Subject:  Tragic 3 diopter over-minus prescription -- CONFIRMED.

    What does this do the the refractive STATE of the
fundamental eye?  What happens to a child's refractive
STATE when a child with 20/50 vision
is put into a -10 diopter lens?

    OVER MINUS PRESCRIPTIONS by -1 to -3 diopters!  WOW!
Imagaine what THAT over-prescription does to the refractive STATE
of the eye -- over-time!

Note:  A trial-lens frame and lenses perform
the same function as a phoropter.

Perhaps obtaining your own trial-lens kit would be a
good idea -- to make certain you are not over-prescribed
by -3 diopters.

Just one man's opinion.

Otis

++++++++++++=

Philip F.  Kearney Jr.    O.D.  - Prevent Over-Minusing Your
                Patients

Statement:  "Over-Minusing" Our Patients May Becoming Pandemic

    It is not unusual for an optometrist to occasionally examine
a new patient with visual complaints that were not alleviated by a
relatively new vision correction.  We all see patients who have
been examined within the last 6-9 months who are not satisfied
with their visual comfort.  After performing a complete exam, we
awkwardly find ourselves in disagreement with the prescription or
therapeutic recommendations of the previous doctor.

    While doctors may disagree about what is best for a patient,
especially those that present with complex ocular findings, we all
expect to be within "clinical tolerance" with our optometric
brethren in analyzing and prescribing for the majority of
patients.  As a simple example, I expect to be within an eight or
at most a quarter of a diopter of the "true" refractive error or
Rx when I prescribe glasses or contacts for a myope.

    However in the last five to six years, I personally, and
other colleagues, have noticed an increasing and somewhat alarming
clinical trend.  Patients have consulted me for a second opinion
about their glasses or contacts and I have found a significant
difference from what I would prescribe and what the patient was
actually wearing in their latest spectacles or contacts.  In all
of these instances, there had not been enough time for the usual
one to two year shift in refraction to occur, nor was any
pathology present to account for the differences found.

    Interestingly, many of these cases showed a significant
monocular difference between my refractive findings and what had
been prescribed by other doctors within the last few months for
these patients.  For the most part these have been prescriptions
for myopes - either children or young adults.

    Experienced optometrists are finding significant numbers of
myopic patients who have been overcorrected binocularly by 0.75 to
1.00 diopters.

    We are also finding patients overcorrected in one eye by one
to three diopters of minus.

    I might expect erratic refractive findings in cases of mild
amblyopia, early lenticular changes, mild accomodative spasm, and
divergence fusional anomalies.

    In the "overminused" cases that I have observed, no such
anomalies were present nor did these cases have unusual
phorometric findings that might motivate the previous doctor to
vary the subjective findings to compensate for a high phoria.

    These patients were not unreliable or erratic, young
juveniles who were confused by the refractive methods.    Indeed
they were patients who followed my subjective exam procedures
without any difficulty.

    We all know that myopes like to "eat minus" but that does not
account for such serious overcorrections in one eye.

    I have come to the conclusion that either the doctors were
either in an awful hurry when they examined these patients, or
they may not be as well trained in refractive techniques as
doctors were some 20-30 years ago.

    Upon further inquiry, I discovered that the doctors who
"overminused" their patients were indeed young doctors who had
graduated in the last ten years.

    It is not my purpose to blame or condemn either the doctors
or their graduate schools, but rather to help so many
uncomfortable patients.  We may take this "overminusing"
phenomenon as an indication that all is not well in optometric
education but it can easily be remedied.  All the doctors have to
do is use an old reliable refractive procedure.

    More than twenty years ago, I wrote a brief article
describing a very effective clinical technique that I use every
day during each refraction to prevent my "overminusing" a patient
either monocularly or binocularly.  It is called the "Adding Plus
to Blur Out" technique.

    It is easily done in the following manner.  After performing
retinoscopy, leave each eye with a 0.25 to 0.50 diopter fog (more
plus or less minus).  Reduce the plus or add minus until the
entire 20/20 line can just be discerned.  Then refine the cylinder
and axis, taking care to incorporate minimal cylinder.

    Next, tell the patient you are going to blur out the 20/20
line and she is to report when none of the letters, or only one of
the letters, is discernible.

    Then add more plus or less minus monocularly until the 20/20
line is completely blurred out.  ( If the patient's responses are
uncertain, she should be questioned as to how many letters can
still be read.

    Emphasize to the patient that the first complete blur out is
the end point of the procedure.) Now deduct 0.50 from the
monocular "blur-out" sphere, leaving the maximum plus for 20/20
visual acuity.    Then repeat the procedure on the other eye and
record this finding.  Follow this with a prism dissociation
binocular balance of the 20/25 acuity line.

    After that do a binocular blur out of the 20/20 line.
Binocularly the patient will blur out with more plus than
monocularly.  If you deduct 0.75 diopters from each eye, you will
have the maximum binocular plus that the patient will accept
binocularly for 20/20.

    With the 0.75 deducted from the phoropter, have the patient
now read the 20/15 line.  In many instances, the patient will also
read this line wearing the full plus.  If the entire 20/15 line is
not read, deduct an additional 0.25 sphere to detect any
measurable improvement in acuity.

    If you should have a patient whose best acuity is worse than
20/20, you can use the blur out procedure on either the 20/25 line
or the 20/40 line instead.  The following table contains the
standard monocular and binocular deductions for each acuity line.

Visual
Acuity     Monocular   Binocular
Line     Deduction   Deduction

20/20      -0.50 D    -0.75 D

20/25      -0.75 D    -1.00 D

20/40      -1.00 D    -1.25 D

    Always compare the binocular to the monocular findings; there
is usually very close agreement.  If there is a discrepancy
between the two findings, the binocular findings (more plus) are
always used.  If the patients responses are erratic, blur out more
than one acuity line and compare the net spheres.

    The maximum plus finding is not necessarily, and often isn't,
the final prescription.  When indicated, it should be modified
according to the clinical judgement of the refractionist based on
the symptoms, the case history, the supplemental phorometric data,
and the habitual prescription of the patient.  I have found this
technique to be very reliable for patients of almost any age, for
either cycloplegic or manifest refractions, for hyperopes as well
as myopes.  It permits better patient control during the
subjective refraction, establishes a good base-line from which to
modify the correction and helps to insure that those patients who
need the maximum plus or the least minus for their visual demands
will receive it.

    Recently a 26 year old male presented for a contact lens
exam.  He wore soft disposable lenses during the day and glasses
in the late evening.  He had a history of significant
anisometropia and his older Rx was O.D.  -1.00 and O.S.  -5.00
which he had been wearing for about 3 years.  He had just gotten
new glasses and contact lenses about 45 days earlier at that same
location and was given O.D.  -1.50 and O.S.  -6.00.  He was
getting headaches at work and wanted us to give a second opinion
about his contact lenses.  Retinoscopy revealed less minus in both
eyes.

    The subjective exam confirmed this finding and the patient
accepted O.D.  -0.75 20/20 and O.S.  -2.75 20/20.  The Rx was
trial framed; the patient saw 20/20 monocularly and binocularly
but his vision fluctuated in and out because of long term, induced
accomodative spasm.  He was told about his refractive status and
given temporary disposable lenses of O.D.  -1.25 and O.S.  -4.00.

    These were worn for 10 days with improved patient comfort.
At the second visit, the accomodative spasm had improved so new
lenses were prescribed O.D.  -1.00 and O.S.  -3.00 and these
became the final Rx.

    Six weeks later the patient was seen for a follow-up exam and
reported clear vision at all distances and the absence of
headaches.

    If contact lenses are not being worn, an overminused patients
may temporarily be given a mild cycloplegic to take home with
their "correct" Rx.  One drop may be administered each evening to
break up the accomodative spasm while the newer Rx is being worn.
Usually the improved, less minus Rx will be accepted in less than
a week under this mild cycloplegia.

    It is customary for many of today's patients to overwear
their soft contact lenses and to endure almost constant edema.
Patients with significant edema will give erratic subjective
findings during their exam and often do not see a clear 20/20.

    In these circumstances, the refractionist may add more minus
to improve the refraction.  Naturally the patient reports an
improvement because she is now overcorrected; she sees letters
that are darker because the light that has been concentrated into
a smaller retinal image.

    This tendency to overcorrect an edematous myope could account
for some of the overcorrections that are being seen today in our
young patients.

    It is necessary for all patients be examined without their
soft lenses in place and essential that all patients undergo a
"Plus to Blur Out" procedure to prevent "overminusing" the
correction.

    Inaccurate refractions must not be allowed to become
pandemic.

    The traditional "soul" of Optometry has been the pride we
have always had in providing our patients with an exacting
refraction and the prescribing of a clear, comfortable vision
correction.

    We spend a great deal of time today concentrating on other
areas of optometric expertise -- contacts, pathology,
therapeutics, orthokeratology, low vision, developmental vision
and visual training.

    We cannot become expert in all of these areas at the expense
of our basic mission -- to provide the best vision to our
patients.  We must be skilled at all aspects of patient care.  It
only takes another one to two minutes to do monocular and
binocular blur out techniques during a refraction.  Patients will
be much happier if you include the "Plus to Blur Out" procedure in
your standard examination routines.