To refract or not to refract...OD vs OMD

[dk23]

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Hi all,

Need a new lens prescription and was wondering who would offer the better refraction...ODs or OMDs? I'm thinking an OD since it's a large part of their training, also don't OMDs dislike refracting? Don't mean to start a controversy 😱 ...just need honest advice.

Thanks.

 

[orbitsurgMD]

Hi all,

Need a new lens prescription and was wondering who would offer the better refraction...ODs or OMDs? I'm thinking an OD since it's a large part of their training, also don't OMDs dislike refracting? Don't mean to start a controversy 😱 ...just need honest advice.

Thanks.

How about an autorefractor?

 

[DOCTORSAIB]

Hi all,

Need a new lens prescription and was wondering who would offer the better refraction...ODs or OMDs? I'm thinking an OD since it's a large part of their training, also don't OMDs dislike refracting? Don't mean to start a controversy 😱 ...just need honest advice.

Thanks.

Honestly, I don't think it matters. With enough practice, you can teach a monkey to do refractions.

If you go to an OD, just make sure you don't get talked into getting "reading/computer" glasses when you aren't even close to being presbyopic! OD's have a tendency to prescribe these to patients < 40, especially when their office is linked with an optical shop.

 

[Richard_Hom]

Hi all,

Need a new lens prescription and was wondering who would offer the better refraction...ODs or OMDs? I'm thinking an OD since it's a large part of their training, also don't OMDs dislike refracting? Don't mean to start a controversy 😱 ...just need honest advice.

Thanks.

1. Many ophthalmologists use refracting technicians who will start with the autorefractor result and then derive the prescription. In some circumstances, the ophthalmologist may also refract without a technician but with the autorefractor result also.

2. The base refraction is probably going to be equivalent regardless of the source if both perform the subjective refraction and not depend solely upon the autorefractor result.

3. Redefine your own expectations on what a good refraction means. Does it mean a comfortable pair of glasses? Does it mean the sharpest, clearest vision that you can obtain? Does it mean no spectacle distortion? Does it mean that you can see in all reading angles? Is it trying to solve a particular comfort problem?

4. #3 differentiates the approach of the optometrist and the ophthalmologist. Optometrists include the functional component in prescribing glasses and often adjust the base refraction to make the actual prescription of the glasses. In my opinion, ophthalmologists mainly prescribe for the best vision.

5. Anybody can be taught to perform a subjective refraction to derive the base refraction.

6. Whether you can tolerate the glasses or have your expectations met is another matter and is probably the reason why patients pursue either the optometrist or ophthalmologist for a glasses prescription.

Richard Hom OD FAAO

 

[orbitsurgMD]

1. Many ophthalmologists use refracting technicians who will start with the autorefractor result and then derive the prescription. In some circumstances, the ophthalmologist may also refract without a technician but with the autorefractor result also.

2. The base refraction is probably going to be equivalent regardless of the source if both perform the subjective refraction and not depend solely upon the autorefractor result.

3. Redefine your own expectations on what a good refraction means. Does it mean a comfortable pair of glasses? Does it mean the sharpest, clearest vision that you can obtain? Does it mean no spectacle distortion? Does it mean that you can see in all reading angles? Is it trying to solve a particular comfort problem?

4. #3 differentiates the approach of the optometrist and the ophthalmologist. Optometrists include the functional component in prescribing glasses and often adjust the base refraction to make the actual prescription of the glasses. In my opinion, ophthalmologists mainly prescribe for the best vision.

5. Anybody can be taught to perform a subjective refraction to derive the base refraction.

6. Whether you can tolerate the glasses or have your expectations met is another matter and is probably the reason why patients pursue either the optometrist or ophthalmologist for a glasses prescription.

Richard Hom OD FAAO

Dr. Horn's suggestions are excellent.

And one thing you always can do, when your MR is not giving you much better acuity than your patient's spectacle, especially if there is a significant change in axis or cylinder, is to have the patient compare the phoroptor (or trial) with their own clean glasses. Do this regardless of the objective streak or autorefraction findings. Change is not always better. Better is not always better.

 

[KHE]

Honestly, I don't think it matters. With enough practice, you can teach a monkey to do refractions.

If you go to an OD, just make sure you don't get talked into getting "reading/computer" glasses when you aren't even close to being presbyopic! OD's have a tendency to prescribe these to patients < 40, especially when their office is linked with an optical shop.

This statement is way off.

I'm not sure how much a 2nd year osteopathic student knows about phorias, vergence ranges, and accommodative facility testing but you should try learning a little bit about them before implying that reading glasses are useless for people under the age of 40.

And while it may be true that you can teach a monkey to "refract" it takes a lot more skill and training to prescribe glasses that people can actually use.

 

[DOCTORSAIB]

This statement is way off.

I'm not sure how much a 2nd year osteopathic student knows about phorias, vergence ranges, and accommodative facility testing but you should try learning a little bit about them before implying that reading glasses are useless for people under the age of 40.

And while it may be true that you can teach a monkey to "refract" it takes a lot more skill and training to prescribe glasses that people can actually use.

What I know about refraction has nothing to do with me being a 2nd year osteopathic student, but thanks for pointing that out. I worked as an ophthalmic tech for 2+ years and must have seen well over 6000 (assuming 12 patients/day, a very conservative estimate) patients in that time. One of my duties included refracting patients, so I'm quite good at it.

Refraction is both a skill and an art, but by no means do I consider it difficult. Please don't argue with me on that point.

And yes, my theory of OD's prescribing unnecessary reading/computer glasses to young patients (non-presbyopes) has yet to be proven wrong. Is this anecdotal evidence? Probably. It just bugs me that "coincidentally" there happens to be an affiliated optical shop with the OD's practice whenever these unnecessary glasses are being prescribed...

 

[Richard_Hom]

(...)
And yes, my theory of OD's prescribing unnecessary reading/computer glasses to young patients (non-presbyopes) has yet to be proven wrong. Is this anecdotal evidence? Probably. It just bugs me that "coincidentally" there happens to be an affiliated optical shop with the OD's practice whenever these unnecessary glasses are being prescribed...

I think your retort was unfortunate because it didn't answer KHE's post. Despite your wealth of experience, what do you know of the contribution of the binocular vision system to refraction and its outcome in glasses wear?

Richard_Hom

 

[KHE]

What I know about refraction has nothing to do with me being a 2nd year osteopathic student, but thanks for pointing that out. I worked as an ophthalmic tech for 2+ years and must have seen well over 6000 (assuming 12 patients/day, a very conservative estimate) patients in that time. One of my duties included refracting patients, so I'm quite good at it.

Refraction is both a skill and an art, but by no means do I consider it difficult. Please don't argue with me on that point.

And yes, my theory of OD's prescribing unnecessary reading/computer glasses to young patients (non-presbyopes) has yet to be proven wrong. Is this anecdotal evidence? Probably. It just bugs me that "coincidentally" there happens to be an affiliated optical shop with the OD's practice whenever these unnecessary glasses are being prescribed...

As I said, refracting is not difficult. Prescribing is.

You are right. Most ODs (and it seems more and more ophthalmologists) do have dispensaries as part of their practice.

But in no way does that preclude the necessity of prescribing near vision glasses for some people who are symptomatic, yet not presbyopic.

If you want to have a serious discussion about how and why optometrists manage near point vision problems, I would be happy to have that conversation with you.

I have a feeling (and please correct me if I'm wrong, as I mean no disrespect by this) that you are simply parroting what some ophthalmologist told you along the way...that being:

1: Pre presbyopes who are not strabismic never nead reading correction
2: As long as you can read 20/20 letters on a chart at distance, glasses (or any type of vision correction is not needed)

I would submit that that is not true.

 

[DOCTORSAIB]

As I said, refracting is not difficult. Prescribing is.

You are right. Most ODs (and it seems more and more ophthalmologists) do have dispensaries as part of their practice.

But in no way does that preclude the necessity of prescribing near vision glasses for some people who are symptomatic, yet not presbyopic.

If you want to have a serious discussion about how and why optometrists manage near point vision problems, I would be happy to have that conversation with you.

I have a feeling (and please correct me if I'm wrong, as I mean no disrespect by this) that you are simply parroting what some ophthalmologist told you along the way...that being:

1: Pre presbyopes who are not strabismic never nead reading correction
2: As long as you can read 20/20 letters on a chart at distance, glasses (or any type of vision correction is not needed)

I would submit that that is not true.

Last time I checked, I had a brain of my own.

I worked with some very well-known ophthalmologists, authorities in their respective sub-specialities, especially in neuro-ophthalmology, so I suggest you give them a little more credit.

 

[KHE]

Last time I checked, I had a brain of my own.

I worked with some very well-known ophthalmologists, authorities in their respective sub-specialities, especially in neuro-ophthalmology, so I suggest you give them a little more credit.

As Dr. Hom asked, Despite your wealth of experience, what do you know of the contribution of the binocular vision system to refraction and its outcome in glasses wear?

 

[Richard_Hom]

Last time I checked, I had a brain of my own.

I worked with some very well-known ophthalmologists, authorities in their respective sub-specialities, especially in neuro-ophthalmology, so I suggest you give them a little more credit.

Dear doctorsaib,

Well-known or well-respected neuro ophthalmologists may be well versed in their subject area, but they don't necessarily see the average patient who makes up 75% of the population who just wants to get a good pair of glasses and contacts. I have been treated by a neuro ophthalmologist myself for the past 15 years and we have talked frankly about the optometry and ophthalmology debate over those years.

I feel, therefore, that until your own dispensary or private practice has lost patients or have lost money that you will understand the significance of binocular vision in spectacle and contact prescriptions. Lastly, I'm sure you will make a fine surgeon, but alas, you might find yourself scratching your head "...why is the patient still complaining...I wrote the prescription out and I've done it 6000 times already.....🙂) Really, I do wish you good luck in your career.

Richard _Hom

 

[DOCTORSAIB]

As Dr. Hom asked, Despite your wealth of experience, what do you know of the contribution of the binocular vision system to refraction and its outcome in glasses wear?

Honestly, it's kind of silly to sit here and attack each other for what you perceive as lack of knowledge about binocular vision. You're both stuck on this one point. Get over it. I'm out...

 

[KHE]

Honestly, it's kind of silly to sit here and attack each other for what you perceive as lack of knowledge about binocular vision. You're both stuck on this one point. Get over it. I'm out...

No one is attacking anyone.

You have made a generalization that ODs overprescribe near vision correction for pre-presbyopic patients.

We're just asking what you are basing that on. For whatever reason, you seem reluctant to provide your opinion.

Of all these patients that you have seen that have you think have been needlessly prescribed glasses, have you spoken to any of their ODs to find out why they were doing it? Have you spoken to ANY ODs for that matter about how and why near vision correction may be needed?

 

[DOCTORSAIB]

No one is attacking anyone.

You have made a generalization that ODs overprescribe near vision correction for pre-presbyopic patients.

We're just asking what you are basing that on. For whatever reason, you seem reluctant to provide your opinion.

Of all these patients that you have seen that have you think have been needlessly prescribed glasses, have you spoken to any of their ODs to find out why they were doing it? Have you spoken to ANY ODs for that matter about how and why near vision correction may be needed?

$...🙂

 

[KHE]

$...🙂

I guess its a safe assumption that you did not in fact speak to any of the ODs who you feel mishandled people, nor have you even bothered to ask ANY OD why they sometimes prescribe near vision correction.

And basically you're saying that since you don't understand why near vision prescriptions are sometimes prescribed to pre-presbyopic patients, it must be because of money.

That's really too bad. You could have learned something here.

 

[DOCTORSAIB]

I guess its a safe assumption that you did not in fact speak to any of the ODs who you feel mishandled people, nor have you even bothered to ask ANY OD why they sometimes prescribe near vision correction.

And basically you're saying that since you don't understand why near vision prescriptions are sometimes prescribed to pre-presbyopic patients, it must be because of money.

That's really too bad. You could have learned something here.

Yes, I have learned something here. It's confirmed a few things too.

 

[f_w]

Yes, I have learned something here. It's confirmed a few things too.

Pssst. It is against the rules of this forum named 'Ophthalmology: Eye Physicians & Surgeons' to post any messages that could be construed to imply that shop based ODs occasionaly factor monetary aspects into the need for a prescription.

 

[VA Hopeful Dr]

Pssst. It is against the rules of this forum named 'Ophthalmology: Eye Physicians & Surgeons' to post any messages that could be construed to imply that shop based ODs occasionaly factor monetary aspects into the need for a prescription.

There's bad apples in every profession, there's no need to rehash these old arguments.

Bickering between MDs and ODs about business practices doesn't solve anything, and usually is anecdotal evidence anyway.

 

[Ben Chudner]

Ken, you are much more patient than I am.

 

[f_w]

Going back to the original post:

Refraction is the only thing I go to an OD for. This is what they are trained for and if you go to a good independent OD you have a chance to get your moneys worth.

 

[Richard_Hom]

Going back to the original post:

Refraction is the only thing I go to an OD for. This is what they are trained for and if you go to a good independent OD you have a chance to get your moneys worth.

f_w,

Thanks for such an enlightened opinion. Are you an OD or a resident in ophthalmology or someone who has work experience in that regard. I'm just wondering what kind of exposure you've had to optometry.

Richard_Hom

 

[f_w]

I'm just wondering what kind of exposure you've had to optometry.

Repeat customer who more than once experienced the 'but you need bifocals' bit. Once I ran into an independent OD who just did his thing, adjusted my prescription a bit and gave me a script for the new glasses without trying to sell me the contents of his store. I am one of these weird people who are under 40 but need reading glasses, but that is all I need, my distance vision is just fine.

(I also happen to be married to, and partner in business with, an opthalmologist who built her practice in a optometry saturated market 😉 )

 

[Richard_Hom]

(...)(I also happen to be married to, and partner in business with, an opthalmologist who built her practice in a optometry saturated market 😉 )

Dear f_w.

I'm not clear why an ophthalmologist would ever feel competitive pressure from an optometrist. They are often symbiotic. If an ophthalmologist feels that they are successful against optometrist, I'm wondering if that ophthalmologist is not busy enough in the OR. I would hope that the ophthalmologist would be spending her time more surgically than doing routine examinations and selling glasses.

Of course, it isn't difficut for an ophthalmologist to do well in any market. Why else would someone enter that specialty but to make a ton a $$.

Richard_Hom

 

[f_w]

I'm wondering if that ophthalmologist is not busy enough in the OR. I would hope that the ophthalmologist would be spending her time more surgically than doing routine examinations and selling glasses.

Certainly no lack of surgical cases. We don't sell glasses and patients who inquire about a routine eye exam are given the option to go to one of the ODs in the same office building (whom we indeed have sort of a symbiontic relationship with). Refractions and routine eye exams are only a small part of the practice.
(the reference to the OD saturated market was more in reference to the cut-throat business practices they engage into against each other. For the core business of the practice, I don't see much competition from the local ODs)

Of course, it isn't difficut for an ophthalmologist to do well in any market. Why else would someone enter that specialty but to make a ton a $$.

Because it is actually an interesting medical/surgical specialty maybe ?

You won't hear me complaining about the money, but you seem to know a rather skewed sample of ophthalmologists if this is your impression of the field.

 

[Richard_Hom]

(...)Because it is actually an interesting medical/surgical specialty maybe ?

You won't hear me complaining about the money, but you seem to know a rather skewed sample of ophthalmologists if this is your impression of the field.

Dear f_w,

I think I've seen or talked or worked with nearly 100 ophthalmologists during the past few years. Some were during their residency training and many while on staff at several hospitals. For a very large part, I have great respect for ophthalmology having been a long time patient myself. However, I don't believe their business development methods are any more ethical than in optometry.

Richard_Hom

 

[Ben Chudner]

Repeat customer who more than once experienced the 'but you need bifocals' bit. Once I ran into an independent OD who just did his thing, adjusted my prescription a bit and gave me a script for the new glasses without trying to sell me the contents of his store. I am one of these weird people who are under 40 but need reading glasses, but that is all I need, my distance vision is just fine.

Bifocals for someone whoes "distance vision is just fine" does not mean the OD is trying to sell you the contents of his store. There are circumstances in which it makes sense to have bifocals even with 20/20 distance vision. Maybe these OD's were actually looking at your lifestyle and thought you would benefit from not having to remove your reading glasses to see something in the distance, such as when looking at a chart and then looking up to address the patient. What the OMD's see as trying to sell the patient on something he doesn't need is, in fact, actually listening to the patient's needs and making the appropriate recommendation. Until you realize there is more to dispensing glasses than merely writing an Rx, you will always see it as selling.

 

[fredmanny]

as a medical student who has a number of eye problems and who's seen optometerists and opthamologists, I see distinct defined roles for both professions. I don't see why there is a gray area or why there are conflicts between the two professions. Optometerist should check vision, prescribe glasses and fit contact lenses. As long as you're good at these things, you'll always be in business. Ophthalmologist should see patients with pathology, diagnose diseases and treat them surgically if necessary. Pretty black and white if you ask me.... If you need refraction and have no history of eye problems, you should go to see an optometerist. There's no need to waste the time of an opthalmologist.

 

[trilla]

Pretty black and white if you ask me.... If you need refraction and have no history of eye problems, you should go to see an optometerist. There's no need to waste the time of an opthalmologist.

Thanks, fredmanny. I could not have said it better. However, I would like to point out some key words: no history of eye problems.

 

[f_w]

What the OMD's see as trying to sell the patient on something he doesn't need is, in fact, actually listening to the patient's needs and making the appropriate recommendation.

There is exactly one situation that my vision is an issue, and that is prolonged reading or monitor work. This is what I went to the ODs for, and by trying to sell me bifocals they ignored my needs and put their financial gain above my benefit. There might be some circumstances where bifocals make sense for someone with good distance vision, I don't fall into this group.

 

[Tom_Stickel]

as a medical student who has a number of eye problems and who's seen optometerists and opthamologists, I see distinct defined roles for both professions. I don't see why there is a gray area or why there are conflicts between the two professions. Optometerist should check vision, prescribe glasses and fit contact lenses. As long as you're good at these things, you'll always be in business. Ophthalmologist should see patients with pathology, diagnose diseases and treat them surgically if necessary. Pretty black and white if you ask me.... If you need refraction and have no history of eye problems, you should go to see an optometerist. There's no need to waste the time of an opthalmologist.

Fredmanny,

I can see why you've been banned for trolling. Since you're obviously trying to start (or further inflame) something, I won't rise to the bait. But I do find it amusing that you consider yourself an expert on the roles of eye care professionals when you can't spell optometrist or ophthalmologist correctly twice in a row.

 

[DOCTORSAIB]

There is exactly one situation that my vision is an issue, and that is prolonged reading or monitor work. This is what I went to the ODs for, and by trying to sell me bifocals they ignored my needs and put their financial gain above my benefit. There might be some circumstances where bifocals make sense for someone with good distance vision, I don't fall into this group.

Just curious, were you ever evaluated for dry eyes?

 

[f_w]

Just curious, were you ever evaluated for dry eyes?

yes, not the issue.