). Hey, it wasn’t clear but it was the bonus round anyway I remind them! =)

Patients are scared when their vision is poor, but love it when they are exceeding expectations. The trick is you can artificially set low expectations to give yourself the opportunity to compliment them when they have surpassed your made-up goals (patients love getting extra letters on the bonus round).

Binocular BVA – I don’t want to see the patient for an Rx recheck and over-plussing a patient (besides cyl changes) is one of the most common things students/new OD’s are guilty of. When I am at the end-point of my binocular BVA, I then ask them to differentiate by adding +0.25 and say “does this blur you at all?” This is better than asking “1″ or “2″. If he/she says it makes it even a little blurry, I am done.

20/15?! I don’t show them this line often at VA Vegas. When I do it is always near the end. This goes back to my desire to avoid showing lines that patients won’t be able to see to avoid their frustration.

* addendum: because a dozen people have asked me recently, these are my just tips and not my complete refraction process (so I do indeed do binocular balance!)

Lastly, this doesn’t have to do with refraction but when working with a 90D lens, if you are still mastering it always start with LOW magnification. It’ll be easier to aim the beam into the pupil and to figure out where you are in the retina if you start with lower mag.

Thanh Mai, proud AOSA member/contributor

Current SCCO student c/o 2012, who also maintains an optometry blog at blog.drmai.info

 

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