Which is Better, Number One, or Number Two?

There’s an old, kind of morbid joke about an optometrist who visits a long-time patient on his death bed.  His body frail and his voice raspy, the patient summons up his strength as the doctor leans in. “So I have to know before I go, Doc.  Which one really was better, number one, or number two?


Of course, there really is no “right” or “wrong” answer to the question, though that’s no comfort to patients who have test anxiety.  But what I’d like you to reflect on for a moment is the question rather than the answer.  Notice that during a refraction the question posed is “which one is better“.  At fist blush that seems a bit odd, doesn’t it?  After all, the patient is viewing letters on an eye chart across the room and what the refractionist really wants to know in jotting down the subjective power is which lens made the letters look easier to see, or sharper.  So why not pose the question that way?  Which one is clearer, number one, or number two?

I believe the old masters of refraction were on to something in the choice of the word “better” over the word “clearer”.  At some level they knew, intuitively, that the effect of a lens was not just on clarity.  A lens effects change at a visceral level, and we therefore want to know something more.  When contemplating a change in prescription, particularly with a patient who is visually sensitive (by whom you could probably calibrate a phoropter), it is powerful to put the lens in a trial frame or simply hold it in front of their current Rx if it is a change in sphere.  Get the patient out of the phoropter and looking down the hallway or through the window and ask this question as you interpose or change the axis of a lens: “How does it look, and how does it feel?”  The question isn’t meant to have a single best answer.



3 thoughts on “Which is Better, Number One, or Number Two?

  1. I appreciate this post. What to say to a patient and how to say it…even for this portion of an eye examination should not be rote. One needs to be sensitive to each patient and know when to adjust the routine and perhaps add multiple steps to assure the success of the prescription. While many likely do some version of what follows, here is what I think about and do when necessary.

    What adjectives click for that particular patient? How can one tune into how they are processing the stimulus? Do they prefer the sharpness and how does it impact periphery? Is it bigger even with minus? And would that be a better endpoint? Then, once we have mutually determined a possible prescription, it is trial framed and I ask them to slowly move their head from side to side and ask if they feel nauseous or sick. (Sometimes the look on their face eliminates the need for the question!) Then, after adjusting, if necessary, I show them the near card and ask if the corners still appear to be right angles. If so, then I have them move around the room and based on how they are walking I can generally tell if the Rx will be tolerated. However, I still ask the patient how they feel as they are walking. They should not feel drunk, dizzy or like they are walking on a strange surface. If so, I adjust again before prescribing. This is a lot of work and takes time, but fortunately, I do not have to resort to all or many of these steps too often and even less so over the years. I suppose that is because we get better at reading our patients and have become better at the art of prescribing.

  2. I like also on some of other tests that are assessing ranges or limits – “tell me when you can’t read it anymore”. This allows the person’s processing style to enter the finding. Some will stop when they feel it’s too small rather than too blurred. Others need “perfect” clarity in order to be comfortable reading the chart. It’s a reminder that we are really measuring much more than “accommodation” and “convergence”.

  3. So how do we get this point across in the optometry schools? I constantly see patients who are over-corrected, sometimes to an amazing degree! What do you say to the patient with torticollis who is wearing 3.00 of cyl/axis oblique, and really needs +2.50 OU? (Yes, it got rid of the torticollis.) Too many ODs are dependent on equipment-based tests administered by staff, and never actually look at their patients’ eyes.

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