I just wanted to ask how many of you guys do NRA/PRA at your practices and believing balancing them/changing the ADD based on that is important. Because I've seen several optometrist don't even perform it in their practices. I would really appreciate your opinion and advice on this. Thanks
NRA/PRA question
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For presbyopes, NRA/PRA method of add determination is pretty much useless because the PRA is essentially zero.
For kids, if they need an add I use MEM almost exclusively so I guess the answer to your question is I rarely perfom that test.
90% of these silly chair tests are useless. They are little tests made up 80 years ago so that optometrists would have something to do other than a basic refraction. At the time, ODs did virtually no ocular health evaluation (slit lamps didn't even exist).
So to pretend their exams were worthy of money, they made up these silly PRA/NRA, FCC, AC/A, etc........simply to pretend to the patient that they were doing something 'fancy'.
You will very rarely, if ever, use most of them in practice--ESPECIALLY at Mart-Wal and the other commercial places new grads will most likely be working.
Refraction, on most people, takes 30-45 seconds and can be taught to your high school graduate technician.
Add power goes by age for the most part. If they are 42 and say they can't read the newspaper. Put up the phoroter and dial in +1.00. They will say "wow" and you're done (provided the auto-refractor doesn't show any cylinder). If they are 50, put in +2.00..........go up and down a little and they will tell you what they like.
All the silly accommodative tests just confuse most of the low-information voters you will be seeing. Not to mention, you will go broke doing a 40 minute refraction.
So to pretend their exams were worthy of money, they made up these silly PRA/NRA, FCC, AC/A, etc........simply to pretend to the patient that they were doing something 'fancy'.
You will very rarely, if ever, use most of them in practice--ESPECIALLY at Mart-Wal and the other commercial places new grads will most likely be working.
Refraction, on most people, takes 30-45 seconds and can be taught to your high school graduate technician.
Add power goes by age for the most part. If they are 42 and say they can't read the newspaper. Put up the phoroter and dial in +1.00. They will say "wow" and you're done (provided the auto-refractor doesn't show any cylinder). If they are 50, put in +2.00..........go up and down a little and they will tell you what they like.
All the silly accommodative tests just confuse most of the low-information voters you will be seeing. Not to mention, you will go broke doing a 40 minute refraction.
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Sad, but true.
I think the NRA/PRA test is important as it gives you a way to refine the add you have in place. Not everyone's add is dependent on their age. Also, the PRA is only 0 for presboyopes who have no accommodation left (ie those over the age of around 60)
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I rarely (very rarely) perform F.C.C. or N.R.A./P.R.A. In determining an ADD power, these techniques are, in my opinion, horribly disconnected from real-world demands, and really quite pointless.
Know how old your patient is, see what her working distance is, start with an ADD that makes sense, then refine on top of everything. Much more sensible.
(P.S.: Maybe send an e-mail to the N.B.E.O., to share this ground-breaking philosophy; minding Part III of their examination, I don't believe they've received the news.)
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I rarely use FCC, NRA/PRA. You spend semesters learning this crap in school but the reality is it doesn't always translate to real world issues because many patients are terrible subjective responders.
I still perform phorias, RET and MEM. MEM is a great, quick objective measurement for accommodative function. Another test that I use with discretion is the red/green filter test.
If there is one thing you can learn from refractions is that some patients are just too stupid for them. Muddling things up with NRA/PRA, FCC, only makes things more complex.
I still perform phorias, RET and MEM. MEM is a great, quick objective measurement for accommodative function. Another test that I use with discretion is the red/green filter test.
If there is one thing you can learn from refractions is that some patients are just too stupid for them. Muddling things up with NRA/PRA, FCC, only makes things more complex.
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These accommodation samples are not performed on everyone. On presbyopes I use Range through their working distance especially first time wearers - it is a good teaching tool, as they may have be calling clear what was blurry but readable.
Watch for their positive reaction at endpoint. All tests are a teaching tool except the heuristics of subjective refraction. I talk about the test while I perform it - engaging the patient and controlling their ruminating, spinning thoughts. when parents are in the room I half-engage them to get a threeway conversation- the children are more involved that way and case presentation to parents is the final stage not the initial one. Children and patients reporting eyestrain get them.
FCC finds the resting point of acc. It should be +.75 or+.50. If +1.00 - too loose and the will be over and under-acc'ing; +.25 or - demonstrates a tight system- the live with tension. Same with RA - norms used to be +- 2.00 now it is +-1.00 that is normal. -.25 pra is a tense habit- comfort and efficiency is limited - it can't last. Connect with their mind by tuning your
voice and timing to theirs- that is info. Do this enough and you get it, same as refraction.
The rest is easy. +.75 for esophores +.50 for exos. Tell them where the clarity is and what is "soft". If you encounter resistance let it go - they weren't hurting enough to do what fixes their problem. Lots more can be said, but ignorance of plain old optometry is no excuse for discounting it.
Watch for their positive reaction at endpoint. All tests are a teaching tool except the heuristics of subjective refraction. I talk about the test while I perform it - engaging the patient and controlling their ruminating, spinning thoughts. when parents are in the room I half-engage them to get a threeway conversation- the children are more involved that way and case presentation to parents is the final stage not the initial one. Children and patients reporting eyestrain get them.
FCC finds the resting point of acc. It should be +.75 or+.50. If +1.00 - too loose and the will be over and under-acc'ing; +.25 or - demonstrates a tight system- the live with tension. Same with RA - norms used to be +- 2.00 now it is +-1.00 that is normal. -.25 pra is a tense habit- comfort and efficiency is limited - it can't last. Connect with their mind by tuning your
voice and timing to theirs- that is info. Do this enough and you get it, same as refraction.
The rest is easy. +.75 for esophores +.50 for exos. Tell them where the clarity is and what is "soft". If you encounter resistance let it go - they weren't hurting enough to do what fixes their problem. Lots more can be said, but ignorance of plain old optometry is no excuse for discounting it.
