It is a truism that, If you operate, you will have
complications. Wise surgeons plan ahead to avoid complications and to
manage those that unavoidably occur. Also a truism clinicians who
prescribe glasses will have the occasional unhappy patient returning to the
office. Planning for this event will both reduce its occurrence and ameliorate
the pain of patient and refractionist alike.
One may ask, Why bother? It is only a pair of glasses. Some
offices respond to patient complaints about spectacles with, It takes
time to get used to a new pair of glasses. However, a patient who has
paid $400 to $800 for glasses and experiences intolerable headaches or diplopia
whenever he or she attempts to use them will not be a person who is likely to
accept such platitudes.
Is this a significant problem? In the authors practice, all
spectacle prescriptions have a reminder at the bottom to Please bring
these glasses back to the office to have them checked for accuracy. A
majority of patients avail themselves of this service and, each year,
approximately 5% of patients have some complaint about their new glasses.
Similar rates of complaint have been documented in other offices. Although more
than half of the complaints are minor and often are resolved with more time or
minor frame adjustments, about 2% of prescriptions result in significant
complaints. Each of these patients may require 20 to 30 minutes of office time
for the clinician to determine the source of the problem, a charge for which
these unhappy patients would consider inappropriate. After the clinicians
hourly rate is factored in, it is easy to see that unhappy refraction patients
cost real money if they return, and loss of the patient if they do not.
These are truly unhappy patients, and some may be vehemently unhappy.
They have struggled with unsatisfying glasses for weeks or months. They may
have been put off by a receptionist for weeks before being allowed in the
office door, and have probably been in the waiting room a while before the
technician tried to evaluate the problem, and then have sat in the exam lane
awaiting the clinicians arrival. That patient may be worried that he or
she made a mistake answering the refraction questions or that he or she may
have a serious eye disorder causing the visual difficulties, or he or she is
wondering who is going to pay for the remake of his spectacles. In this
setting, the refractionists interaction with the patient may confirm the
patients impression of the clinician as an excellent, caring physician or
as an insensitive professional undeserving of his or her patronage.
Most of the complaints of patients with new spectacles fall into three
categories systemic, visual, and mechanical.
Headache is perhaps the most frequent
complaint of unhappy refraction patients. The pain may vary from mild to severe
and may be perceived in the orbit, periorbital, or frontal regions, or temporal
or even occipital areas. Dizziness or a swimming sensation is a frequent
symptom with new glasses or new prescriptions and is sometimes associated with
nausea. Many patients will voice less-defined symptoms such as general fatigue
when using the glasses, tired eyes, a pulling sensation, burning,
or aching of the eyes. Some simply say, I cant use these glasses.
They make me sick.
Blurred vision or just not seeing the way
the patient expected to see will bring patients back to your office. The
difficulty may be observed in the distance, when reading or performing other
near vision tasks, or when trying to see mid-range targets such as a computer
monitor or store shelves. The complaints may be more about distortion than
blur, although many patients will not differentiate between these two symptoms.
Your patient will not ignore diplopia that is created by a new spectacle
prescription. The list of symptoms also includes a sense of tilting of the
environment (floors, tables, walls), inappropriate image size or disparities in
the two eyes, distance judgment concerns, or inability to walk down stairs.
Frame or Mechanical Complaints
Patients often complain that
their frame fit is not satisfactory. It may feel too tight behind the ears or
on the nose. It may slide down the nose too readily. They may simply not like
the look of the frame. The bifocal may be too high, too low, too
small, or too large, or the bifocal line may be too prominent. The glasses may
fog over, or they may scratch too easily. Patients often wonder if the lens
edge is too thick and shows too much. Some patients are aware of a
rainbow effect at the periphery of their glasses.
Who Made the Mistake?
The source of the error in a patients glasses can be
determined with an organized evaluation of the patients complaints.
Almost all will fall into one of four categories: refractionist errors,
optician errors, patient errors, and optical effects inherent in spectacle
Refractionist errors include incorrect reraction; incorrect prescription
for the patients needs; incorrect transcription of the numbers from the
record to the prescription; failure to identify and adjust the prescription for
facial anomalies; asymmetric accommodative amplitude; anisometropic
aniseikonia, or anisophoria; failure to include vertex distance on the
prescription; or incorrect advice to the patient regarding choice of
Optician errors include incorrectly filling the prescription, wrong
positioning of optical centers, wrong conversion of or neglecting to convert
vertex distance of the prescription to that of the spectacles, errors in
placement of bifocal, inappropriate changes of bifocal type, inappropriate
changes in base curve or lens thickness, and failure to advise patients of the
best frame for their specific facial and optical requirements.
Patient errors predominantly are caused by poor choice of the frame.
Patient expectations may be inappropriate, resulting in complaints.
Occasionally, a patients ability to tolerate perceptual changes is the
cause of problems and, infrequently, a patient simply has decided not to buy
the spectacles and is looking for a way to obtain a refund of the cost.
Optical effects of lenses are a frequent cause of problems, some of
which are unavoidable. Changes in base curve or lens thickness may seem to be
necessitated by changes in prescription power. Anisometropia may cause sensory
or motility problems for even the most tolerant patient. Progressive addition
lenses will always be associated with distortion of peripheral vision and a
small reading area. However, many of these problems can be minimized with
proper frame selection and adjustment of prescriptions.
Evaluation of the Dissatisfied Refraction Patient
Regardless of the problems origin, it is the refractionists
responsibility to determine the source of the difficulty and attempt to satisfy
the patients needs. An organized plan will expedite the evaluation and
reduce the time required to identify the problem source. A preprinted form can
be used to outline the information needed for technicians and physicians (Slide 1).
Each office should have the tools needed to carry out the planned
evaluation. These include a lensometer, prism set or vertical and horizontal
prism bars, a tape measure and a millimeter ruler (Slide
2), a lens clock and a lens calipers (Slide 3), and a
distometer (Slide 4). An accommodative ruler (Slide 5) is useful, although the same determination of
accommodative amplitude can be performed with a tape measure. A trial lens set
and trial frame is the preferred refraction method for rechecking problem
patients; however, a phoropter may be acceptable for a patient with a
refractive error below 6 D. An autorefractor will not suffice as a means for
re-evaluating the refraction of a patient with complaints.
Slide 1. A form to organize evaluation of glasses
Slide 2. Tape measure, scaled in inches and
millimeters. Small hand-held ruler.
Slide 3. Lens clock and lens calipers.
Slide 4. Distometer with conversion guide.
Slide 5. Accommodative ruler.
As with all patient interactions, the workup of a dissatisfied
refraction patient starts by taking a history. This should elicit as focused a
description of the patients difficulties as possible and should include
the following questions.
- Were the symptoms present immediately upon receiving the
- Does the problem occur every time they are worn, and as soon as they
are put on or only after a period of wear? How long a period?
- Is the problem present with vision at all distances or only certain
- Is the problem present only in certain positions of gaze or head
positions or body positions?
Once the nature of the malady is known, the workup should proceed with
the following steps:
- Measuring visual acuity of each eye at 6 m with old and new
- Determining the optimal reading position of each eye and the smallest
type easily read at that distance, measured with the old and the new spectacles
- Measuring the vertex distance of the old and new spectacles, if lens
power is higher than 6 D (Slide 7)
- Measuring the interpupillary distance with pupillometer (Slide 8) or millimeter ruler (Slide 9)
and comparing this distance to the distance between the optical centers of the
old and new spectacles. Simultaneously, one should take note of any facial
asymmetry (Slide 10)
- Measuring the seg (bifocal) height of the old and new spectacles.
Also the seg position relative to each eye when the glasses are in their usual
position on the patients face (Slide 11)
- Comparing lens size, vertical and horizontal dimensions, of the old
and new spectacles (Slide 12)
- Comparing the base curve (front curve in the distance vision area) on
each lens of the old and new spectacles (Slide 13)
- Comparing the center thickness of the old and new spectacles (Slide
- Performing a repeat manifest refraction, by the best refractionist in
the office. If there is any question of accuracy, a cycloplegic refraction
should be performed, even in the early presbyope.
Slide 6. Measuring the optimal reading
Slide 7. Measuring vertex distance of spectacles with
Slide 8. Pupillometer.
Slide 9. Ruler measurement of interpupillary
Slide 10. Facial asymmetry with left eye
significantly higher than right eye.
Slide 11. Bifocal position relative to pupil
Slide 12. Measuring spectacle lens
Slide 13. Measuring lens base curve with lens
Slide 14. Measuring lens thickness with lens
The most important step in satisfying an unhappy patient is obtaining
the history. Listening carefully to a patients complaints provides the
clinician with valuable information leading to the diagnosis of the problem
source, but even more valuable may be the proof to the patient that his or her
complaints have not broken the doctor-patient relationship and that the
concerns will be resolved. The clinicians obvious attention to the
patient constitutes reassurance to the patient that his or her difficulties
will be eliminated or reduced. Well over half the time, the history will allow
a quick diagnosis, as the patient may disclose that he or she manually raises
the frame to read or has double vision when reading or with distance vision, or
the glasses hurt behind the ears, or another symptom that will define the
origin of the problem.
Problems from choice of
frames: Frames that are too small may not permit adequate seg size to
allow comfortable reading, especially with progressive addition lenses. Frames
that are significantly larger than the previous pair will feel heavier and may
produce an increased awareness of peripheral distortions when high index,
thin lenses are used or when progressive addition lenses are
present. A frame that is too loose, either because of imprecise match of bridge
width to nasal width or from poorly adjusted temples, will slide down the nose
and result in a bifocal position too low before the eyes, making them
nonfunctional. The patient may explain the problem by complaining the glasses
must be lifted to read better.
The choice of an unusually wide or oddly shaped frame may result in an
unsightly, thick lens edge, usually at the temporal periphery in myopic
spectacles. A rounder frame with optimal bevel placement on the lens edge will
reduce this cosmetic defect as much as possible.
Problems from frame
fitting: At times, the pantoscopic tilt may be a cause of cosmetic
complaints or may result in reading problems in bifocal wearers. Frames may be
too tight or too loose for the patients comfort. Often, simple
adjustments of nose pads will eliminate many problems in spectacle
If the frame is the problem and the patient is in your office chair, you
can be certain of the following: first, the optician will have to be the one to
resolve the problem and, secondly, the patient has not yet been able to get the
optician to resolve the problem. You will want to explain the cause to the
patient, and if it can be rectified by adjustment of the current frame or if it
will require changing to a different frame. Then as you send the patient back
to the optician, it would be wise to make contact with the optician to be
certain the modification is understood.
Some prescription problems are easy to diagnose. If the optician erred
in filling the written prescription, the first moments of the office visit will
be all that are needed.
If a refraction error or a mistake in transcription of the refraction to
the prescription has been the cause of the problem, your repeat refraction
should make this immediately apparent. Overminusing or underplusing may cause
headache or asthenopia in a pre-presbyopic patient and blurred vision in
presbyopes. An error in astigmatic axis and/or power may produce similar
symptoms. An open acknowledgement of the source of the trouble, combined with
assurance to the patient that he or she will not be charged to rectify it, will
usually suffice to assuage both your sense of guilt and the patients
If the patient complains of blur and the glasses are over 6 D, the
clinician should determine whether pulling them a few millimeters farther from
the face or pushing them in as close as possible improves acuity. This may
indicate a vertex distance problem. Every highly ametropic prescription should
have vertex distance recorded, and it should be checked with the glasses when
the patient returns with a vision disturbance. If the prescription had a vertex
distance recorded and the optician did not convert the prescription for the
actual spectacle vertex, another remake is in the future.
Problems in choice of bifocal are many and varied. One of the most
common is making the bifocal too strong. Just because a patient says that a
+2.25 D add makes print look sufficiently large and sharp in the office does
not mean that it is the best choice. If the +2.25 D add results in an optimal
reading distance of 13 inches in a 45-year-old patient but he or she actually
wants to use the glasses for reading a newspaper set on a desk at 19 inches,
then she will be back complaining within the week. The same +2.25 D add may be
perfect for a 45-year-old tailor, although he or she may also want a +1.50 D
add for reading at home. Each prescription must be tailored to each
patients visual requirements.
Continuity is a comfort to most of us, and change forces adjustments
upon us. When a patient chooses a new bifocal style (round to flat top, flat
top to progressive, etc.), symptoms may occur. If the change is the only source
of symptoms, it may be an instance when allowing additional time for adaptation
will be successful. If not, a return to the previous bifocal type is
Loss of focal range with new glasses is a frequent cause of complaints
If the distance prescription is changing more plus, the bifocal of the
old glasses will be focusing farther out than when they were first prescribed,
perhaps providing clear vision at such valuable positions as the store shelves,
the computer monitor, or the dinner table. Suppose your patient was 48 when he
received the last glasses, +0.50 OU with +1.75 add, providing reading at 17
inches. Now, 3 years later, the bifocal is focusing best at 22 inches and he is
having problems reading, and the new refraction is found to be +1.00 OU and it
takes a +2.00 add to read well at 17 inches. A new pair with stronger plus in
the distance RX and in the bifocal may improve reading at the expense of loss
of the mid-range, which he was seeing well through the old bifocal. It may be
time to switch to trifocals!
If the distance prescription is shifting more minus, then the old
glasses will be focusing closer through the bifocal than when first purchased.
Lets say your patients prescription at age 65 was -3.00 OU with a
+2.25 add (power though bifocal = -0.75) which provided excellent reading at 16
inches. Now he has returned at age 69 and you find he is reading at 12 inches
with the old glasses, though perhaps quite comfortable in doing so. His new
refraction is found to be -4.25 D OU, which explains the shortened reading
position, since his old glasses undercorrect his distance vision and leave him
with 1.25 D of uncorrected myopia. The effect through the bifocal of his old
glasses is the power through the bifocal (-0.75 D) plus the uncorrected myopia
(a +1.25 D effect) resulting in a power of +0.50 D. When you prescribe a new
pair with -4.25 D OU, which pushes the patients focus out to infinity,
and a new add "appropriate" for age 69 (+2.50), the result is a loss of total
plus effect at near (-4.25 + 2.50 = -1.75) and a focus through the bifocal
which is farther out than the old lenses. The patient may complain of trouble
reading from the loss of magnification. But if you increase the add power to
keep the focus at 12 inches (+3.50), then the patient will have lost the
mid-range focus which was present through the top of the underminused old
glasses and will not be able to see in that range, through either the distance
correction or the bifocal. Again, this is a time to consider trifocals.
Incorrectly matching the spectacles to a patients occupational or
recreational needs generates many complaints. Computers and bifocals were not
invented in the same century and the ergonomics of computer desks leaves much
to be desired if you are a presbyope. Patients may need trifocals (with or
without a large middle segment), a separate pair of glasses for desk work with
bifocals set higher than usual, or a pair of bifocals in which the top has a
prescription for the distance of the monitor and the bottom for the reading
position. Many golfers cannot use bifocal or progressive lenses on the links,
where they may have trouble focusing when addressing the ball." They
still need to be able to read the distance to the green or to keep score, so a
very small bifocal set low in the frame may be ideal.
When the prescription seems accurate but the patient has complaints, the
source may be the lenses in the frame. If the optical centers were not
positioned correctly before the line of sight, the patient may have diplopia or
asthenopia from induced prism. Such misplacement may also cause reading
problems if the eyes are too close to the edge of the bifocal when reading or
outside the functional zone of progressive lenses. The author marks at the
lensometer the spectacle optical centers and measures the interpupillary
distance on all patients returning with complaints about their glasses.
Changing the base curve or center thickness of spectacles can produce
asthenopia. One must maintain a high level of suspicion to avoid missing such
cases. It should be standard practice to measure these parameters on the old
and the new glasses.
With a change of astigmatic correction, especially a change of axis,
some patients will experience a tilting of the environment upon first using the
glasses. The greater the change from the old glasses to the new, the more
likely a patient will be aware of this symptom. This seems to be the result of
sensory adaptation to the retinal correspondence of the distortion in the old
glasses, and a subsequent lack of adaptation to the retinal image of the new.
In most instances, continued use of the new glasses results in satisfactory
adaptation, and the world seems correctly proportioned. In fairly rare
instances, it is necessary to prescribe less than accurate spectacles with the
same astigmatic correction as the old glasses or a partial change toward the
new refraction result. When doing so, it is wise to maintain the spherical
equivalent found in the new refraction.
Many complaints are related to the bifocal in the glasses. The bifocal
line may be too high, causing problems with distance vision or awareness of the
blur from the bifocal when looking straight ahead. It may be too low, making it
impossible to use the reading area effectively. This is a frequent problem with
progressives, but may be present with any bifocal style. While the standard
bifocal position is at the lower lid, the best bifocal height is the one that
satisfies the individual patient. Some patients may keep their chins high and
would find a bifocal at the lower lid in the way of distant vision, whereas
others prefer the seg 6 mm to 8 mm below the lower lid. Generally, a good
history and observation of the patient will direct ones attention to
these problems, which may be resolved by adjustment of the frame or a
For some patients, the choice of progressive addition lenses is a poor
one, and they may never adjust to the need to turn the head to view targets or
to the small reading area. One must be specific in prescribing other bifocals
for these patients. Senior citizens who have used flat-top or round bifocals
for many years seem to have the greatest problems changing to progressives.
Myopes in the -1.50 D to 3.00 D range also are not as likely to use
progressives with full satisfaction. While they often adapt well to driving and
shopping in progressive lenses, a majority remove the glasses for reading to
avoid the constricted reading field the progressive lenses inevitably
Faces are rarely symmetric on the two sides, but the importance of this
in spectacle comfort is too often missed or ignored. When a patient looks like
the gentleman in Slide 15, glasses problems are a real
possibility. The optical centers would be off the visual axis on one of the
eyes, unless the optician was acute enough to have noted the mild facial
asymmetry and placed the centers at different heights in the two lenses to
match the eyes. Without such compensation, the person with single vision lenses
may have blurred vision, asthenopia, or diplopia from induced prism, while the
bifocal wearer would see above the seg with one eye while looking through with
the other or even may experience monocular diplopia if one eye is looking
through the seg line. A good way to find facial asymmetry is to mark the
optical centers of both lenses and then have the patient fixate on a muscle
light or penlight as the chin is slowly raised. As the eyes meet the optical
centers or the bifocal line in such glasses, the asymmetry will be obvious.
Slide 15. Mild orbital asymmetry. Ruler highlights
the 2mm difference in vertical ocular position.
Anisometropia is a frequent cause of spectacle complaints. The
aniseikonia or anisophoria induced by the spectacle correction is a problem for
Video 1. How to measure optimal reading
Video 2. The use of the accommodative ruler to
measure accommodative amplitude.
A rare but important cause of complaints is unequal accommodative
amplitude. If a patient is a bifocal wearer (usually 40 to 55 years of age),
this problem should be found when the optimal reading position with his or her
old glasses is determined to be significantly asymmetric (Video 1). Since accommodation is most often expressed
equally in the two eyes, an asymmetric reading point would indicate the
presence of significant change in the refraction a hyperopic shift in
the eye reading farther or a myopic shift in the one reading closer. If the new
refraction does not find this change, then one must suspect asymmetric
accommodative amplitude and measure accommodation of each eye with an
accommodative ruler (Video 2). In the pre-presbyope, one
must simply maintain a high level of suspicion and measure accommodation
whenever there is reason to suspect problems. Whenever asymmetric accommodation
is found, look for a cause. It may be the result of a childhood viral disease,
long-forgotten trauma, uveitis, systemic disease such as diabetes or multiple
sclerosis, Adies tonic pupil, uncorrected hyperopia or overminused
spectacle lens. A cycloplegic refraction will often be necessary, but if the
cause were not found in the eyes, a referral to the internist would be prudent.
If the accommodation is asymmetric, the solution should be too. While
prescribing one bifocal or asymmetric bifocals goes against the grain of our
normal habits, it is the best way to make these patients see comfortably.
Second only to maintaining good relationships with patients is a
refractionists relationship with the optician. If you are dealing with an
experienced optician, it is much more likely that a patients problems
result from errors you made with the prescription or from unavoidable problems
than from optician-related causes. But the optician must generally bear the
costs of remaking spectacles when there is a problem and refractionists should
bear that in mind when talking to patients about the problems. We benefit from
the generosity of the opticians as well as from their expertise, which prevents
many of these problems before they occur.
Successfully resolving our patients complaints is our goal in all
we do, and achieving that goal is a worthy use of our time, whether in the
operating room or in the office. Caring for the dissatisfied patient is
time-consuming and emotionally challenging, but it may result in more
functional improvement in the patients life than many of our other
activities, and it certainly confirms for your patient the interest you take in
his well-being. Solving your patients spectacle problems is good for for
both of you.