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Why Refraction Can Be An Important Tool In Uncovering Ocular Disease


It is important that younger OD’s know what we do every day may be mundane, but, vitally important, including refraction.

As new ODs get busier in clinic, and their speed picks up during examinations, they’re more likely to lose perspective.

The following highlights an encounter shared by Nick Despotidis, OD, from last summer identifying why something like refraction, which on the surface may appear monotonous, can play a significant role in patient care.

“Dr. D, you have an Rx check in room 1.”

It’s Friday.

“An rx check?,” I respond.

“Mom is really concerned, her son sees double with his new eyeglasses. His younger brother wears corneal reshaping lenses with us.”

I press the home button on my phone, 15 minutes before closing.

As I walked into the exam room to obtain the history, I could not help but notice the child seemed uneasy, feverish or perhaps just annoyed.

He returned from baseball practice and saw “two balls” with his new sports goggles, which were filled at a nearby optical.

My optician was in the exam room with me, she states “the PD’s are 10mm off.

I wonder why she did check the PD’s prior to seating the patient in my exam chair. I struggle to calculate the induced prism using Prentice’s Rule.

But something inside of me kept telling me to look further.

“Do you see double with your regular eyeglasses?” I ask the 14 year old.

“No, well kind of.”

I look at my watch, I hear my staff closing up the other exam rooms. I go into autopilot and perform cover test, ocular motilities, pupils, color vision…something is not making sense.

As I perform the testing, I can’t help but notice the boy seemed under the weather.

I ask the mom, “does he look sick to you?”

Mom looks at me blankly, “I brought him to the pediatrician, she says he has a virus.”

“Pupils seem sluggish, but no APD, OEM’S, cover test, color vision all normal. My tech looks at me as if I’ve lost my mind, the office is closed and she’s never seen me perform so many tests on an Rx check.

I open my mouth to say, it’s the eyeglasses, the centers are off.

But instead what comes out of my mouth is, “lets dilate him.”

My optician looks at me with bewilderment.

To this day I don’t know why I suspected papilledema.

The patient was admitted to Children’s Hospital of Philadelphia that night, where he remained for one week and eventually diagnosed with Lyme’s meningitis.

What does this have to do with practice management?


Marketing and practice management are paramount to our survival.

But when parents entrust their children’s care by selecting us as their eye care professionals, it’s easy to overlook the burden that’s placed on us as health providers.

This young boy was not my first case of papilledima secondary to increased intra-cranial pressure and won’t be my last.

The moral of the story, we undertake a responsibility with every examination we perform.

Ask yourself, are you properly reimbursed for the time, expertise and accountability?

Our staff, spouses, significant others, insurance carriers, and patients can never appreciate the number of factors we take into account with each examination, when we ask, “which is better 1 or 2.”

Mistakes happen to even the best clinician, but never set yourself for oversights by working on volume, both you and your patients deserve more.

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About Nick Despotidis OD, FCOVD, FAAO, FIOA

Nick Despotidis
Nick Despotidis practices in Hamilton, NJ with two partners, Barry Tannen and Ivan Lee. Their multi-disciplinary practice offers a variety for specialty services including vision rehabilitation, treatment of vision related learning problems, and specialty contact lenses. Together they have one of the largest practices in the country. Nick is the lead author of the book, My Children are Nearsighted Too and his practice management workshop, SuperChargeYourPractice, is one of the most highly attended workshops offered at the American Academy of Orthokeratology and Myopia Control annual symposium.

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