Can you recommend a protocol to follow for that will help me eliminate simple mistakes that lead to mine and patient frustration, and longer chair time?

Simple mistakes can lead to increased chair time, expensive remakes of lenses, poor patient confidence and damage to the business finances. Reducing mistakes to a very low level will help in all of these and others I can’t think of at the moment. Handling the consequences of a mistake in refraction and or dispensing effectively will help prevent the same mistake and maintain patient confidence and practice reputation

I came across a very useful protocol on trouble shooting problems patients sometimes experience with new glasses. This was prepared by eye specialists at the University of Iowa, USA and have adapted it. See below:

  1. Ask about visual problems with the new glasses specifically. Is it for distance vision? Near? Asthenopia? Diplopia? Pain behind the ears or at the bridge of the nose from ill-fitting glasses?
  2. Make sure the new glasses fit the patient correctly. This is especially important for multifocal lenses.
  3. Check whether the reading segments are in the correct position.
  4. Check the pantoscopic tilt. Normally the tilt is 10 to 15 degrees, so that when the patient reads, the eye is perpendicular to the lens. The patient may be noticing that the tilt is different compared to the old glasses.
  5. Check the optical centres in comparison to the pupillary centres.
  6. Check whether the old glasses were made in a plus cylinder design using a Geneva lens clock.
  7. Check whether the base curve was changed using a Geneva lens clock.
  8. Read the new and old glasses on the lensometer and compare. Make sure the new prescription is the prescription you wanted the patient to have.
  9. If you feel the prescription is reading differently than prescribed on an automated lensometer, check the prescription on a manual lensometer to be sure.
  10. Digital lenses, particularly digital progressive lenses, will not measure exactly to the power prescribed. This is because digital lenses are designed to adjust to the different vertex distances the patient will have when viewing through different parts of the lens.
  11. Make sure the old glasses did not have any prism.
  12. If the patient has a high prescription, check the vertex distance. Often, it is easier to refract such patients over their old pair of glasses to keep the vertex distance the same.
  13. Iif the diameter of the lens is much larger in the newer frame, the patient may be noticing distortion in the periphery of their lenses. Encourage a smaller frame. If the new frame is significantly smaller, the patient may notice the edges of the lenses, or the reading area of their multifocal lens may be too small to use efficiently. Encourage the use of a larger frame.
  14. Check the patient for undetected strabismus with cover testing.
  15. Evaluate the patient for dry eye.
  16. With postoperative glasses, evaluate for diplopia in down gaze due to anisometropia.
  17. The add may be too strong or too weak. Check the patient using trial lenses and reading material.
  18. Refract the patient again, possibly with a cycloplegic agent, if the symptoms warrant.
  19. Test the new prescription in a trial frame with a walk around the office; you do not want to go through this process again.
  20. If you can find nothing wrong with the prescription and the optics of the lenses, encourage the patient to give the glasses another try. An adaptation period may be necessary, especially for progressives. Book an appointment for a review in a couple of weeks to see if the patient has adapted. You don’t want the patient to go to another practice for a second opinion.

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