All That Jazz

Ever hear of Oscar Seaton Jr.? Hint: he’s a drummer. Still no bells? You don’t lose any points for not knowing that he’s the long-time collaborator of Grammy Award-winning jazz pianist and composer Ramsey Lewis. I first encountered him as a pleasant surprise on a drum solo in the midst of George Benson’s On Broadway:

Seems like every day brings at least one surprise, and thankfully that surprise is oft-times pleasant. TC is a 34 year-old female who previously brought her two children to my practice who we helped considerably. She decided, “what the heck – maybe he can do something for me”.

Her basic problem? For quite some time now, she has complained about her glasses “not being right”. She can never seem to get a satisfactory power, and she’s been to several doctors, each of whom “tweaks her prescription a little”. It affects her at all distances, but lately she has been on the computer more and is finding the eye strain intolerable. She went back to her most recent prescribing doctor who insisted that “the glasses are right, and there’s nothing else to be done”.

I’ve written before, in Clinical Pearls in Refractive Care, how a reliable auto-refactor can be appreciated as a smart retinoscope, and gives you a clue about what to expect when looking at entering visual acuities and link it to the patient’s chief complaint (if there is one). Sure, it has its limitations in not being able to see the quality of the retinal reflex and color changes. Yet it has the advantage of being able to show numbers to the patient which can enable them to appreciate what is happening. Here are TC’s auto-refractor findings.

But here’s the problem: TC’s habitual Rx is:

OD: -4.50 -0.50 cx 110 (20/30+)

OS: -4.50 -0.50 cx 085 (20/25+)

When you see that much discrepancy between the habitual Rx and a reliable auto-refractor or retinoscopy finding, you’re expecting the patient to welcome a reduction in power. That doesn’t always turn out to be the case, but in this instance over-refraction of +1.25 OD and +0.75 OS resulted in the best binocular balance between distance and near, with 20/20 through each eye at all distances. So objective refraction was largely if not entirely compatible with the subjective refraction.

TC showed a slight binocular imbalance horizontally, with a convergence insufficiency profile (not convergence excess, as might be expected). But if your accommodative system is messed up from being chronically over-minused, getting into the ideal lens Rx for binocular balance is the priority without worrying about prism. We can always fine-tune that down the road once the accommodative system is stabilized.

So why did the previous exams not see the low-hanging fruit here? Well maybe they did, but there’s a little wrinkle to TC’s case. The first thing you think of when you see a discrepancy in habitual versus current refraction is blood sugar fluctuation. I asked TC, and she said she has no history of diabetes, nor is there any in her immediate family, but at age 14 she was diagnosed with POTS (Postural Orthostatic Tachycardia Syndrome).

TC told me that this has been an ongoing issue with her through the years, and when her blood pressure drops low enough her blood sugar level can be affected. It’s unlikely this is a factor in her case though, since her visual issues are better explained by being consistently over-minused rather than by fluctuations in refraction.

If I didn’t already have a relationship with the patient’s family, I might have held off prescribing until obtaining records of her previous examinations and delved further into her heath history. But both she and I were comfortable in making the assumption that the cut in minus, made asymmetrically based on best binocular balance, would significant improve her overall visual function, especially at near. (In a paradoxical way, finding out that she just needed “a good refraction” was a pleasant surprise.) We agreed to go with the flow instead of getting deep into the weeds of disease masquerade syndromes and all that jazz.