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I realize that I’m preaching to the choir if I write about how to refract… the collective skill and knowledge
of our readers on this subject is the finest in the world. Nevertheless, in the interest of continuing the
quest for refractive accuracy and efficiency, I’ll share a few ideas that have worked for me. It’s
interesting that the topic of refraction is almost never seen in any of our journals, yet it’s probably the
most frequently performed procedure in our field and it’s the basis for most of the work we do. We all
do it all day; we just don’t talk about it!
As with every aspect of my practice, I think about refraction from the patient’s point of view. The
patient’s experience in my office and the confidence he develops in our services are of paramount
importance. I think the subjective manifest refraction is a little unsettling to patients. They wonder if they
are giving the wrong answers, and will this affect how well they see with new glasses? Let’s face it;
some of the choices we present to the patient are inherently difficult. Many choices are not difficult at
all – but some are, such as adding an extra -.25 D. sphere in a young person, or the axis choice in a JCC
test when the handle is close to the final axis, and there is low cylinder power. These choices will look
about the same, as we all know, and it’s hard for an untrained person to choose, or even describe what
they are seeing, when they’re being asked which choice is better.
So here are few thoughts to consider on refraction:
My goal: To make the refraction fast, easy, pleasant, and of course, accurate – while instilling
confidence in the patient.
Starting point. My technician dials the starting lens prescription into the phoroptor before I even
come into the room. Every few seconds counts when you add up days, weeks or months of patients, and
I don’t want to be distracted from my conversation with the patient to do it myself. My starting lens is the
habitual distance prescription, if there is one, or the autorefraction if there isn’t. I was taught in school to
start the refraction from a position of high plus, and then unfog, but with experience, I learned I can just
fog one or two clicks to make sure I’m not over-minused, and then find BVA with spheres before
proceeding with the JCC.
Communication. I like to keep the instructions simple. I used to give what I thought was an
impressive speech about what I was about to do in this test, but now I just do it instead of talking about
it. Patients aren’t impressed; they just get more confused when you try to make it complicated. I can
provide more explanation if needed as we go along, but a simple “which is clearer; lens #1 or #2, or are
they about the same?” works well.
Easy Snellen line. I like to use a line on the acuity chart that is easy for the patient to see when
I’m giving them choices. I can go to a smaller line to determine the final VA, but the choices are easier to
make if the patient is not straining to see it.
Patience. I think some ODs get annoyed when patients don’t respond perfectly. They may not
even realize the annoyed tone in their own voice – but it speaks volumes to the patient. You’d think
we’d be used to confused patients by now! Many patients have trouble making refractive choices, or
understanding directions. Keep in mind, if the refractive experience is unpleasant for the patient, they
won’t want to return and they won’t refer others. I like to reassure the patient frequently that all is going
well with phrases like: “You’re doing great.” “Some of these choices are easy, some aren’t.”
All the time in the world. While I work hard to make the refraction quick overall by working
smarter on the procedural steps, during the test, I want the patient to feel that I’m in no rush at all.
That’s not a dichotomy – it’s an art that we can work on. A short pause between choices and speaking
slightly slower does wonders.
Reversals. At the end of the refraction, I want my patient to think: “that wasn’t so bad – I think
I did well on that”. Recognizing that the toughest choices are the ones where I am at the end point of
sphere, cylinder or axis, I try to avoid what I think the end point is. For example, if I think the axis is going
to be 80, based on the lensometry and autorefraction, I will set the cylinder axis at 70 when going for axis
with the JCC. If the patient moves me toward 80, I’ll then go to 90 and do the axis test again. If they
move me back toward 80, I’m done with the axis test, and the patient never had to make a tough choice,
which would have occurred had I set the axis right at 80.
Minimalistic. I try to keep the number of lens choices requested of a patient to an absolute
minimum by offering only choices that yield maximum results.
Quick cylinder check. If I think the patient has no astigmatism, but I want to confirm that
subjectively, I dial in .50 D. cyl axis 180, and I use the JCC to test for power at 180. The patient should
choose white dot (on my minus cylinder phoroptor), rejecting the .50 D. I then rotate the axis to 45
degrees and repeat the power test. If I continue to find the cylinder power rejected, I go on to test it at
90 and 135. If the patient ever chooses the red dot at any of my 4 test axes, I know they have more
cylinder near that axis.
Quick over-minus check. There are many good tests to prevent over-minusing, including
duo-chrome, but one of my favorites goes like this. When I believe I’m at the end point binocularly, I say
to the patient, “tell me if the next lens I show you makes your vision worse”. I then add +.25 D. sphere
OU. He should say yes, that he notices a slight blur. It seems very simple, which is the beauty of it.
After asking the patient to always choose the better lens, asking him if a lens makes things worse puts
him in a different perspective, and he can easily judge.
Next time you get one of these classic patient responses, remember to keep smiling!
Doc: Which is better, number three or number four? Patient: Actually, number two was better.
Doc: Can you read that line? Patient: I can read the T, Z, V and L but I can’t see the E or the C.