My Best Patient

by Specs4ever

As I stood behind the counter at the optical store where I work as both the optometrist, and the optician when needed, I watched the young 13 or 14 year old girl as she came through the door with what I assumed was her mother. It wasn’t hard to tell why they were here, as the myopic squint on the girls face gave it all away.

“May I help you?” I asked.

“Would you have anyone available who can test my daughter’s eyesight? Her teacher said that she thinks that Melanie might need glasses.” The mother said.

“I am the optometrist, and I do not have a booking for this early in the morning. However my assistant isn’t here yet and I really shouldn’t leave the store unattended. She should be in within the next 15 minutes or so. But in the meantime I can fill out the paperwork right now.” I replied.

So I took down all the necessary details. Melanie was a few weeks past her 13th birthday and was in 7th grade. She sheepishly admitted to me that she hadn’t been seeing things off in the distance very clearly since school had started in September. I had the forms filled out fairly quickly, and fortunately Steph, my optician in training arrived early. So I took Melanie into the examination room, and sat her down in the chair.

I flipped the lenses in front of Melanie’s eyes up to a prescription of -1D. She could see the eye chart projected on the wall fairly clearly with that prescription. Then I gradually doubled the prescription to -2D. Melanie could still see everything on the chart. I flipped in a cylindrical lens of -0.50D and rolled it around all the degrees to see if there was any astigmatic correction needed, but it appeared that things were not as clear with that lens, so I went back to the -2.00D lens. I was pretty sure that I had given this young lady about -0.75D more correction than she had needed, but at her age she would get used to this very quickly. I had given a few kids her age a little bit more correction than they needed, and so far every one of them had also needed an increase within the first year of their wearing their glasses.

Melanie picked out a frame she liked, and I had Steph prepare a pair of -2.00D lenses while she was looking at the frames. Then when she had chosen the frame I gave it to Steph to fit the lenses. I fitted the new glasses to Melanie’s face and she was thrilled at how well she could see.

A few days later I was standing behind the counter chatting to Steph when the door opened and Melanie walked in accompanied by a man who I thought was likely her father. My first though was ‘Oh shit, I’ve been caught”, but it turned out that her new glasses were hurting her where they fit behind the ear. This was a simple little problem and easy to fix, and when they left Melanie was again grinning from ear to ear. I had asked her how her vision was and she had exclaimed that it was great.

I don’t really make a habit of giving my patients more minus than they need. But I have found that there are a few patients who seem to readily accept a little stronger prescription than the machine shows they need. In Melanie’s case she could see most of the 20/20 line easily with a -1D lens. The -1.25D lens made it a bit clearer and I could likely have stopped there, but as I worked my way up to the -2D lens I eventually gave her she had no problems seeing the chart. In some of my other patients I had given them the lowest possible lens they could get away with, and in a few cases they had been back for another eye exam and a pair of stronger lenses that my boss had to supply for free. You see, we had a policy of supplying free lenses if the patient needed a new prescription within 6 months. And when that happened it made me look bad. So if it looked to me that a patient might be back to take advantage of this policy I generally gave them a little boost in their prescription.

It had been just under 6 months when Melanie and her mom appeared in our store again. Melanie was having trouble seeing the board again. So I checked her eyes again. This time I was able to get a good refraction with a -2.50D prescription. But I knew that if Melanie’s eyes had adapted to the other glasses and had even gotten a little worse it was highly likely that she would be back again in less than another 6 months. I was already going to look bad for having to give Melanie free lenses this time.

I increased the power of the lenses up and up until I reached -4.50D. This was a full -2D over where I had first stopped. I was going to stop there, but then I thought about my own eyesight and how it had gotten worse and worse within a very short period of time when I was the same age as Melanie was right now. So I went a little further. Melanie could still see well with a -5.00D lens, so I did stop at that point.

Since they had only paid for a regular plastic lens that was all I was going to replace her old lenses with. I gave the slip to Steph and left Melanie with her glasses on until Steph needed them to fit the lenses. When she had the lenses fit I looked at the thickness of the new lenses and was pleased to see that they looked pretty thick – much like my own lenses looked like when I was her age.

“Your glasses are ready Melanie. You needed lenses that were quite a lot stronger than your old ones, and I need to warn you that they will probably take a bit of getting used to.” I said.

“They do look a lot thicker.” Melanie’s mom said as I slid the glasses onto Melanie’s face.

“She had quite an increase in the strength of her prescription. You had only paid for regular plastic lenses before, so that is what we replaced them with at no charge. I would suggest that the next time she has an increase you might consider getting her a high index lens.” I replied.

“Are you telling me that she will need even thicker glasses in the future?” Melanie’s mom asked.

“There is no way we can predict anything. My eyes were about the same as Melanie’s were when I was her age. Now my glasses are -15D, and they have been that strong since I was around 18 years old. So all you can do is wait and see what happens.” I replied.

About 6 months later I had just gone out the door and was about to lock up the store one evening when I saw Melanie walking past on the sidewalk. I called to her and she looked my way.

“Hi Melanie. How are your glasses working for you?” I asked.

“They still seem to be all right. They are a lot easier to wear now than they were when I first got them.” Melanie replied.

“I am not in a hurry to get anywhere tonight. Do you want me to give you a quick checkup?” I asked.

She accepted my offer and we went inside. After checking her vision I could tell why she felt it was easier to see through her glasses now. Her prescription was right around the range of -4.25D. I told her that it looked like her prescription was still pretty good, but I suggested that her mom might want to make an appointment for her in another 3 months. I told her that often if a persons eyes didn’t have strong enough glasses they strained their eyes and their prescription got worse faster. This has been proven to be true, so I wasn’t worried that she could find out any differently.

About 3 months later I was glancing through the appointment book for the day. I saw Melanie’s name written in for a 4:30 appointment. I liked that time for an appointment for a younger person because they had been in school doing a lot of close work for the entire day, and I had discovered that their eyes generally needed a little more minus than if they had come in first thing in the morning.

“How are you doing Melanie?” I asked.

Ok I guess, but things have gone all blurry again. It’s a good thing that you told me to tell mom to make me another appointment.” Melanie replied.

“Well, let’s see if we can get rid of that bit of blur for you.” I answered.

Her prescription had climbed up a bit on its own. I wasn’t sure if it was really -5.75D or -6D. I was able to work my way all the way up to -8.50D before she told me that things were less clear. So I dropped back to -8D, and she seemed pleased with the results. This time I let her try the -8D lenses in a trial frame. She thought that this prescription was pretty good.

I explained to her mom that Melanie had required quite a large increase again. We had a sample of a -10D lens that was cut in half in regular plastic, as well as 1.67 plastic and 1.74 plastic. The 1.74 plastic was about 1/3 the thickness of the regular plastic, but was more than twice the price. The 1.67 plastic was about ½ the thickness of the regular plastic, and was a bit cheaper.

“How long will these glasses last her Doctor?” Melanie’s mom asked.

“I really can’t tell you the answer to that. They might be good for 6 months, or they might last 2 years.” I replied.

“What would you do if it was your daughter?” She asked.

“Probably I would just buy her the cheapest lenses like my parents did for me. My prescription stopped going up when I was around 18, and after that I got the thinnest lenses I could get. Now I have the 1.74 hi index lenses in these glasses. But if you get the regular lenses be prepared that Melanie’s glasses will be about as thick as mine are, even though my eyes are twice as bad as hers are.” I answered.

Melanie’s mom thought about the cost for a minute before she told me to go ahead with the regular plastic lenses. There are a few tricks we can use to thin the lenses down a little, so first I told Steph to use a plano front base. A normal lens of this power usually has a little bit of a curve on the front and the amount of the front curve has to be added to the curve in the rear. So if a normal -8D lens had a front curve of +1D then the rear curve needs to be -9D, but if you remove the front curve the lens only needs to be -8D, decreasing the edge thickness a little. Then I helped Melanie pick out a frame that had a little smaller eye size than she had first chosen. I explained that by doing this the lens would be smaller, and since the thickness in a minus lens is at the outer edge the lens would not be as thick. I had guided Melanie to a rectangular plastic frame with wide temples, also to help hide the thickness. Steph had a lens blank that was flat on front and had an anti reflective coating, so I convinced Melanie’s mom that the anti reflective coating would be beneficial. Once the lenses were finished and inserted into the frame I fitted the frame to Melanie’s face. They did seem to be a little thick, but I had prepared Melanie and her mother for the worst, and I didn’t think they looked bad at all. They ended up leaving the store fairly pleased with the glasses.

I didn’t see Melanie again for about 2 years. She was now 16, and she needed a new prescription so she could pass the eye exam for her driver’s license. When I checked her eyes I discovered that Melanie had gone up to around -9.50D, and she could see quite well though a -10D prescription. I didn’t think it was a good idea to go any higher, especially with her eye test for her license ahead of her. This time she convinced her mom to buy her the1.67 index lenses, and since she had gone 2 years with her old glasses her mom agreed to spend the extra money for the thinner lenses. But we didn’t have the lens blanks for her prescription in stock, so we had to order them from the lab.

Our lab gives us 24 hour service, and the lenses were there the following afternoon. Melanie had also chosen a new frame, and Steph had the lenses fitted to the frame before closing. I called Melanie’s mom, and told her if they were coming by I would wait until 5:30 for them, but they couldn’t make it until the following evening. Again Melanie was thrilled with being able to see clearly again.

I didn’t see Melanie again for about 5 years. One day the door to the store opened and an attractive young lady wearing glasses with lenses that looked even stronger than my -15D lenses walked in. As she came up to the counter I recognized her.

“Melanie! It’s good to see you.” I said.

“We moved away Mrs. Johnson, and I haven’t had a proper eye exam since I was last here. Would you have time to do one for me today?” Melanie asked.

“I do have a customer who is supposed to be here in half an hour, but I think we can give you a quick once over Melanie. I replied.

“That would be great. I haven’t been able to see very well since the last time you checked my eyes.” Melanie replied. 

“What do you mean Melanie?’ I asked.

“It seemed that I could see all right when I left the store with my new glasses, but within a couple of weeks I was having trouble seeing things and I had to squint at everything again.” Melanie replied.

“But your prescription appears to have increased quite a bit.” I replied.

“Sure, but that’s because I had to go back for new glasses every 4 or 5 months. And none of the places I went to offered free lenses if your prescription changed in less than 6 months like you people do. I always remembered what you told me that sometimes your prescription increased a lot faster if you were not properly corrected, and I am sure that is what happened.” Melanie replied.

When I checked Melanie’s eyes I saw that her now -16D glasses were definitely not strong enough for her. I settled on a prescription of -17D as being the prescription that Melanie probably needed, and then I clicked the lenses up a few more numbers. As I got close to -19.00D I could tell that I was likely going for too strong a lens, so I went back a couple of clicks to -18.50D. That seemed to be the best lens choice for her, so I stopped there.

My next patient was waiting, so I let Steph look after selecting Melanie’s new frame. My patient was older lady who was developing cataracts, and while she didn’t like it when I told her that new glasses would not really help her much until after she had her cataracts removed she thanked me for my honesty, and left.

Melanie and Steph were still talking about lens choices, and they wanted me to weigh in on the discussion. I felt that the choice was simple. With -18.50 D lenses Melanie either needed to order regular plastic myodiscs, or else the really expensive 1.74 index plastic thin lenses. Melanie was sick and tired of spending a lot of money on the super thin lenses that she had been trying, so she asked me to tell her more about the myodiscs. Finally she decided that she would try them, since they were a lot cheaper than her other choices. Most of the labs that supply a myodisc lens of this power do so by grinding the minus power into a plus carrier, and I don’t like the appearance of that, so for the past few years Steph and I have been ordering our high power minus lenses in just a regular lens. Of course the area that the lens bowl covers is far less than the size of the blank, so there is quite a circle with a very low power of around -3 or so around the outer edge of the lens before it is sized to fit the frame. Steph and I have gotten pretty good at using sandpaper placed on a flat sheet of glass, and sanding the rear carrier of the lens into a flat surface. Then we use finer and finer grades of water paper until we finish off with 2000 grit. At this point Steph then fits the lens to the frame, and then we take it back out and give the flat area that is left a buffing using a very fine buffing compound on a cloth wheel. We have only done this for a couple of customers but they have both been very pleased with the final appearance.

It took 2 days for the lenses to come in. They had been done exactly as I had requested, and Steph started sanding the backs of the lenses down on the sandpaper. We had to be pretty careful how we went about it, because we had gotten an anti reflective coating on the front surface, and we didn’t want to mark it or scratch it. Finally the lenses had both been sanded with 2000 grit and we had a nice 30 mm bowl. I had seen some lenses that had been left without polishing them any further, and while this also looked pretty good I still wanted to polish the flat area around the bowl, so Steph fitted the lenses to the frame. Then she gave them back to me and I polished them very carefully. This was a tricky part, because if you were not really careful the buffing wheel could grab the lens and throw it across the room. If it did that you could pretty well be guaranteed that the lens would be going in the scrap bin. But I managed to get the edges around the bowl polished up, and Steph put them back into the frame. I was pleased with the look, and hoped that Melanie would be as well.

I called Melanie to tell her that her new glasses were ready, but since she no longer lived in town it took her a couple of days before she could get in to pick them up. She thought that the vision they gave her was terrific, but she found it a little hard to get used to the myodisc lens. I told her that it wouldn’t take long before she realized that she had to turn her head rather than move her eyes around so that she would keep her eyes inside the bowl. She did look fantastic wearing the myodiscs, and I have to admit that I seriously thought about having Steph order a pair of regular plastic lenses in my own prescription so I could make them into myodiscs, but I didn’t. For the first time in my life I thought my own -15.00D prescription was too weak, but at the age of 40 I knew that I would never have another increase.

It was another 2 years before Melanie came back to the store. She walked in looking as pretty as ever, and I couldn’t help but thing that the myodisc lenses in her glasses gave her a special look.

“It is nice to see you Melanie. You are looking fantastic, but I don’t suppose you dropped by just to see us. Do you need another eye exam?” I asked.

“Yes I do. I probably should have phoned to make an appointment, but I had to come to town anyway today and I dropped by on the chance you could fit me in. If you can’t see me right away I could go to my appointment and then come back later this afternoon.” Melanie replied.

“My 10 am isn’t here yet and I have 15 minutes before she is due. Come on in and we will take a quick look, and if need be I can see you after lunch if you can come back at 2:30.” I replied.

“Sure, I can do that.” Melanie replied.

So I took Melanie back to the examination room and sat her in front of the phoropter. I took her glasses off and saw the blank look come over her eyes. Once a high myope reaches -10D or more they can’t see much of anything without their glasses, and they just stop trying to focus their eyes, giving them a blank unfocused appearance. I adjusted the phoropter to her old -18.50D prescription and asked her to read the letters projected on the wall. She was able to read them, although she had to guess between an O and a Q, and between and O and a C. I bumped her up another -1.00D, and she could read everything. I asked her how that was, and she asked for a little more, so I went up another -0.50D. She still wanted more, and I went another -0.50D, and when that didn’t satisfy her I went up another -0.50D. Then I added another -0.50, but she asked me to go back to the previous one. That would make her new prescription exactly -21.00D. I had run out of time, and Steph poked her head in and told me my 10 o clock was here. So I suggested that Melanie could come back at 2:30 and we could just double check my findings. 

I had a 10:30 after my 10:00 am, and was busy right through lunch. I finally grabbed a break at 2:00 pm and when I was eating my sandwich Melanie came back. I had spoken to Steph earlier and told her that it appeared that Melanie would require new lenses that were -21.00D this time, so while I had looked after my other appointments Steph had phoned the lab and they were able to finish a pair of -21.00D lens blanks for us. While I had Melanie in double checking my previous findings the delivery guy from the lab came by and dropped off the lenses. When Melanie came out from the examining room Steph had the lenses already flattened down on the back to a 30mm bowl. I showed the lens blanks to Melanie.

“This is your new prescription Melanie. I took a chance and ordered your lenses this morning after you left, hoping that you would like the same type of lens. We can go a little thinner if you want, but to do that we have to reduce the size of the bowl you will be looking through.” I told her.

“I don’t think I want a smaller bowl. I can handle the thickness, and I know my boyfriend won’t mind.” Melanie said.

“Oh, I take it you have found a guy who likes you wearing glasses.” I said.

‘Yes, I did. He likes me for me, but he says my glasses really turn him on, and when I told him I needed stronger glasses he asked me to get the same type of lenses.” Melanie said.

“I guess it is a good thing we went ahead and ordered them for you then.” We better choose a frame for you so that Steph can fit the lenses to the frame. Then I have to do a little polishing as that is my specialty around here.” I replied.

We chose a frame and Steph fitted the lenses to the frame in just a few minutes. She brought the glasses out to Melanie with the lenses in them, and Melanie tried them on. She commented that they were just perfect, so Steph stayed in the store with Melanie while I took the glasses back into the lab and removed the lenses from the frame. Again I carefully polished the flat area around the bowl with a very fine compound. I finished off the polishing with toothpaste, and then I used a fiberglass polishing wax to really finish it off. I had never done this for a customer before, but I had tried this out on a scrap lens a few weeks ago and it made the lens look even better. Some people also polish around the edges, but I don’t as this seems to cause too many reflections. I put the finished lenses back into the frame and brought the glasses back out to Melanie. She loved them and when she put them back on her face she looked very nice.

“I hope your boyfriend likes them.” I said.

“I am sure that he will. Thank you so much Mrs. Johnson, and thank you Steph.” Melanie said.

A couple more years went by before we saw Melanie again. This time she made an appointment over the phone and when she came in she was with a very good looking guy who she introduced as her fiancé. He waited in the display area while I took Melanie back in for her eye exam.

“This prescription is still pretty close to what you need Melanie. I could give you another -0.50D if you want to change your glasses, but you still see pretty close to 20/20 with the lenses that you have now. It looks like your myopic progression has stopped.” I said.

“Can you make them just a little bit stronger Mrs. Johnson?” Melanie asked.

“Your glasses are already very strong Melanie. If I were to give you a little stronger lens than you need you might end up having your eyes become a little more myopic.” I replied. “I have you right at 21.50D with the machine. If you really want me to I will go up to -22.50D. But I don’t feel that it would be a good idea to go any higher.” 

So I took Melanie up to -22.50D, and she was very happy with the results. This time we had not gotten new lenses for our supplier, because I was hoping that we could leave Melanie right where she had been at -21.00D. But she wanted more minus, so I had given in and gave her what she wanted.

I wondered if Melanie had decided that she would find another eye doctor who would give her a little more minus, as I think I had made it pretty plain that I didn’t want to do so. I didn’t see her again for about 5 years, and when I did see her she just dropped by the store to say hi. She was still wearing the same glasses, and told me that she hadn’t really felt the need for an increase yet, but just wanted to have a quick check.

The -22.50D prescription that I had given Melanie 5 years earlier was exactly what she needed I went up to a -23.00D prescription and she did like that better.

“I could give you another -0.50D in your prescription and that would make things marginally better.” I said.

“Could you give me another -1.00D?” Melanie asked.

“I am pushing the limits with another -0/50D Melanie. I don’t really want to go any higher.” I replied

“But you have always done that before for me.” Melanie said.

“You are correct, I have, but that was when you were growing and your eyes were changing a lot. Now you have pretty much reached the end of your myopic progression and there would be no real reason to give you any more power than you need.” I replied.

“I would rather have -1.00D more, but I guess if you won’t give me that I will have to be satisfied with -0.50D. At least you have always been willing to give me a little more than I needed. That is better than the other doctors I went to would do for me.” Melanie said.

“You were aware then that I had given you a little stronger prescription than you needed?” I asked.

“I wasn’t the first time, but then when you replaced my first pair of lenses for free I knew that my glasses were too strong. But I liked the feeling, and I figured I would just end up getting used to it. And I did. Then when I had my next increase I made my eyes try to adapt to the strongest lens I could, so that is when I ended up with -8D. But when you gave me the eye test for my driver’s license you really didn’t make my glasses strong enough.” Melanie said.

“That is because I didn’t want to give you too strong a prescription in case the person who checked your vision at the DMV found out it was too strong.” I replied.

“But then when we moved every time I had my eyes tested after that my new glasses were too weak again after only a short period of time. That is why I had to come back to see you again.” Melanie said.

“I certainly could give you an additional -1.00D again Melanie. That would make your glasses -23.50. But I am almost positive that if I only give you an increase of -0.50D you will be good for a couple of years. And it would be better for you if you don’t increase your prescription higher or quicker than you really need to as -23.00 is a very strong prescription and you are gradually going to loose the ability to see close to 20/20.” I replied.

“I will listen to you this time. But if I need to come back for an increase in less than a year you have to give me new lenses for free.” Melanie said.

“Of course I don’t want to do that. Your lenses are fairly expensive and while Seph and I do the extra work for free it is still our time we are giving away. But in this case I would rather see you with only a small over correction, and I feel that a full -1.00D would be too much. So I will go with my gut feeling and only make your lenses -23.00D.” I replied.

So Steph and I made Melanie another new pair of glasses with the same type of lenses that we had been making them with. This time we made the bowls 27 mm instead of 30, and the lenses were not quite as thick. They were probably about the same thickness as the first pair of myodiscs we had created for Melanie. She noticed the slightly smaller bowl, but since she had been used to myodiscs for the past few years she didn’t mind it. 

Two years later Malanie came back for another eye exam. Her prescription remained exactly the same as it had been previously, so I advised her that it looked like her myopic progression had ended. She smiled and told me that she felt the same way, but she was happy to hear me confirm her thoughts. So Melanie ordered a new pair of glasses in her same prescription, and when they were ready she came in to pick them up. They looked lovely on her and I told her that she was a gorgeous looking lady with a great looking pair of glasses.

That was about a year ago, and I don’t expect to see Melanie again for another year, but she is never far from my thoughts. She was the best patient I have ever had.


June 2012