Friday, October 17, 2008

Case #1

I'll start us off with the first case out of the VA.   

55y/o WF presents for an annual eye exam. 
LEE: one year ago
OHx: The patient reports that she has always had a "bad left eye" since she was a child and that it has been "legally blind" for many years.  She wears her glasses the majority of the time and her prescription is one year old although her Rx hasn't changed in several years.   She thinks her first visit to an eye doctor was around age 10.
MHx: Unremarkable
OD 20/20, 
OS 20/80, PH 20/50
Entrance Tests: all unremarkable
Habitual Rx:  
OD: +1.25 sph 
OS: +1.25 sph  
 +2.25 ADD
Subjective Rx
OD: +1.50 sph  20/20
 OS: +2.25-3.00x25  20/25
+2.00 ADD

The rest of the exam was unremarkable - this is mostly a good case about refraction-

I was confused as to why she had been walking around for 20+ years with this "bad eye" when it really wasn't bad in the first place.  I was so excited to have discovered this new-found vision for her but when I presented this case to my preceptor, he had a different opinion.  He asked me what I wanted to do and I said that I wanted to cut back the Rx I found, that I trial framed it and she liked it.  So I wanted to order her this Rx:
OD: 1.50sph
OS: +1.75-2.00x25
+2.00 ADD
We ended up doing that but my preceptor said that giving her the glasses was a "judgement call".  He said that someone else may have also found this Rx for her before and gave her the glasses and she hated them so they just kept everything the same (although the patient didn't remember this).  Since the patient didn't come in with any visual complaints, we could just leave her Rx the same and if we were in a private practice, we may not give her the glasses because we may end up eating them.   My argument was that I think that we should at least try and because the glasses are free in the VA, we should order her glasses and if she rejects them there is no monetary loss for her or us.  But, if we were in a private practice, why wouldn't we just educate the patient that she may not like the glasses and that we are not responsible if she can't adjust to them, sort of like she is buying them at her own risk?  What is your opinion on this?  If the patient hasn't told you that she tried a pair of glasses that she hated, are we doing her a disservice by not giving her the true Rx simply for money's sake?

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