Prescribing Tips PDF

OPT505:Prescribing Tips Intended Learning Outcomes Be aware of the factors to consider when deciding upon the final prescription Be aware of the factors to consider when recommending to a patient Understand how to effectively communicate with a patient Core competencies 1.1.1 Ability...

OPT505:Prescribing Tips Intended Learning Outcomes Be aware of the factors to consider when deciding upon the final prescription Be aware of the factors to consider when recommending to a patient Understand how to effectively communicate with a patient Core competencies 1.1.1 Ability to communicate effectively with the patient 1.1.4 Ability to make a patient feel at ease and informed – understanding their fears, anxieties and concerns about their visual welfare in the eye examination and its outcomes 1.2.1 Ability to take a structured, efficient H&S with a wide range of ophthalmic problems and needs 1.2.2 Ability to produce comprehensive, legible and organised record keeping with appropriate detail and grading 1.3.2 Ability to interpret and respond appropriately to patient records and other relevant information How do you decide what to prescribe? Symptoms: Visual, asthenopic, functional Consider the age of your patient Consider the lifestyle of your patient Consider their occupation Legal requirements? Listen to what your patient is telling you Can you improve things for them  How do you decide what to dispense? Visual Improvement Style/efficiency Profit Does the rx improve the VA New style Spare pairs Are the lenses in v poor condition Spare pairs Upgrades Will an tint/coating help holidays Sunglasses Will sep pairs be better-easier to Task specific Multiple pairs read? PEP Upselling Symptomatic relief-prism, rx Sports wear Membership scheme modification Fashion Other products: dry eye, DVLA magnifiers, cls, OCT etc prescribe dispense Offering Giving advice options Best interest Generate of px income Clinical Practical decisions  ‘’Being person-centred is about focusing care on the needs of Patient centred care individual. Ensuring that people's preferences, needs and values guide clinical decisions, and providing care that is respectful of and responsive to them.’’ https://www.hee.nhs.uk/our-work/person-centred-care Always be thinking about your management -Appearance, old specs, H&S, refraction, health etc etc -Drip feed advice during exam Reassurance Sum up the most important information at the end -relate findings back to presenting complaint/symptoms -discuss refraction Main message -Discuss health -Explain any pathology/change/ things you will monitor -Any other advice: Amsler, nutrition, dry eye etc -Anything to be aware of? -Recall, with advice to return if any new concerns Action Asking for trouble… At the end of refraction: Let’s compare my rx to your Is there anything else you How does that feel? old glasses wanted to ask me? We’ve made a big change to Don’t be surprised if your your prescription, come Has anyone ever new glasses feel a bit back and let me know if you explained……………… funny……………. have any problems Do we prescribe/dispense* our new subjective? Yes Maybe not The VA improves They are happy with They want new glasses their old specs and anyway there’s no real change We are including a new They tell us they don’t prism want new glasses We suggest a Latent hyperopia tint/coating/new lens Asymptomatic type Full time cl wear?? Poor lens/frame Ortho K condition Awaiting surgery Fluctuating rx  BUT…. We may duplicate their old rx Dispense their old rx in a new frame What to prescribe? Give a modified rx based on accommodation/BV status Give a partial correction In general, we will give the Give a modified Add patient a copy of our final Change a BAL lens subjective refraction. Alter the BVD (This is in fact a negotiation Decide the prescription is ‘not significant’ between us and them ) Prescribe glasses for over contact lenses Only alter one lens * NOTES, NOTES, NOTES! *  BUT…. Small rx may be beneficial if px does a lot of detailed work If px has a Type A personality (NB: ‘’sensitive visual Small RX/small system’’) change Small rx improves VA subjectively (driving?) May give (placebo/real) symptomatic relief of eyestrain Can give to px to ‘try’ In general, only prescribe if it will 12-year-old girl syndrome actually improve the vision. Ensure: Pay attention to compensation of phorias and NPC May actually need BV interventions Review in a sensible time frame Make px aware the rx is very small and note reason for giving on record  GOS rules https://www.abdo.org.uk/wp-content/uploads/2022/05/MACE-guide-2022.pdf  In your current eye examinations, you don’t have the Considering the previous rx previous rx or glasses, but in practice, you probably will. Always record the habitual prescription AND the last prescription if you have it Ask the px if they are happy with their current specs, comfort, vision etc Compare your final rx to the habitual one yourself, look for: -Large sphere changes -difference between R& L -Changes to cyl axis and power -Changes to ADD -wearing position/set-up of habitual specs -changes over time: myopic shift, increasing cyl? Show the px the old v new rx physically Does it make sense? ‘’Thinking refraction’’ does the outcome fit with H&S, VA etc? Rx is normally symmetrical(ish) Cyls axes are often the same, or mirror images e.g. 90 & 90, 180& 5, 45 &135 Cyls are normally stable, or gradual to change  The 3 way handover Px adds anything they want to mention, gets to hear a repeat of advice from optom Optom introduces DO has a start point px and DO to have a discussion Summarizes what is with px required  What sort of glasses? Bifocals Varifocals Occupational Sep Pairs Existing wearer Most new Office workers Vari non-tols Vari non- tol presbyopes Presbyopes Anisometropia Prism control Existing wearer with v small dv Pathology Children BF upgrade? rx Close wd Some Additional pair requirement occupations + SVD vertigo Most manufacturers have a new wearer non-tol policy for first time varifocal wearers  Myopes love minus: don’t over-plus Beware of reducing existing minus Myopes 6m testing chart can lead to over-plussing by +0.17D in relation to the ‘real world’ High rx tends to slip down, thus reducing effective minus BVD of trial frame BVD of intended/habitual frame Shorter uncorrected wd-habitually more plus for Add In high myopia, may not need near add until much later due to dropping down nose ( NVEE) If px keeps poking their specs up their nose, may need more minus Don’t forget heights and mono Pds on mode/high RX  Go for max ACCEPTED plus, don’t OVER plus This is where your BB/binoc refraction is critical Hyperopic rx to do with comfort and acuity much more Hyperopes than myopes Some asymptomatic hyperopes can be left uncorrected Bear phorias/tropias in mind EXPLAIN to px and advise about any adaptation Low hyperopes REALLY hate becoming presbyopic Demonstrate to px their accommodation working  Remember, the stronger the cyl power, the more the axis is important Try binocular methods of refraction to avoid cyclophoria error ( or BB x-cyl) Cyls do not generally rapidly increase (lid lesion, cortical cat) Suggest not adding cyls 0.50DC or smaller found on ret to trial frame. Quicker to find subjectively. Astigmatism If they misread rather than can’t see the letters: could be a cyl Don’t forget BVS ( some quite large astigmats are ok uncorrected due to this) Can gradually increase cyl if required/partially change axis Don’t forget about keratoconus ADAPTATION and px EXPLANATION are key Adds Large cause of non-tols Make sure you compare to previous and check the range make sure you note facial features. Habitual practices which may effect reading Consider pathology----field loss? Central scotoma Maybe they need more light, or a magnifier? Consider BI prism for convergence if giving high near add for wd2.00(ish) +2.00 +5.00 Aniseikonia: differing cortical image size Result of unequal spec mag Due to poorer vertical wrt horizontal fusional reserves, differential prism more likely to cause BV issue at near For BSV both eyes need a reasonably equally clear image otherwise fusion won’t take place—no need to correct for it. Anisometropia Not always bad-natural monovision-listen to px If asymptomatic with a near-plano ‘good’ eye, can leave uncorrected* May give rx for part-time wear Sometimes we use BAL lens if VA is very poor/rx is very strong. BUT, is it worth it?  Anisometropia Try to keep lens form same as previous (tolerated) specs, esp high plus Aspheric lenses have less spec mag as lens is flatter, plus better cosmesis. But px may miss the mag for near. Can design iseikonic (size) lenses, which increase spec mag only ( not power) in weaker lens. Other lens is given a standard lens. (APP and computer software available!) Aim is to reduce difference in spec mag to the point where BV system can achieve fusion There are four variables we can change to reduce the magnification difference: Vertex distance Material – index of refraction Base curve Center thickness  High rx Match lens design Note prev non tols and match prev frame/lens design Pay attention to frame fitting pay attention to BVD Reassure patient if an explanation for their symptoms is NOT found… Example: “Your headaches do not appear to be due to a problem with your eyes. Your eyesight is excellent and your glasses do not need changing. Your eye muscles are working normally and there is no sign of eye disease” – Record as ‘advised H/A not ocular, see GP if persist’ Discuss any requirements of a prescription… When should the Rx be worn? What other visual tasks is the Rx suited to? Example: “You should wear your new glasses for driving as you cannot drive legally without them. However, you might also find them useful when you are walking outside and watching TV” - Record as ‘Rx for driving legally, walking, TV’ Reassure the patient when eye disease runs in the family… Example: “you mentioned that your mother has glaucoma. There are no signs of glaucoma in your eyes as your eye pressures and fields of view are normal and the back of your eyes look healthy” - Record as ‘advised no glaucomatous signs, review 12 months’ Discuss any possible problems with the prescription… Warn of adaptation problems if: Rx worn for the first time Relatively large change in Rx Bifocals/varifocals worn for the first time Example: “These varifocals may be distorted around the edges at first but this will become less noticeable with continued wear” - Record as ‘Advised Re: adaptation to varifocals’ Discuss prognosis… Examples include: - Expected disappearance of symptoms with treatment/Rx over time - Expected progression of refractive error (e.g. progressive myopia, late-onset myopia, presbyopia) - Expected progression of untreatable pathology (e.g. only central vision is reduced in AMD and its progress is variable) - Likelihood of success of treatment (e.g. orthoptic treatment for amblyopia, refractive surgery) ALWAYS record your advice Remember the previous optometrist may not have just missed something you have uncovered! Previous optometrist may have intentionally: - Partially corrected a cylinder - Modified a cylinder axis - Partially corrected hyperopia Take care when considering/discussing a previous correction or colleague Discuss recall… 2 years, unless: - Child wearing glasses (esp myopia) (6 or 12 months) - Diabetic (12 months) - Age over 70 years (12 or 24 months?) - Age over 40 with family history of glaucoma (12 months) - Pathology that requires monitoring (6-12 months) Record advice: ‘Recall 12/12(FH glaucoma)’ Inform Px to make earlier appointment of problems arise before then i.e. recall 24/12 – return sooner if any probs Break : 10 mins. Please eat outside the lecture theatre 1 Would you prescribe the following? Old Rx: RE: +3.00/-0.25x90 LE: +2.75/-0.25x90 New Rx: RE: +3.75/-0.25x90 LE: +3.75/-0.25x90 Aged 19, been getting headaches when studying on the computer 1 Considerations Old Rx: New Rx: RE: +3.00/-0.25x90 RE: +3.75/-0.25x90 LE: +3.75/-0.25x90 LE: +2.75/-0.25x90 2 Would you prescribe the following? Old Rx: RE: +5.00/-2.75x90 DVA: 6/9 NVA: N6@40cm LE: +4.50/-2.25x90 DVA: 6/7.5 NVA: N6@40cm New Rx: RE: +5.25/-3.75x90 DVA: 6/6 NVA: N5@40cm LE: +4.75/-2.75x40 DVA: 6/6 NVA: N5@40cm  2 Considerations Old Rx: RE: +5.00/-2.75x90 DVA: 6/9 NVA: N6@40cm LE: +4.50/-2.25x90 DVA: 6/7.5 NVA: N6@40cm New Rx: RE: +5.25/-3.75x90 DVA: 6/6 NVA: N5@40cm LE: +4.75/-2.75x40 DVA: 6/6 NVA: N5@40cm 3 Would you prescribe the following? Old Rx: Lost specs, 25 years old New Rx: RE: +4.00/-1.00x90 VA: 6/6 LE: +6.00/-2.00x180 VA: 6/60 4 Would you prescribe the following? RE: +0.50/-0.25x180 DVA: 6/6 NVA: N5 @ 30cm LE: +0.50/-0.25x180 DVA: 6/6 NVA: N5 @ 30cm 15 year old, asymptomatic 4 Considerations RE: -0.50/-0.25x180 VA: 6/6 LE: -0.50/-0.25x180 VA: 6/6 15 year old, board blurry at school when sat at the back of the room Background Learning Soon you will start full routine practice. Think about and plan how you would explain things to your px: myopia, hyperopia, astigmatism, presbyopia etc without using technical language and jargon Write out a few scripts/phrases for yourself on how you would manage various situations Read some CET articles about prescribing in different situations