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1. FINE ART OF
PRESCRIBING GLASSES -
THE ART OF DISPENSING

2. HELLO!
I am Jasmin modi
3rd year
Hari jyot college of
optometry Navsari
Gujarat
I am here because I love to
give presentations.
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3. Aims & Objectives
3
▸ Introduction
▸ Prescribing glasses is a big deal?
▸ Optometrist’s at Technical point of view,
Take troubleshoot ,Give solution
▸ Optometrist’s at Refractionist point of view,
Dissatisfied Refraction Patient
▸ The Way of satisfaction
1.The evaluation tools
2.The investigation routine
▸ Big concept !

4. What is the fine art
of prescribing
glasses?
4
What is the art of
dispensing?

5. 1 2

6. Introduction
▸ Prescribing glasses is a big deal!
6
Analysis of prescription lens selection
Age Associated
condition
Frame selection
Patient need and
choice
Occupation Specific
prescription
Occupation &
Routine activity

7. THE OPTOMETRIST’S TECHNICAL POINT OF VIEW
▸ Education In refraction routinely touches only lightly on
dispensing.
▸ What complain or problems proceeds this work
▸ Technical skills are added like magic in every individual
dispenser (Optometrist)
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8. Take troubleshoot , give solution
▸ Nose hurts from pressure
▸ Indentation or redness at sides of
nose
▸ Pressure & discomfort behind the
ears
▸ Glasses slide down nose
▸ Glasses are scratched & they are only
one month old
▸ Cannot learn to use the new bifocals
▸ Objects swim with the new
progressive
8
▸ Vision not as sharp as it was during
refraction
▸ Duplicate glasses are not Comfortable as
original pair
▸ Cannot see as well for reading as with old
glasses
▸ Sunglasses are too dark or too light
▸ Child’s glasses won’t stay on nose
▸ Glasses cost more than two years ago
▸ Eyes feel strained with new glasses

9. Pressure & discomfort behind the ears
▸ Temple discomfort
▸ By relived the pressure of temple to the ear cartilage or the mastoid
process
1)Changing the length of the temple
2)Change the temple style –
▸ Sometime retro-auricular contact dermatitis occurs due to reaction
of aluminum or nickel frame but don’t confuse with seborrheic
dermatitis
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Skull temple Library temple Riding bow

10. 10

11. Glasses slide down nose
▸ Most common problem patient is complaining about glasses are
slipping down after some month.
▸ Occur due to rocker nose pad , they spread slightly every time when
glasses are worn
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12. Trick to be different,
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Normally optometrist do,
▸Checking their spread
▸Bending them inward
▸Changing temple length.
We can think about,
Zyl frames with moderate spring tension
“V” profile shape frame (Viewed from above)
Tightening hinges
Altering pantascopic tilt
Angling end-pieces

13. Glasses are scratched and they are only one month old
▸ All plastic lens require coating with scratch resistant
material
▸ Also some manufacturer gives warranty of their coatings
13
Using protective
case
Proper care
Don’t
tosses
spectacle
Never resting
them face
down on a hard
surface

14. Eyes feels “strained” with new glasses
▸ Complain of strain ,fatigue or eyes pulling while wearing glasses
▸ Recheck the position of optical centers & comparing with the patient’s
PD
▸ In the higher refractive errors
▸ Any vertical or horizontal misalignment of the optical centers can induce
sufficient prismatic effect to be responsible for symptoms.
▸ Sometimes cases Diplopia
How to manage?
▸ Temple pad adjustment!!!
▸ Solution is lenses need to be remade with proper compensation of
vertical alignment & vertex distance
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High
Myopia
Aphakia

15. Vision not as sharp as it was during the refraction
▸ Incorrect fitting of prescription
▸ Uncompensated vertex distance
▸ A disparity between the pantoscopic tilt of the trial lens that of the
new spectacles
▸ Inappropriate correction
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Advice to patient :-Try them for a week or two and if they
still trouble –some ,go see your doctor

16. Duplicate glasses are not comfortable as original pair
▸ Diffrence occur due to Lens power, optical center sepration, cylinder
form, face form, pantascopic tilt & size.
▸ Sometimes this factors are not controlled,
▸ Eyewire is larger in the new pair
▸ Lens thickness will be greater
▸ How to avoid this difficulties?
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Inspect the old pair of spectacles & point out the
changes to be expected in new ones

17. The new glasses cause too much glare or too many
reflections
Glare
▸ Patient piques their curiosity is wears sunglasses inside the optical
shop
▸ Some definition to differentiate glare
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DAZZLE Veiling glare True photophobia
Glare
Uncomfortable degree of
brightness from a light source
Simultaneous exposure to multiple
light source or the effect of both
direct & reflected light entering the
eye from same light source)
No ocular pathology but complaining
of glare it is

18. 18
Dazzle
True photophobia

19. Continued…
REFLECTION:-
▸ Reflection occurs due to internal reflection of two lens surfaces or by re –reflection
from cornea.
▸ Reflections will depends on,
▸ Low power lenses especially minus
Front & Back surface Increase the number of ‘’ghost” by intensifying them
▸ Higher power plus lenses rear surface is relatively flat, it will create reflection large
& vague
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Position of the reflected image
Their focus
Their intensity relative to the
surrounding field

20. Child’s glasses won’t stay on nose
▸ “We just can’t afford to have any more children”
▸ Criteria must be follow:-Frames with a 30-32mm diameter
-Cable temple or straight temple
-Affix an elastic plastic headband
-Frames with inverted nose pads with flat bridge
▸ In case of accommodative esotropia , who wears bifocals Segment line
must remain high enough to discourage the child from using the distance
correction for near activities
▸ Parental understanding required
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21. OPTOMETRIST’S AT A REFRACTIONIST POINT OF VIEW
▸ I just can’t wear my glasses
▸ Dissatisfied patient consumes from
15 to 60 minutes of time to resolve
the problem
Form of equation,
▸ D(T)= T/ P
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Discomfort
threshold
Time interval since
last glasses
Change in some
variabie

22. DISSATISFIED REFRACTION PATIENT
▸ Mechanical discomfort from lenses
▸ Visions blurs at distance
▸ Patient cannot read with new bifocals
▸ See doubles when reading
▸ Eyes tire or pull with new glasses;
Has headaches and/or nausea with them
▸ Objects are tilted
▸ Vertical lines seem to curve inward or outwards
▸ The size & shape of the bifocal segment is objectionable
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23. Visions blurs at distance
▸ Patient is aware of distance blur with new pair of glasses
▸ In higher refractive errors, vertex distance & prescription are not
co inside with that used during refraction.
▸ Also because the refraction is performed at 6 Meter or under 6
meter
a correction that is proper for 6 Meters will be incorrect by 1/6 D
when focus is attempted at 100-200 meters
How to manage?
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Verification immediately with lensometer
If needed repeat the refraction
Also measure vertex distance
For Hyperope,hold -0.25D sph over new
glasses
Target is given remote object
Responce be like “That’s it,”
Reduce +0.25D from prescription

24. Patient cannot read with new bifocals
▸ Refractionist sometimes prescribe too much add.
▸ In case of nuclear sclerosis, myopia increases the patient’s far point creeps
closer until the bifocal segment is abandoned & all close work done with distance
lens.
How to manage ?
▸ When you prescribed enough plus in the new add to maintain the same reading
distance as was present in original segment ,you create a marked over plus at
near.
▸ Also indicate the positioning of segments has been altered.
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25. Wearing spectacle correction
Patient have to read monocularly With alternative both
eye
If monocular occlusion relives the symptoms
Confirm binocular disturbance
Re check refraction & balancing near points
Eyes tire or pull with new glasses;
Has headaches and/or nausea with them
▸ Patient has any of these symptoms and no
problems with visual acuity, The main cause is
disturbance in binocular mechanism,
▸ How to determine?
▸ Another aspects is induced prismatic effect,
vertical or horizontal , will result from
incorrect positioning of the optical centre of
the lens
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26. Case analysis 1 continued..
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Leon Age 57 had been regular visitor to our clinic for 24 years
.one fateful day in another city , he had a sudden episode of
“spots before his eyes. ”the ophthalmologist examined him
carefully ,found a vitreous detachment ,but decided was a
new pair of glasses . these promptly give him a headache.
One year old glasses
OD:-3.25+1.00*20 -------20/15
OS:- -3.50+0.75*145 ----20/15
Add OU +2.00D
New prescription
OD:-3.25+1.00*20------20/15
OS:--3.75+1.25*155 ----20/15
Add OU +2.25D
Old pair New pair
63mm Optical centre 70mm
1.0 BO Prismatic effect 1.3 BI
Design
PD 66 mm
Total shift 1.3
1.0= 2.3 BI Induced esophoria
New glasses remade on 65mm A compromise between PD & OC Separation of old glasses

27. See doubles when reading
▸ Occasionally , hyperopes (Whose lenses thickest at center)
troubled by reduplication of the segment lines . They may
describes blur as “seeing double”
▸ Bifocal segment placed asymmetrically placed relative to
pupil
▸ Asses this by Patient tilt their head back slowly until the
segment line of right lens straddles the centre of the pupil
▸ Left segment line should be similarly bisecting the pupil if
vertical alignment is proper.
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28. Continued case analysis 2
▸ Mr. Albert was a meat cutter & bifocal wearer since 3 years.symptoms after
prescribing new glasses,
▸ Sometimes at work he saw double, his head & neck hurt,but fine to reading at home
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Pt PD = Dist. 70mm
near 66 mm
OLD GLASSES NEW GLASSES
Base curves +8.25 +6.25
Optical centers 65mm 69mm
Bifocal add
+2.00D +2.25D
Segment height 6mm low OU
Left seg 2mm
lower than right
Symmetical Asymmetrical
How to manage?
•Left seg align by elevating
2 mm
•Matching the base curve
so remake the both lenses

29. Vertical lines seem to curve inward or outwards
▸ Bowing of straight lines may be explained by,
▸ 1. Magnification changes In any lens from its centre to periphery
▸ 2.The location of the pupillary aperture within optical system
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PLUS LENS MINUS LENS
Straight lines appear concave producing
‘’pincushion” effect
Straight lines appears convex producing
“barrerl” effect
Management
Increase the lens curvature
Increasing curvature simultaneously
increases magnification Which is problem
therefore choose between the two effects
or possibly compromise
Minus lens inherently have steep inside
curves which do not create peripheral
distortion but further increase in the
curvature will reduce distortion

30. The size & shape of the bifocal segment is objectionable
▸ Segment may also be a play role to avoid wearing bifocals full time
▸ Misconception:- Bigger is better
▸ You should always give your patients idea of that their glasses looks like,
especially if you order a change from their previous glasses
▸ If patient first exposure to bifocals and add is +1.50D or less , he should be
pointed in the direction of progressives ….
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31. THE WAY OF
SATISFACTION

32. Way of satisfaction…
32
The Investigative Routine
it is helpful to have a standardized course of
action for investigate the problem.
The Evaluation Tools
Being arming yourself with a
simple set of tools.

33. Evaluation tools
▸ Lensometer
▸ Lens gauge – Geneva lens measure
▸ Pupilometer
▸ Wax marking pencil
33

34. ▸ Lens caliper
▸ Fixation light
▸ Distometer
▸ Simple scale / Protector
34
Evaluation tools cont.

35. ▸ Listen :- proper pin point problem “My Glasses slip”, “My nose hurts”.
▸ Measure V/A with the new glasses and compare it to that with the old glasses
▸ Neutralize the lens with lensometer & also mark optical center
measure front & back vertex power
measure segment power
▸ With high refractive errors ,measure the vertex distance and compare it with noted
prescription
▸ Use Geneva lens clock to measure base curve of each lens ,To check warpage
35
Investigate routine

36. Investigate routine cont.
▸ Using millimeter rule ,measure between ink dotted optical centers of the new lenses,
and compare with patient’s PD ,
Trick to measure PD accurately with millimeter rule,
▸ Measuring distance PD
36
Step 1 Sit facing & Slightly to one side usually the
right of the patient
Step 2 Fixation target is your Right ear.
Step 3 Measure from temporal limbus of the pt’s right
eye (using your left eye)to the nasal limbus of the
patient’s left eye (using your right eye)

37. Using millimeter rule cont.
▸ Measuring near PD
▸ Important note:-the ruler should be held in the plane of spectacles not against the brow
▸ Monocular measurements & facial asymmetry measurements cant done accurately with
manual methods
▸ Near PD is accurately measured for proper fitting of Bifocal segment
37
Step 1 Fixation target given at 40 cm
Step 2 patient fixate eye on pupils or the bridge
of the nose
Step 3 while you use only one eye to measure
from the patient’s right temporal limbus to the
left nasal limbus

38. Evaluate the pantoscopic tilt visually
▸ Case study:-
Mrs. Margret 72 year old housewife were ordered glasses to replace a broken pair.
Rx is, Complain is blurring of vision & not provide clear vision as earlier glasses
OD:- +5.00 +2.00 *180 20/20+ Add OU :-+2.50D
OS:-+5.00 +2.00 *180 20/20+
▸ During investigate she dropped vision to 20/25 OU
38
Lenses were positioned flat on her face
No pantoscopic tilt & since the trial frame used in her refraction had
been tilted some 15 degree,
After the calculation
+5.00 +2.00 *180
+4.88 +1.50 *180

39. Cont,
▸ A change in the pantoscopic tilt alters both the sphere & the cylinder.
▸ For plus & minus lenses increase tilt adds increase in plus sphere , minus
sphere & cylinder axis at 180.
▸ Remember +10D lens is tilted 15 degree on its horizontal axis, +0.75*180
cylindrical error is induced as well as +0.25 sphere
▸ Pantoscopic tilt involves rotating the horizontal meridian the only change is
cylindrical power will be in the vertical meridian ( the axis of course at 180)
important while calculate prism induced along the vertical meridian.
39

40. Compare the frame size to that of the old glasses
▸ Law of fashion is:- Fashions changes!
▸ Task is to explaining pros & cons of these smaller frames will
usually responsibility of us
▸ At this point if you find that neither the new lenses nor the frame
construction is at fault
40
Inspect the lenses for scratches ,waviness or other evidence of
defective finishing
Re-evaluate patient’s history ,especially with job requirement &
repeat the Refraction

41. BIG CONCPT
PSYCHOLOGICAL SUPPORT
41

42. 42
CUSTOMER SATISFACTION

43. Special thanks to,
43
B.Optom M.Optom. FIACO Pursuing PHD
Mr. Nirav Mehta
I/C Principle at hari jyot college of optometry
B.Optom M Optom, FIACLE, FBCLA, FAAO
Mr.Nilesh Thite
Woked at bausch+lomb

44. Organisation
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45. References
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▸ Milder B: The dissatisfied refraction patient. J Okla.
EENT Nov.1962
▸ Optics for clinician ed 2
▸ Havener WH: Metaphysical therapy . Opthalmol
surg 5:59-62
▸ www.triadpublishing.com
▸ Image courtesy:- Google images
▸ Fine art of prescribing glasses Benjamin Milder &
Melvin L. Rubin

46. Credits
Special thanks to the audience who attending this
session
▸ Presentation template by SlidesCarnival
▸ Photographs by Startupstockphotos
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THANKS!
Any questions?
You can find me at jasminmodi782@gmail.com