You were asked for your thoughts on two different non-tolerance cases.
Case study 1
‘After collecting her new bifocals, she returned to the practice the following week complaining of ‘eyestrain and headache’ when reading with the new spectacles. She reported that the symptoms were less severe when reading at home, and that reading her tablet was much easier with the new spectacles. She had no visual complaints regarding the distance vision with the new bifocals.’
This case revolved around the patient with a significant intermediate requirement at work (using the till) for which her new bifocals were likely to be unsuitable. Her new spectacles had an increased addition of +0.50DS but, as often is the case with hyperopes, the distance had a small increased plus requirement too. In effect, this resulted in a 0.75 increase for the near correction which, though fine for evening reading where the working distance was likely to be closer, was also probably the reason for problems resulting from her longer working distances we assume she used in the workplace.
Sensible solutions from you included ‘the main cause would be that the tablet she uses at home is probably at the near working distance which bits would help but when she is in work, her till is at an intermediate distance and the big segment being set for near would be too strong now. Hence why eyestrain worse in work. So to avoid in future, she would be better with varifocals and that occupational needs should be discussed in full and that if the optometrist hasn’t given an intermediate Rx, this should be raised with the optometrist.’
Many considered intermediate single vision lenses for work, other a progressive lens. This respondent gave the following advice – ‘The situation could have been avoided by asking her “lifestyle”’ questions prior to dispensing, for example: what is her occupation? Does she drive? Does she use a computer, tablet? I would have offered the patient three choices during the dispensing process:
- Vocational lenses
- Varifocal lenses
- A single vision pair of intermediate lenses with MAR coating’
Case study 2
‘Mrs CP (51 years of age) attended for a routine eye examination with no visual complaints. However, her spectacle frame was in poor condition and she was interested in choosing a more modern frame design as well as a second pair for work purposes. She was working full-time as an insurance agent, mainly in the field, and was also a car driver.
She was dispensed with two pairs of progressive power lenses which were the same design as she had been wearing previously. Shortly after collection the patient returned complaining of ‘reduced DV and distortion’ with pair two. She had no complaints regarding pair one. On re-checking, both pairs of spectacles were found to be identical. In addition, the refraction was checked twice over a period of time and ‘no change was found’.
The dispensing optician advised that nothing could be found to explain the symptoms with the new spectacles and that a new order would be sent for replacement lenses in case there were any optical lens flaws that could not be confirmed. At this point the patient asked if she could select a different frame as new lenses were being ordered.
This case was a little different in that the main problem appeared to centre on a frame being dispensed which the patient did not like and was reluctant to continue with. Most of you picked up on this well, though a significant number were convinced the problem lay in the technical elements of the dispense rather than the more communication and psychology-related factors. Ensuring the patient is happy with the final product is as important as ensuring all measurements are correct. This was nicely summarised as follows; ‘The tell-tale sign is where once the offer to change the lenses is give, she asks if she can change the frame. There may not have been a major problem with the spectacles, just that she was unhappy with the choice of frame style. As she was being dispensed, the fit of both frames could have been checked to make sure they were okay, and she could have been asked several times that she was happy with the frames, but at the end of the day, if she goes home and her family and friends say they like one pair, but not the other then, it is probably best to let the patient choose another pair.’
Another approach was, ‘due to the patient’s prescription she may not have been able to easily discern her appearance when trying on the frames. Possible ways to help the patient could be to fit a pair of disposable contact lenses of an appropriate power, take a digital photo of the patient, use a magnifying mirror or take a video photo on a computer.’