Re-Framing Binary Choices

Runninger with Borish & Milder
Dr. Runninger pictured on your left

Dr. Jack Runninger, an optometrist who left nothing to chance (having written his own obituary before he died), was fond of relating the story about a gravely ill patient that he visited bedside. When asked if there was anything he could do for him, the patient replied: “Doc, before I die, I just have to know the answer to the question. Which was better? Number one, or number two?”

I don’t recall the last time I asked a patient that binary question behind a phoropter. I have held different lenses or prisms loosely, or sometimes have the patient hold up various lenses or prisms, and ask them comparison questions. Occasionally I’ll put it in a trial frame. But those iddy biddy 38 mm holes that make the patient feel like they’re peering through a periscope are a sad substitute for what the lenses or prisms will do in real space.

Even if you go for the binary question, what does it mean to the patient when you ask “which is better”? Better in what sense? Ah … that’s where the payoff is. Think of how you explain to a parent (or patient), for example, that the low plus or low prism glasses you’re prescribing have nothing to do with how sharp things look. So exactly what is the Rx supposed to do? Therein lies the right words in posing the question when you’re “refracting”. Or more to the point, when you’re probing. How does the lens make you feel? Does it change the way things look? Is it different depending on when you look through it with one eye open or with both eyes together?

Binaries are okay in terms of bigger/smaller, closer/further, easier/harder, softer/harder/, and of course sharper or blurrier. But sometimes it’s better “not to lead the witness” in terms of framing either/or binary choices. Does a contemplated lens/prism change out in the real world make things look or feel weird in any way? Or just the opposite – does it seem to calm things? Maybe it creates a greater change in the space between things. Surely, if the patient has no idea what to say, express her feelings, or what the heck you’re talking about, by all means go with the binary choices. This is particularly true with the “I dunno” kids.

Lastly, understand your patient’s principal needs. If the patient expects to be immersed in a book or computer most of the day, with all due respect to visual hygiene he or she may not have the luxury of taking frequent breaks. In some cases distance visual needs are almost irrelevant, and you want to focus on best visual performance at near. Again, not necessarily the binary of sharper vs. blurrier, but which lens and/or prism combination makes it easier to concentrate, focus, make print bigger, easier to look at, keep your place when scanning, and so forth. I’ll always hand the patient a book at and them to read a little bit while making comparisons. Or if they’re laptopers, come on over to my desk and give the lens/prism comparisons a try. Hard to do that through those iddy biddy phoropter 38s.

Sometimes this works like a charm. Recently I had a 22 year-old Rabbinical student who came in with the following refraction:

OD: -1.50 sph => 20/20

OS: -4.75-0.50cx170 => 20/25

He was in the habit of removing his Rx for near, and pulling in his text to read at about 15 cm through his left eye. (This is not the actual patient, but a simulation of what he was doing.) The closer the working distance, the easier it was for him to suppress his right eye.

Another doctor had prescribed a modified monovision spectacle Rx of:
OD: -1.50 sph

OS: -3.50 sph

But the patient found that he still preferred to remove his Rx and pull the text inward. The problem was that he couldn’t sustain working at this excessively close distance for the lengths of time required of him. In addition, he found it very difficult to scan and keep or re-locate his place. The problem in this case is that the patient had adapted to his anisometropia by using his right eye for distance and left eye for near but not in an efficient way.

We tried several different combinations and working distances before deriving that the best balance between right eye and left eye was:

OD: -0.75 sph/ 1^ BI

OS: -2.50 sph

This essentially was half of the full refraction to best distance acuity, and in conjunction with 1^ base-in for the left eye provided the highest level of binocular function including good random dot stereopsis at a more reasonable working distance closer to 40 cm.

“Which is better, #1 or #2” is entirely irrelevant in this case because the challenge wasn’t in refracting for maximum distance visual acuity. Or even near monocular visual acuity. Although by the way, Dr. Runninger‘s patient was reassured to learn, before he departed this earth, that number one really was better.

6 thoughts on “Re-Framing Binary Choices

  1. On the better-one-or-two question, it’s easier to Google it. Times have changed since we went to school. That said, I’ve been exploring the role of emotion in vision, and your “How does that feel?” Fits in well. We see what we value. The feel of value could be emotion, just as belief could be value on the steroids of emotion. And seeing is believing. Tell someone they are NOT seeing something they believe to be in front of them and get ready for a fight.

  2. During the lectures in Berlin, which I was allowed to enjoy Hans-Joachim Haase in the 70´s, he was engaged to teach us that one should find out the “BEST” visual acuity. That’s how I followed his recommodation in the beginning years. However, throughout of my life I have learned that the comfort and impression of the examinee are more important than just acuity. I want to second David Cook’s words above.

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