medications, antidepressant use, systemic conditions that reduce mobility, cardiac problems, etc.) or who may be more dependent on their vision for balance control (patients with somatosensory system dysfunction such as diabetes and/or peripheral neuropathy; or those with vestibular system dysfunction, such as Ménière’s disease):

1.Do not prescribe multifocal lenses (progressive addition lenses or varifocals, trifocals and bifocals) unless they have successfully worn them previously. Multifocal lenses double the risk of falling (Lord et al. 2002).

2.Established multifocal lens wearers should be prescribed single vision distance lenses for walking outside the home and when using stairs, etc. Multifocals should only be used for other tasks such as watching TV or driving.

3.Avoid prescribing significant changes (greater than 0.75 D) to the refractive correction as this can lead to an increase in falls in older patients (Cumming et al. 2007).

4.24.6 Most common errors

1.Changing the spectacle power, particularly the cylinder power or axis, of a patient who was happy with the vision in their old spectacles but just wanted a new frame.

2.Prescribing the refractive correction found with subjective refraction without consideration of the change in prescription or the patient’s symptoms.

3.Not offering a patient who has no change in prescription the possibility of changing their frame and/or lenses.

4.Prescribing a low-powered prescription to a patient with no symptoms.

5.Not offering spectacles as a diagnostic tool to a patient whose symptoms you are not sure are caused by ametropia or a decompensated phoria.

6.Prescribing multifocal lenses or making a large change to the refractive correction of elderly patients at high risk of falling.

4.25 COUNSELLING

A small section regarding counselling is included here at the end of the refraction section, as many of the points made relate to ametropia and its correction.

4.25.1 Cause of the chief complaint

1.At the end of the examination, you must discuss your findings, particularly those that relate to the patient’s chief complaint and other secondary complaints. What is the cause (if known) of the chief complaint? Give a full explanation of the diagnoses in lay terms, unless your patient works in the medical field and has some knowledge. It can be very useful to have a cross-sectional diagram of the eye to help you in this explanation.

2.Make sure you go back to the case history and try to explain each of the patient’s symptoms.

3.It is generally best to discuss your findings in order of the patient’s relative importance of their problems rather than your own opinion of the relative importance of the diagnoses.

4.25.2 Reassurance

1.If the cause of the chief complaint or other problem is not determined, then indicate to the patient what conditions you have not detected (Blume 1987). For example, if a patient’s chief complaint was headaches and no oculovisual reason could be found on examination, present your negative findings in a positive manner: ‘I do not believe that your headaches are due to a problem with your eyes or vision, Mr Smith. Your eyesight is excellent and there is no need for glasses/ change in glasses; your eye muscles and focusing muscles are all working normally and are working well together and there is no sign of eye disease from any of the tests that I have performed.’

2.In all such cases, always indicate to the patient that they were correct in attending for examination (Blume 1987).

4.25.3 Treatment options

1.Discuss with the patient possible treatment options and whether referral for further assessment or treatment is necessary.

2.Be wary of overestimating the importance of price to patients and include a discussion of the highest specification (and usually most expensive) lenses. A report of a small sample of UK optometrists indicated that some omit discussion of the highest specification of lenses due to overestimating the importance to patients of price (Fylan & Grunfeld 2005).

3.Explain when the patient should wear spectacles. Do not assume that the patient will understand when to wear them. For example, if a patient’s chief complaint was distance blur when driving, it may not be enough to indicate that they should wear the glasses for driving and assume they understand that they can wear them for any other distance vision task. Indicate that the glasses could be used for TV, cinema, and theatre, watching sports and when walking about outside if the patient wants to wear them for those tasks. In this regard, it is very important to inform a patient who drives without spectacles whether they are legally allowed to do so.

4.Possible problems with the treatment: For example, if making a relatively large change in refractive correction, warn the patient of possible adaptation problems. This is most important when making any cylinder changes, particularly with oblique cylinders. Take note of a patient’s previous reaction to refractive correction change. It is better to overestimate the time that adaptation will take rather than underestimate the time.

5.It is useful to have information booklets available to explain the ametropias and the various treatment options available.

4.25.4 Prognosis

Explain what is the likely prognosis of the patient’s condition(s). For example:

1.Explain what symptoms should disappear with the spectacles and over what time period.

2.If appropriate (e.g. early myopes and presbyopes), explain that progression is expected, and why. Advise young myopes that wearing their spectacles will not make their eyes worse, it just gives then clearer vision. Also, the patient should know that not wearing their spectacles will not make their eyes worse.

3.Explain that a gradual reduction in unaided vision is expected in hyperopia with age. It is very common for hyperopes to conclude that the glasses ‘ruined their eyes’ when their accommodation gradually declines and they need their spectacles more and more often.

4.25.5 Next appointment

1.Finally, indicate to the patient when you would like to see them again.

2.If this is less than a standard time (typically 2 years or 1 year for children and the elderly) explain why.

3.Always inform the patient that if they have any problems with their vision or their eyes before that time, they should make an appointment to see you.

4.25.6 Most common errors

1.Using technical language and jargon to explain diagnoses and treatment plans.

2.Not explaining to myopes, hyperopes and presbyopes the likely progression of their condition.

3.Not explaining to patients when they should wear their spectacles.

4.Not warning appropriate patients about possible adaptation problems.

4.26 BIBLIOGRAPHY AND

FURTHER READING

Benjamin, W.J. (2006) Borish’s Clinical refraction, 2nd edn. St Louis: Butterworth-Heinemann.

Carlson, N.B. and Kurtz, D. (2004) Clinical procedures for ocular examination, 3rd edn. New York: McGraw-Hill.

Eskridge, J.B., Amos, J.F. and Bartlett, J.D. (1991)

Clinical procedures in optometry. Philadelphia: J.B. Lippincott.

Grosvenor, T. (2002) Primary care optometry, 4th edn. Boston: Butterworth-Heinemann.

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