Melissa Valdellon

How to manage a difficult refraction

One of my students recently brought up a good case of discussion. She was working with a 65 year old Asian female who came in for her annual exam reporting that her vision was not as clear anymore.

She had last come into our clinic in 2021 and due to cataracts, was best correctable with the following:

OD -3.00 -0.50 x 060  20/40
OS -1.25 -0.75 x 120  20/50

This is in comparison to refraction results from 2019:

OD -4.00 DS               20/40
OS -0.75 -1.75 x 120  20/40-2

Both times, she’s been noted to have moderate mixed cataracts in both eyes but she wasn’t ready to pursue cataract surgery.

When she came in for this year’s exam, however, she was wearing something completely different:

OD plano -2.00 x 090  20/200
OS plano -2.00 x 093  20/50

The student also did auto-refraction before bringing starting her refraction and got this:

OD -5.00 DS
OS -3.00 DS

Afterwards, the student let me know that with all the different data, she didn’t know where to start her refraction so she had started with a random one and tried to work with them all to see if she could get anything better.

Her final refraction ended up being:

OD -5.00 -1.00 x 120  20/40–
OS -3.50 -2.50 x 156  20/40–

The patient was told about her cataracts again and she was now ready to pursue surgery since we mentioned that we’d have to change her prescription a lot for minimal gain in clarity.

After the patient left, the student and I discussed how she could have had a smoother refraction, and it relates to simply asking a couple extra questions:

The patient had mentioned her vision was more blurry. Where were things clearest? With the pair of glasses she brought in today, with an older pair she got from us previously, or without glasses at all?

The student recognized how getting this extra info could have directed her to a better starting point for refraction. She already knew that the patient’s cataracts were affecting the best visual acuity for a number of years now and that refraction was unlikely to yield anything better, but it would have saved her time knowing which direction to start from.

I hope this helps drive the point of asking more detailed questions when the data doesn’t make sense. It doesn’t hurt to clarify things in a way to help you understand the patient’s point of view or expectations, and it makes them feel like you’re invested in working with them to find the best solution for their needs. Win-win for all.

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