Prescribing Pearls Checklist from Dr. Greene

  • Make friends with your patient.
  • Talk to the patient, the family will be listening.
  • Control the interview- get to the important facts fast—what do they want to accomplish?
  • They’ll talk about reading—you should ask about seeing faces and making eye contact- do they feel isolated?
  • Have them do their homework- make a list of the activities that they would like to improve- this speeds up the history.
  • Review their present glasses and magnifiers- find out what they use and find most helpful now.
  • Do a quick refraction- if you can’t improve acuity by at least two lines, and can’t improve their ability to see a face from across the room- don’t prescribe!
  • If VA is 20/70 or better spend a bit more time doing a refraction- I always use a trial frame-  If VA is 20/100 or less, and retinoscopy is close to neutral I don’t spend much (if any) time on refraction. 
  • If retinoscopy is dull, find out why- this will reduce acuity and contrast- is there a medical/surgical option to clear up the media?
  • Check fixation in each eye individually- have them touch your finger- if they can’t do it, you won’t be able to help them much.
  • Check their gross depth perception- can they touch your finger held sideways? If not, is lack of stereopsis affecting their function?
  • Have them look through a 4x12 handheld telescope (pre-focus it first)- see which eye they take it to- that’s the dominant eye- you want to prescribe to the dominant eye if at all possible.
  • I hope the patient can read fluently 4x better with the telescope, but I also want them to see a face from across the room well- if they can that’s promising, if they can’t than telescopes may not be indicated.
  • If there is a dominancy conflict- meaning the better seeing eye is the non-dominant eye- try to prescribe binocularly if at all possible
  • Acuity goals for fluent reading with magnifiers are at least 20/40.  If you want your patient to read 20/40 fluently you need to give them enough magnification to read two lines smaller (though not necessarily as fluently).
  • When prescribing reading aids, consider breaking up the magnification between a prism half eye and a 2x condenser magnifier- this works very well for acuities better than 20/100 as is maintains a more normal working distance.
  • When writing checks to pay bills- you need less magnification to write the check than you do to see the bill- use the prism half eye to write the check and combine it with the magnifier to read the bill.
  • Don’t forget about ergonomics- use an inclined reading stand to bring the material closer
  • Don’t forget about lighting- bright lights are probably half the solution- the broad-spectrum OTT lights are usually not bright enough for AMD patients.
  • Always show CCTVs if for informational purposes only. Patients who get them love them- don’t think about the money- that’s the patient’s decision not ours.
  • Find out the furthest distance the patient can see your face well- that’s the distance they should watch TV. If all they want to do is watch TV, a larger TV is often a better solution than any telescope we can offer.
  • If they want to see better at a distance, once the refraction is the best you can give them, they either have to walk up closer, or use a telescope. That’s all the options there are. Telescopes and bioptics work great. I have many seniors who use them regularly. Demonstrate them- let them see their family from across the room- they will sell themselves.
  • Promise less than you expect to deliver.
  • Offer them a prognosis of how likely they will achieve their goals.
  • Offer to help them learn how to use the devices- they are not on their own.
  • Tell them what your refund policy is- don’t short change yourself.
  • Make recommendations- don’t decide for them.
  • Don’t let the family decide for the patient what they will get.
  • Tell them they don’t have to decide right away (unless they can)- they can always call back to order something- take measurements first if it’s a custom order- this lowers the pressure they feel.
  • Enjoy yourself- low vision is fun!