Dr. Add More Minus

by Specs4ever

The excitement was building between us as my wife and I headed towards the new city that we would be living in. After graduation from university I had recently completed my internship as an optometrist, and was now fully a fully licensed doctor of optometry. With a pretty good loan from the bank, I had purchased the practice of Dr. Arvin Moore, who, at age 73 was finally going to retire, although he had promised me that he would stay on for six month to a year to ensure I was properly set up.

The city, or should I say large town, was situated in the heartland of America, and both my wife and I were excited to be leaving the hustle and bustle of Chicago life. I was, after Dr. Moore retired, going to be the only eye doctor in town, and since the town also appeared to support 2 optical stores, I figured there would be enough business to keep me hopping. Helen and I had been to visit the city a couple of times when I was arranging to by Dr. Moore’s practice, and had arranged to rent an older house. We felt that within a couple of years our family would be large enough that we would want a home of our own. It wasn’t going to be long before that bulge in my wife’s tummy became a child, and we were sure we wanted at least one, maybe even two more.

The real estate office was open when we arrived in town, so we stopped by and picked up the keys. Monica, our agent, had opened the house that morning for the moving crew to place our furniture. Monica had a long face though, and when I asked her what was wrong she told me that Dr. Moore had passed on 2 days before, and that his funeral would be the following day. This was not a real problem to me, because the money had already been paid to the good doctor for the purchase of his practice. And I was a little relieved in that I would not have him looking over my shoulder for the next few months. I did feel badly that he hadn’t gotten to enjoy his retirement at all, however he had previously told me that he loved his work, and had not wanted to retire.

Helen and I decided that we would grab a room at one of the local motels, so we checked in and settled into our room for the night. I planned to go to Dr. Moore’s funeral the following day, and Helen was going to spend her day at the house getting the place habitable.

As I looked at the crowd at the funeral I was a little surprised that every one of the mourners wore glasses. And as I glanced around I noticed that everyone I could see had minus lenses in their glasses. Some were weak minuses, but there were a few pretty strong prescriptions there as well. But of course, Dr. Moore was an optometrist, so it wasn’t that unusual that his mourners would wear glasses.

That afternoon, after the funeral I went by the office. I had a key, so I looked through the appointment book, and noticed that the following day was fairly well booked up. There were notations that Shirley, the receptionist, had called all the patients, and they understood that they would be seeing Dr. Moore’s replacement. I guess that they had better understand that, because Dr. Moore was in no position to operate a phoropter.

The first few patients were just normal checkups. In all cases I found it necessary to increase the strength of their prescriptions slightly, but this was not an unusual thing.

My last patient of the morning was an elderly lady, who was in for her annual vision exam for her driver’s license. I had looked at her chart, and this lady had started as a 5 year old under Dr. Bradley, who had been Dr. Moore’s predecessor, with a prescription of -2.50. By the time she was 24, a young Dr. Moore had prescribed her -22.50 lenses, and her prescription had remained stable ever since. The notations in her file told me that when the lady was in her early 60’s her visual acuity was 20/30. By the time she was 78, her acuity had dropped to 20/35, and it had remained there ever since. But upon examining her, I couldn’t seem to get her to read the 20/40 line well enough to sign that her vision was above the legal minimum. I didn’t want to tell her that I could not sign for the renewal of her license, so I went out to discuss the situation with Shirley.

‘So, Mrs. Stone can’t quite meet the minimum requirements Shirley. Do you think it will be a problem if I do not sign for her license renewal?” I asked.

“Mrs. Stone knows only too well that her vision isn’t all that great. She only drives to the grocery store, to church on Sunday, and to her bridge club 2 afternoons a week. I doubt that she would put any more than 1,200 miles a year on her car, but if you take her license away this would mean that she would become a shut in. Doctor Moore understood this, and that is why he fudged the results the last couple of years. You will have to do what you feel is best, but just so you know, Mrs. Stone is the mayor’s mother, and I think you would be well advised to stay on his good side.” Shirley replied.

So, I went back in, and wouldn’t you know it, following further testing Mrs. Stones visual acuity had improved to 20/35 again, so she was able to keep her license for at least another year. After all, driving in familiar territory, and only driving in daylight hours didn’t require as good vision as if she was traveling a lot of miles in unfamiliar surroundings.

The next few weeks were fairly uneventful. I had the usual run of the mill new patients to examine, and there was nothing that seemed out of the ordinary, except that these new patients were mostly children under the age of 5. One little 4 year old girl didn’t have much myopia, and only required a prescription of -0.50D for both eyes, but when I suggested to her mother that she might be well advised to wait another year before getting her daughter a pair of glasses, and that with the proper eye exercises she might be able to prevent her daughter from having to wear glasses, the mother surprised me by telling me just to give her a prescription. I didn’t argue, but did exactly that.

By this time I had noticed that not one of the patients that I had in for reexaminations wore plus glasses. It seemed that all of my patients were nearsighted. And, by this time my wife and I had been in various stores, and restaurants around town. It was really quite strange. Everyone wore glasses, and I could see no evidence that anyone ever wore contact lenses. I had not been asked by any patients to do a contact lens examination since I started.

Most of the older folks, which to me is people in their 50’s and over, seemed to have prescriptions that ranged from about -4D, up to -10. And there seemed to be more that were around the -10D than there were those with lower prescriptions. In the age group between 30 and 50, I noticed that there weren’t many with prescriptions under -10D, and in fact the bulk of them seemed to be wearing glasses that were in the mid teens, with a few that seemed to be close to -20D. And in the group from about age 15 to age 30 there were lots of strong prescriptions. Most of the school aged cashiers in the stores we shopped in seemed to be around 17 or 18, and their prescriptions seemed to roughly match their ages.

My wife and I stood out in the crowd for the weakness of the lenses in our glasses. I was only a -5.50D myope, and my wife didn’t require much stronger, as she wore -7.50D lenses in her glasses. I could have increased my wife’s prescription a little, as I had been keeping her slightly under corrected recently. Her younger sister had just gone through a bout of severe myopic progression, and I was sure that her doctor had just been giving her the strongest lenses that she had needed, instead of trying to hold the myopia back a little. Now her younger sister needed -12.50D, and I was afraid that if I gave my wife her full correction she might require some larger increases. But, with her pregnancy, lately I had noticed that my wife was having to ask me what the information blurb about the shows on the television said, so I was going to have to do something very soon about giving her stronger lenses.

When a doctor examines your eyes, if you are myopic there is a point where you can see fairly well at 20/30. If I were to give you about -0.50D more I can usually get you to 20/20, but I can also go about -0.50D stronger to still give you 20/20, however with the stronger lens you are corrected to the maximum. I seemed to be getting a lot of patients that were borderline 20/20. They were better than 20/30, but they were missing a letter or 2 on the 20/20 line. And if I cranked the lenses up by -0.50D or -0.75D, then they could easily see the 20/20 line. Every one of Dr. Moore’s former patients seemed to show up for an appointment as soon as the 20/20 line started getting a little blurry, and they all seemed to want the maximum amount of correction. I was beginning to understand why there were so many strong prescriptions in town.

I was rummaging around the office one day, and I ran across a number of cardboard filing boxes of old patient records that went back long before computerization of the records. The reading was very interesting, and I started to spend most of my spare time looking at these old records. From what I could see, the reason why there were only nearsighted people in this city was that Dr. Moore’s predecessor, a Dr. Bradley, had given everyone minus prescriptions. Any child that was brought to him for an eye exam left the office with a pair of minus glasses, even if they tested as a low plus. Before too long, wearing minus lenses at a very young age had caused the children’s eyes to become slightly myopic, and now there were no people wearing plus lenses. A minus wearer can remove their glasses to read to a certain point, and after that point they get bifocals for reading. This explained one of my questions.

Dr. Moore had taken over from Dr. Bradley 43 years ago, so most of the main myopic progression in the city had fallen under Dr. Moore. After reading more and more of the case files I could see that Dr. Moore had gotten the citizens to depend on stronger lenses. He had been very thorough in his record keeping, and there was nothing that I could have faulted him on with how he prescribed to his patients, however I had a good feeling that Dr. Moore was bringing each and every prescription up to the maximum strength that he could possibly prescribe, even to the point where he was over minusing some patients. After reading through most of the case files I started to call Dr. Arvin David Moore Dr. Add More, and before long I was referring to him in my mind as Dr. add more minus, because that is exactly what I felt he had done. Now, I had inherited a problem. How was I going to wean the population away from the desire to see as clearly as they possibly could? I had already tried in a couple of cases to suggest to the mother’s of young children that maybe they should wait a year to put glasses on their child, but in both cases my suggestion had been rebuffed, and both kids ended up with low prescriptions in their glasses. Actually, in the case of the first young lady I had suggested this for, after wearing her -0.50D glasses full time for about 6 months, the mother had brought her back for a second exam, and I had been forced to increase her prescription to -1.50D. I could likely have added another -0.50D as well, however I didn’t.

By the time a year had passed I discovered that I was having no luck reducing any of my patient’s prescriptions. The few that I had managed to give lower prescriptions to had come back within a very short period of time complaining that their new prescription just wasn’t right. They couldn’t see what they could see before, when they had gotten their last new glasses. So, I was forced to prescribe even stronger lenses, and because of my policy I ended up having to pay for the new lenses out of my pocket. And, after the birth of Sheila, I finally did bring my wife in for a new exam. I thought I could get away with increasing her prescription to about -8.50D, but she wouldn’t let me stop until I ended up with -9.25D. Even that wasn’t quite as strong as she wanted, but I managed to satisfy her for a while at that point.

Finally I gave in. I no longer tried to minimize the amount of increase that I gave a patient. I just cranked up the minus to a point where the 20/20 line was clear. Then I did the red and green test, and whichever the patient chose was the prescription that I wrote.

It was almost like someone had told all the patients that they should choose the red, because I don’t remember anyone ever choosing green.

As time passed on my wife had a couple more increases. By the time she became pregnant with our daughter Emily her prescription had bounced up to -11.50D. After Emily was born I had to add another -1.50D, and then when she had our son Todd, her prescription jumped again to -15.50D. Now Helen fit right in with all the other ladies her age. Her prescription was a little lower than most of her friends, but not enough to draw attention to her. I had not had an increase at all. My prescription had remained right at -5.50D, and it was a lot lower than any of the other men my age. But no one ever commented on my weak glasses, so that was good.

When Helen brought Emily in for an eye exam when she was 4, I discovered that Emily could get away with about -0.50D to give her 20/20. But, she also tested at 20/20 with a -1D lens. I didn’t feel I could win the argument, so when Helen and Emily left with Emily’s prescription, it was written for -1D for both eyes.

After my wife and daughter left the office I sat back and reflected on things. It then came to me that I had also become Dr. “add more” minus.


December 2009