By Dr. Palmer R. Cook, OD
Remakes are a huge problem for everyone in the ophthalmic industry—including the consumer. Remaking eyewear is expensive and time-consuming. It shakes the confidence of patients. It’s milk turned sour, a situation gone south, a turn down a rocky road. Promoting the idea, “If it’s wrong, we’ll make it right,” begs the question, “Why did you give me something that was wrong in the first place?” Diagnosing the cause for dissatisfaction when a patient returns is the key to avoiding remakes, both for the patient-in-distress and for your future patients.
REMAKES ARE DISRUPTIVE, UNPLEASANT AND COSTLY
Coping with an angry, upset or even a “just disappointed” patient is not a pleasant experience for anyone. Whether you are the doctor, the optician or a staff member at any level, it’s disruptive and unpleasant. Although it might not seem so, it’s a rare patient that takes satisfaction in calling or returning to your office for purposes of lodging a complaint or launching a tantrum.
For a few, dissatisfaction and complaining is a way of life. For others, disappointment with the outcome of their eyecare and eyewear is distasteful so they simply don’t return—ever. For them, venting to friends, family, co-workers and anyone who will listen is their method of relief and sometimes revenge.
The root causes for remakes lie in a failure (at least in the patient’s perception) to satisfactorily meet one or more of four basic expectations. Your patients expect to: 1. See well. 2. Look good. 3. Be comfortable, and 4. Perceive high value when they purchase new eyewear. Successfully meeting these basic tenets is the sure way to avoid eyewear remakes.
SIGNS AND SYMPTOMS
“I can’t see through these things. They just aren’t right. Everything tilts. It’s hard to walk in them. These aren’t the frames I picked. They slide down all the time. I have to hold things too close. They are too heavy. They make my nose hurt. I can’t read signs on the freeway until I get close to them. There’s something wrong, but I don’t know what it is. My old ones had a tint and these don’t. They give me headaches. My eyes feel strained. I don’t like how I look in these (translation: Someone said I don’t look good in these).” These comments are all common “chief complaints” that can turn you too quickly to remaking the eyewear.
It is unfortunate, but true, that some of the above complaints are frequently accurate, and their causes, if recognized, could be easily corrected. Others poorly represent the real causes for the distress the patient is experiencing. Whether the causes are easily apparent or not, the patient’s distress is legitimate and should be correctly addressed.
The first step is to relate the complaints to signs and symptoms. Signs are what you see. Red pressure marks behind the ears or on the nose are signs. Failure of the frame to stay in place is a sign. “I can’t see” is a complaint until it is verified. Once verified, it becomes a symptom. Occasionally a patient will fail to read a Snellen chart when retested with the new eyewear, but after some refractive testing, the chart is successfully read using trial lenses with exactly the same powers. An appropriate question at this point would be, “Do you think if we changed the frame, you would see better?” An affirmative answer doesn’t necessarily mean that a frame change would successfully resolve the problem, but it is a strong indicator that points toward a failure to satisfy either, “looks good” or “high perceived value.”
An accurate diagnosis is not always possible when dealing with potential remake problems, but a successful resolution is less certain without it. When complaints are supported by a little investigation, or when signs and symptoms clearly relate to the complaints, the diagnosis is usually easier and more accurate. A stream of apparently unrelated complaints can be a sign of a buyer’s remorse problem, or it can be indicative of a high level of distress. Unfortunately, buyer’s remorse can elevate distress, so you become faced with additional difficulty in sorting out a successful resolution.
Sometimes simple adaptation problems lead to unnecessary retesting, time-consuming investigation and needless remakes. A good rule of thumb is that if the prescription and eyewear design is correct, the most difficult part of adaptation will be over within three days of constant wear, and adaptation will be completely resolved within another seven to 10 days at most. The key points here are the correctness of the Rx and eyewear, and the question of “constant wear.” Because many patients simply try their new eyewear briefly and subsequently complain, sometimes weeks later, it is important to look for indications that they never really wore the eyewear long enough to adapt. Strong indicators are:
- The patient returns wearing their old eyewear and carrying the new.
- The patient complains of feeling taller or shorter in the new eyewear. This is due to a difference in vertical location of the MRP (Major Reference Point) between the old eyewear and the new. It is an effect that rapidly resolves, so its stated persistence indicates that the new eyewear has not been worn for more than a few hours at most.
- The patient complains the floor in front of them seems “humped up” or “scooped out.” This is a prism effect and is slower to pass, and may be more common if the index of the new lenses are different than the index of the old. Check for an incorrect Rx PD (Pupillary Distance), unwanted prism, excessive frame wrap and base curve changes. If the effect does not significantly improve after three days of constant wear, a recheck of the refraction is indicated. These effects are more common and resolve more slowly with elderly patients.
- Blurring of distance vision at first, especially when the plus power has been increased in patients under 50, is common. Check for excessive or unequal vertex distances and MRPs placed too high or too low.
- “Reading material must be held too close” is a complaint commonly associated with an increase in plus power at near. Shortening the vertex distance at near by increasing the pantoscopic tilt may help. Suggest that more illumination should be used for reading for a few days. This increases the depth of field, giving immediate relief, and it promotes faster adaptation.
- Patients who complain that they must move their heads to read across a line of print also benefit from temporarily increased illumination for reading. Recheck the patient’s PD and the placement of the MRPs, and be sure the vertex distances are equal at both distance and near. Changing the pantoscopic angle may help. Sometimes this problem arises from holding near work too close. In such cases, adaptation will tend to resolve the issue.
- If the patient wearing progressive lenses is doing fairly well at distance and near, but has problems at intermediate distances, be sure the vertex distances are equal and check the location of the near reference points. Patients with excessively long or short vertex distance are prone to these problems. Using digital lenses in designs that require wrap, vertex and pantoscopic measurements may help. Using a target at intermediate distance and occluding one eye while instructing the patient to “find the corridor” by moving his head, then repeating with the other eye occluded may be a helpful training exercise.
HEAD ‘EM OFF AT THE PASS
Some effective ways for eliminating the issues that lead to remakes include:
- Use a penlight to check your refractor lenses, your Risley prisms and your flip-cross cylinders regularly. Like “testing” wet paint, some patients find the temptation of probing your refractor with a finger to be irresistible. Smudged lenses prolong testing, confuse patients and lead to errors in prescribing.
- Cleaning and recalibrating your refractors (especially the prisms) should be done annually. Spot cleaning of smudges should be done as needed.
- Be sure your patient is not tilting his head as you refine your cylinder axes. Patients want to help, and with strong cylinders they sometimes discover they see better if they tilt as you test. This assistance can lead to Rx-ing cylinders at incorrect axes and all the problems attendant thereto including: “Things seem to be tilted,” “My eyes are uncomfortable,” and “Things just aren’t clear at any distance.”
- Demo new prescriptions, at distance and near with trial lenses at the end of the exam. When adaptation or other problems arise with new eyewear, the recollection of how clear things were with the trial lenses is reassuring and motivating. Doing the same demo with the refractor is less effective.
- For patients who are uncertain during frame selection, invite them to return with a family member or friend for the final decision. Order in “special frames,” and suggest patients can return in other attire to be sure before making their decision.
- For patients who are overly cost-concerned, talk about benefits and choices. Discuss their individual needs and solutions. Focus on what will benefit them and why. Stick to facts, don’t over explain or over promise. “The doctor says” is a powerful statement (e.g., “The doctor says a prescription like yours works best with low reflectance lenses,” or “The doctor says a frame with more depth will give you better vision,”). Relating “the doctor says” to the patient’s needs and outcomes can be helpful.
- Poor outcomes and remakes are sometimes the result of patients controlling decisions that are beyond their knowledge and understanding. Don’t be afraid to say “No.” This may save you a lot of time and trouble in the long run. Surprisingly, most patients respect an emphatic “No.” Perhaps this is because it reminds them that you are the professional in the interaction.
Trial Lens Demos Are Important
For PAL trial-Adds, mark the 180 line with an indelible marker. Put the “center of pupil” location several millemeters above the geometric center of the lens so that the patient can easily experience the Add when the trial-Add lens is in the furthest back cell of the trial frame.
Fitting the single vision new prescription into a trial frame is quick and easy. Do it while you are doing your post-exam consultation. The sphere should go closest to the eye, especially for strong Rx’s, and be sure the lenses are not smudged. Setting the PD is important!
For first time bifocal, trifocal and PAL wearers you can insert a trial-Add in the most posterior cell of the trial frame. Trial-Add lenses should be on a flat base curve. If possible, have your lab make them up in chem-tempered glass. The carrier portion of the trial-Add lens should be plano and the Add should be decentered in 1.5 mm in each eye. A set of trial-Adds with several Add powers is needed for effective demonstrations. Select your progressive design with a medium to long corridor for demonstration purposes, and use a permanent marker to ID the R, L and the peripheral locations of the 180 meridian on each progressive trial-Add lens.
Buyer’s remorse is a pervasive problem in our industry. Post-dispensing remakes involve some degree of buyers remorse in every case. Patients, uncertain about their own performance during subjective testing, sometimes refuse needed lens and even frame technologies because they want to limit their risk with the new prescription as well as avoiding buyer’s remorse. Their refusal can lead to a sort of self-fulfilling prophecy. Such situations should be sidetracked by a careful discussion of needs and benefits. Buyer’s remorse is exacerbated by the fact that all eyewear looks pretty much alike to those outside the industry. Worse yet, the purchase of eyewear is a major expenditure for many, and purchasing eyewear is so infrequent that most do not budget for it.
The most effective tools in dealing with buyer’s remorse include stressing benefits instead of cost at the time of frame selection and at dispensing, and including the doctor’s expertise in the eyewear design process. The doctor should include some commentary about frame and lens choices as a seamless part of his post-exam consultation. A demonstration of the new Rx in a trial frame will significantly decrease patient uncertainty and hesitance about following the recommendations needed to achieve the best outcome. Another seldom used tool to combat buyer’s remorse is to dispense a personalized case insert with the eyewear detailing their eyewear purchase. Examples of this include multi-wavelength, low reflectance lenses for better optical performance, mid-index material for reducing thickness and weight, impact resistant lenses for protection and rimless mounting for comfort and appearance. All such specialties should note an exact date and dispenser signature.
Ordering a remake without an adequate understanding of the reason for the patient’s dissatisfaction, or to “get the patient off your back,” is often a quick solution that leads to more trouble. Your chance of achieving real patient satisfaction decreases exponentially if the first remake fails. Word-of-mouth gossip such as “It wasn’t right and they had to make other new ones, and they couldn’t get those right either,” is an outcome no one wants.
Patients who experience one or several unsuccessful remakes may simply go elsewhere. The fact that a patient doesn’t return in a few days is no assurance that success was achieved. The damage to the reputation of your practice caused by such patients may be substantial and hard to correct. Patients who don’t return after you have addressed their problems with re-alignment, encouragement, explanation or a remake need a follow-up. It’s part of your professional responsibility as well as a way of protecting your reputation.
Dr. Palmer R. Cook, OD, is director of professional education at Diversified Ophthalmics in Cincinnati, Ohio.