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Most optometrists are a long way from wanting to delegate refraction to technicians, although some of our colleagues are
reconsidering that position. I'm not here to recommend one approach or the other; I think there are advantages in having
the doctor perform that task, and advantages in delegating it. It's a matter of personal choice. In practices where the
OD does the refraction, however, there are several ways to make the process much more efficient, and I'm a strong believer
in that. While not actually delegating refraction, you may consider these tips as Tech-refraction Lite.
You can shave many minutes off your average exam time if you incorporate these delegated procedures into your routine.
The Phoroptor (refractor)
Editor's note: The word phoroptor is actually a trademark of Reichert (formerly American Optical), but I use it here because
it has achieved such common usage in our vocabulary. It's kind of like Kleenex as a word for tissue.
In many offices, the phoroptor is an instrument that is only touched by the doctor. That need not be the case. Technicians
in my practice prepare the phoroptor for the doctor as they get each patient seated in the exam chair. This means they wipe
the facial plates with an alcohol swab and then dial in the habitual spectacle Rx. Having that Rx in place may seem like a
small point, but try it and you'll see that it really makes a difference.
Back in the day when we did retinoscopy on each patient before the subjective, the retinoscopy result became the starting
lens. I'm sure I'll hear from colleagues who still routinely perform retinoscopy, but in my view, technology has made the
instrument unnecessary for most patients (not all).
It should be noted that digital refracting systems automatically take care of several of the issues described in this
article, by electronically integrating a phoroptor with a lensometer, an autorefractor, and even with the acuity chart.
But practices with standard phoroptors can still gain excellent efficiency.
Tips for having the tech dial in
Visual acuity chart
- The habitual distance Rx, as read by lensometry or taken off patient records if your office made the present glasses,
is the best place to start.
- If there is no previous Rx, my techs are instructed to dial in the autorefractor result.
- Starting with lenses near the patient's refractive error makes the subjective tests go easier.
- You can still use fogging techniques, but it doesn't take many clicks to know where you are.
- Patients feel good being able to see when the phoroptor is initially placed in front of them.
- It's helpful for you to know what acuity line the patient can see as you start (you know because VA was already taken
with the habitual Rx).
- I like to focus on the patient and the case history as I start the exam and I don't like to be distracted by having to
fiddle with the sphere, cylinder and axis.
- Teach your techs that red numbers mean minus and black means plus.
- Teach your techs to not spin the dials too quickly and to use care with the instrument.
- Teach your techs the concept of the habitual Rx. If a patient wears +2.50 reading only glasses, you don't want to start
with that in the phoroptor. But if they are +2.50 hyperope, you do want to start with that.
- Teach your techs to clear all occluders and auxiliary lenses.
Technicians are perfectly capable of measuring visual acuity accurately, and it's a major time saver, yet many ODs still do
it themselves. Try delegating it. It's an easy test to add as your assistant gets the patient ready. Consider these staff
- Review the concept of the habitual Rx again, and only have VA taken with the proper Rx.
- The technician should face and watch the patient as the letters are read. I prefer to hold the occluder for the patient,
rather than try to instruct them on what to do with it. It's helpful if you use a mirrored exam room and can see the chart on
the wall behind the patient.
- Teach your staff to change the letters after one eye is occluded to avoid a binocular sneak-peak.
- I like to use single lines, start easy and jump down quickly.
- Record plus or minus letters when appropriate.
- Change the letters for the second eye to avoid memorization factors.
- Computerized acuity programs displayed on a flat panel monitor are fantastic.
- Take nearpoint VA with proper working distance and good lighting.
I've found standard lensometry to be one of the most difficult tasks to master for technicians - but they all must be
proficient at it in my practice. Autolensometers are great if you have them in enough locations, but I still like techs to
be able to read a lens and understand the number line concept. It helps them understand lens powers.
Don't let staff training and practice stop you from delegating the task of lensometry. It's too time consuming and too
expensive for the doctor to do this procedure on a routine basis.
Autorefractor and autokeratometer
These simple to perform pre-tests provide a wealth of information and make the subjective a snap. I have a blank space on
my exam form where the printout can be taped in place.
Contact lens refractive tests
Technicians can perform several refractive tests for the contact lens patient, during the fitting process and in follow-up care.
Since most astigmatism is corrected with the contact lenses, there are many cases where only a spherical subjective
over-refraction is needed. This test is easy for technicians to do. Just fog them up and bring them down to BVA,
Technicians can also perform an objective autorefraction over diagnostic contact lenses, for an approximate idea of the
level of correction. Coupled with visual acuity with contacts, as measured by the tech, the doctor gains a very good idea
of the final contact lens Rx at a glance.
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
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Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.
Please Note: The views expressed in Management Tip of the Week do not necessarily reflect those of the sponsor.
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