Not Just Surviving, But Taking Charge

By Barry Santini & Palmer Cook, OD

In a pressure cooker economy, it’s more important than ever before to be sure that every “i” is dotted and every “t” is crossed. Mistakes cost a practice money and reduce patient confidence and satisfaction. So, be sure that the measurements taken for patient’s eyewear are right the first time and counsel patients when they want to use the frame that they’ve been wearing for their previous prescription or even one that is even older.

Historically, a down economy has, in the past, seen an increase in the time patients wait between new pairs of eyewear and an increase in the use of a previously worn frame. In this educational series, we examine teachings from the Lenses & Technology section of 20/20 magazine.

THE SUBTLETIES OF BETTER HEIGHTS AND PDS

Take measurements and check them for accuracy. If there are fewer patients spend more time with each. Make them feel special and learn what problems they’ve had with the current eyewear that you can fix.

HEIGHT

Become millimeter sensitive. To understand this, pick a frame that has a minimum eye wire profile width of 1mm at the top of the frame. Then fixate your eye on a line of text on a computer. This works because the distance from you to the computer screen is approximately equal to the distance from your client when taking height measurements.

Try superimposing the frame’s top eye wire over a line of single-spaced text and then tilt your head up or down to just clear the eye wire above or below the text line. Note that the amount of head movement, up or down, required to clear the text line approximates 2mm at the vertex of most eyewear. Note how little your head needs to tilt during this test to change the height and use this awareness when measuring heights or verifying pupil height-related lens adaptation problems.

ANSI also allows 1mm of tolerance for manufactured eyewear so to become more exact, order fitting heights to the nearest 0.5mm. This ensures the most exact eyewear to your measured specifications including ANSI tolerance.

For progressives, order them at dissimilar heights, exactly as measured, to the nearest 0.5mm. For flat tops, be sure they are high enough for easy access and low enough to not be in the way when walking or driving. Remember, height is task related. To test the height, consider masking the segment height with scotch tape. Fit lenses for the way patients will use their lenses most.

PDs

Here is a measurement we often take for granted. Notwithstanding the improved precision and accuracy when using a corneal-reflection pupillometer in place of a PD ruler, ECPs should be aware of potential parallax related fitting errors. To illustrate this:

First, try taking three or four PDs in succession from one client. Now, prompt the client to help stabilize the measuring process by holding their end of the pupillometer as if they were “holding a binocular.” Repeat this measurement technique three to four times. Compare the results. When the client also holds the pupillometer, the measurements include a patient’s posture, which are more stable and involve the patient personally. This personal action is an important contact point that demonstrates how personal eyecare should be. Otherwise, it suggests that it may be just as easy to follow instructions on a web site and order your glasses there.

Additionally, retake a new PD every time you order new eyewear, even if the client is an adult. Even though we assume normal physiological eye growth has usually ceased by age 25, recent studies suggest that the “distance between the eyes” increases as patients’ age. So, take a new PD every time.

FABRICATION AND HUMAN ERRORS

Checking eyewear orders for accuracy can seem like an unrewarding consumption of your time. Lens adaptation problems arising from failure to perform due diligence regarding order compliance poses the greatest potential for embarrassment i.e., when you try to explain how errors occurred after the fact to your client.

Whether mistakes are from the written prescription, your own office work order or order you sent to the lab, it is always easier to accept what’s been written than taking the time and trouble to check if the information actually is complete or makes sense.

Check and confirm if an Rx change corresponds with the client’s vision complaint or expectation. ECPs should be particularly on guard about the ease with which twos and sevens and fives and twos can be confused or illegibly written. Finally, there are the errors that often occur in rush-jobs, where the need to “get it out” trumps the need to “get it right.” When addressing these situations, the time we neglected to spend ensuring proper fabrication initially is now due.

THE PSYCHOLOGY OF OPTICS

It is not uncommon to find clients with a previous Rx that was 0.75D weak, scratched and misaligned, to be especially fussy about just how well they see with their newly updated, unscratched and well-fitted new eyewear. It is also interesting to see some people who don’t complain about wearing an older, out of date, 20/50 correction, seem particularly sensitive to their new eyewear not yielding a full 20/20.

The closer patients get to optimal retinal contrast, whether from a careful refraction or clean, unscratched and newly AR-ed lenses, the more they’ll notice small deviations in perfect sharpness. There is an adaptation phenomenon that I call “one more bite.” Who hasn’t enjoyed a large meal and subsequently feels uncomfortably bloated from taking a small bite of dessert? In most cases, the size of the actual bite is small. The stomach upset that followed seems out of proportion to the extra amount eaten.

Eyewear prescriptions can have a similar effect. We often puzzle how a change of just 0.25D can make some patients feel significantly nauseated. But if said small change mimics the “one more bite” phenomenon, it can produce uncomfortable effects for some people that are inconsistent with the amount of Rx change. ECPs should be sensitive to these types of vision-overload symptoms.

NEW LENSES, OLD FRAMES

Patients who recognize the cost of their eyewear is realistic compared to the value received, tend to be especially appreciative of the care provided. However the uncertainty of today’s economy may cause patients to focus increasingly on eyewear expense. Occasionally, in their zeal to reduce costs, which is not necessarily a good way of achieving a good cost/value ratio, the patient may become locked in, fixated upon and totally convinced they want their new lenses mounted in their old frame. This idea can be as hard to remove as an unwanted tattoo. Patients can be hardheaded on this issue, in part because they suspect your insistence on not using the old frame is based on increasing your own profit. Few of them realize the problems that can arise from using that old frame.

In fact, using an old frame for new lenses is an odds-on favorite for eventual trouble. Even if the old frames have an up-to-date appearance, they will age faster and look ever more out of date during the life of their new lenses. If the old frames are discontinued, the patient needs to realize that if they break, their new lenses may not fit available frames. The patient needs to know that if the frame must be heated to remove the old lenses and then reheated to insert the new lenses, there is an increased likelihood the plastic will become fatigued sooner and subject to splitting, cracking or breaking. If the patient can’t give up the old eyewear to send to the lab, then the lenses must be removed for frame tracing and re-inserted an extra time. This also raises the question of what the patient has for “spare eyewear.”

ATTENTION: RXING DOCS

If you are the prescribing doc, don’t be too quick to say, “Oh sure, I think we can use it again.” Once you have made such a fateful statement, it becomes as though it were set-in-stone in the patient’s mind. A better answer is, “Let’s have Judy out in optical check to be sure it is not discontinued. That way if it breaks, we have a better chance of getting a replacement for you.” If possible, the doctor should try to be an ombudsman if there is a difference of opinion between the patient and the optician over using an old frame.

STRUCTURE FOR SUCCESS

Giving a written warranty on eyewear is a great practice builder that is too often overlooked. A written warranty program builds perceived value with all your patients, not just those who only discover you stand behind the eyewear when they return for parts, repairs or replacement. A written warranty should only be issued for complete new eyewear. Patients who want to order lenses for an old frame should understand that lenses alone cannot be warranted.

Another way of structuring for success is in frame pricing. You may want to price your frames so you can offer a percent off the frame cost if frames and lenses are being purchased at the same time. This encourages the patient to make a single transaction that gets him new eyewear, leaves the old eyewear for spares, lessens the risk for frame breakage after a few months and reduces the number of times you must deal with replacement of old and broken frames. It also gives the patient a new frame that can be better adjusted. Sometimes old frames become misaligned and then, because the frame material is fatigued or dried-out, they cannot be kept in good alignment. An alternative pricing option would be to offer a percent off new lenses if a new frame is purchased at the same time.

Use a pre-exam questionnaire or a pre-eyewear design questionnaire if you are an optician, which asks about problems of eyewear alignment and fit. If the patient indicates problems with the old eyewear, you may wish to remind him of that when the question of using the old frame is brought up.

EVALUATE THE EYEWEAR

A careful evaluation of patient’s eyewear should be a part of data collection. Is the eyewear current or discontinued, is the plastic dry, brittle or cracked, are parts missing, are the hinges worn and loose, are metal parts eroded, corroded or fatigued? Equally important, are the lenses scratched? Front surface scratches can decrease the impact resistance of glass and standard plastic lenses by 20 percent and back surface scratches can decrease impact resistance by as much as 80 percent, according to “System for Ophthalmic Dispensing, Third Edition” by Brooks and Borish.

A discussion of the patient’s present eyewear and needed changes is an appropriate part of post-exam consultations. Patients deserve professional attention in this area.

THEY’RE IN LOVE WITH IT

Occasionally a patient will cling to an old frame no matter what. This may happen simply because the patient received a “My, my, how nice you look in those,” compliment when the eyewear was new years earlier. Often the same patient who is in love with an out-of-style frame is also the one who still has the same haircut style he had in high school decades ago or perhaps she also still clings to the poodle skirt or other clothing styles of yesteryear.

Another reason patients, most often the elderly, want to keep their old frame is because their circle of friends watch one another for signs of “slippage.” The need for new eyewear can be several clicks downhill in the minds of these “friends.” This is especially a problem if all the patient recalls from your recommendations is, “The doctor says I have to get new glasses.” Recognize that older folks spend a lot of time talking about their own health and the health of others. Patients may want to disguise their need for a new lens prescription simply for social reasons, but social or not, those reasons are important to them.

WHAT YOU SAY —
IT’S IMPORTANT IN MANY WAYS

Why not give patients something good to say as long as it’s the truth? “The doctor said my lenses don’t have to be so strong” or “The doctor says my astigmatism correction has decreased” or even “The doctor says my pupils are young (i.e. large) for my age, so my new lenses are going to adjust to the light (e.g. photo-chromics).” When you give your patient something to say, it should be true and it should be short and easy to repeat. Even patients who must receive bad news such as, “Your eye pressure is too high” or “Cataracts are forming,” will remember and appreciate a quotable “good statement” that accompanies the rest of the story.

WHEN YOU SHOULD USE THAT OLD FRAME

No matter what your patient says, he or she will not fully appreciate the problems of using an old frame until the almost inevitable problems arise. But should you decide that using that old frame is in your patient’s best interest, you can avoid some problems and correct others as they come up if you follow a checklist before you order the lenses. It’s an ounce of prevention that could save you and your patient a lot of future problems. Your checklist should be a formulation of the procedure that must be followed if an old frame is to be used.

CONCLUSION

Accuracy and the best practical advice are the building blocks of a terrific business. Be as accurate as possible with heights and PDs, counsel every patient that wants to use their own frame of the potential issues, every patient appreciates the best of care.