Camille was organizing frame cases in the showroom when Dr. Rourke and a patient approached her for a hand-off. 

About Real Deal

Real Deal scenarios are inspired by true stories, but are changed to sharpen the dilemmas involved. The names of the characters and stores have been changed and should not be confused with real people or places.

About the Author

NATALIE TAYLOR is an experienced optometry practice manager for Advanced Care Vision Network and a consultant with Taylor Vision. Learn more at tayloreye.com.

“Camille, I’d like you to meet Doug,” said Dr. Rourke. “Doug’s around a -5.00, he’s new to our office and has a bit of an astigmatic change so he needs to update his glasses. To address his accommodation needs I’d like for him to try a progressive lens.” Dr. Rourke patted Doug’s shoulder and headed back to the exam lanes. 

“Would you like me to find you a pair similar in style to your current glasses?” asked Camille, gesturing at the tortoise P3’s on his face. 

“I think I’d like to find something different,” he said, “Maybe with nose pads? My glasses are always slipping.” 

“Sounds like a good plan! I’m going to select a handful to get us started,” she said. 

Doug eventually decided on a drill-mount with high index and used his vision benefit for a deep discount. Several days later Doug met with Camille for his dispensing appointment. Camille completed her speech for first-time progressive wearers and encouraged Doug to wear his new glasses for the full day tomorrow. 

A few days later Doug came back to see Camille. “I just don’t think I can get used to these,” he confessed. “It’s really hard to work at my desk - after a few hours I had to take them off. Can I just get the kind of lenses I’ve always had?” 

“Of course you can,” reassured Camille. “I hope you’ll keep your mind open to progressives in the future, but for now I will remake your lenses at no charge.”

At Doug’s second dispense, his reaction to the new prescription was frustration. “These don’t feel right. Everything looks weird and it feels like my eyes are… pulling? It’s hard to describe.” 

Camille took both new and old pairs back to the lensometer. Dr. Rourke had changed the axis in each eye by about 20 degrees, so she coordinated a same-day prescription recheck for Doug and met with them after. 

“Well, it seems like Doug really prefers his old prescription,” said Dr. Rourke. “Let’s remake these lenses, and please put a rush on it.” 

“Also, while you were working on the glasses I looked around and found a different frame I like better. Would I be able to change?” asked Doug. He held up a zyl frame retailing for about half the cost of his original drill mount. 

“Sure!” said Dr. Rourke, “That’s not a problem, right Camille?” 

Camille submitted the change to the lab, which charged 50% retail for the second remake. Dr. Rourke approved the charge as a write-off for the practice. Doug came back a few weeks later for his third dispense; Camille wasn’t anticipating any issues so she was caught off-guard when Doug reported the same uncomfortable pulling sensation. 

Perplexed, she asked to see his previous glasses again and went to the relative privacy of the lab. After a few minutes, it hit her: she dotted the optical centers in the lensometer and took them to Doug to try on. Sure enough, his pupils were easily 10mm higher than her marks. 

“Can I ask where you got this pair of glasses made?” she asked.

“I ordered them online; I didn’t have vision insurance back then,” Doug answered. 

Camille did her best to explain induced prism to Doug, but she could see in his expression he thought she had made a mistake and was trying to assign blame elsewhere. Losing his trust was an unhappy moment for Camille. 

“So what is the next step here?” asked Doug. “These lenses are too uncomfortable to wear.” 

The Big Questions
  • Should Camille knowingly make a pair of glasses with that much induced prism, even if the patient has adapted to it?
  • The lab bill for another remake will likely be 100%. Should Doug be asked to pay some [or all] of this?
  • Would you keep the difference in cost of the frames, as Doug used a managed care plan for the purchase? Why or why not?

Expanded Reader Responses

Richard K., OD, Rochester, NH

I would keep the money from what is paid for the first frame. I would redo the lenses one more, (third) time with induced prism, but, I would warn the patient, that it would be the last time and he must accept them as they are, with no refund. Or, he could get a refund from whatever he paid to that point and the frame, too, with a 25 percent restocking fee, which is stamped on all my questionnaires. There has to be a limit on redo's because, who knows when it will end. Better suck up the loss, then continue to lose more and more. Lastly, if he takes the refund, then dismiss him afterwards from the practice. Likely, he could be a never satisfied patient.

Christopher B.  Iselin, NJ

I would trial frame the Rx with half the amount of prism and try to find out how little BD prism he is willing to tolerate. Once I landed on the amount that the client is comfortable with I would take my findings to the doctor and see what he thinks about it. My plan would be to reassess how much BD prism can be pared down on future visits, with the goal of eliminating if possible down the road. If the doctor approves of the Rx change I would remake under the lab’s doctor Rx change.

Rob M., OD Merrillville, IN

Due to the induced prism, I would recut the lenses with half the prism value into the new frame. I would have the doctor explain why the change has occurred and that over time, we would be able to reduce the prism entirely until we had the best Rx available. We would ask our laboratory for a one time voucher to help gain patient confidence. Hopefully by solving the problem with a thorough explanation, the practice will have gained a patient for life. The minor loss on these glasses will be offset by future purchases and the goodwill the patient will spread for the practice.

Steven G. Houston, TX

When you checked the patients old RX, as a standard procedure you should check and document the WOC'S (wearing optical centers), the height and base curves if plus Rx over 3.00 diopters.

Robert M. Edina, MN

She should not remake the glasses again until she has Dr. Rourke see the patient for a re-check. Trouble shooting a customer’s problems is part of what we do. This type of thing is easy to miss the first time through. The glasses should be carefully evaluated before remaking them and solve all the problems at once. At this point it is still Dr. Rourke and Camille’s problem and Doug should not be charged. We do not resell frames that customers had worn. Therefore, since he is buying both frames, I would bill the vision plan for the first one as it was dispensed. It is always best to spot centers on glasses when you are evaluating for an optical concern.

Stewart G., OD San Francisco, CA

The technician should discuss the situation with the doctor. As a practitioner, I had a similar situation with a patient who swore that every pair of glasses she wears came from me, when, in fact I was fooled because the frame she was wearing I used to carry, but she never purchased it from me. After making her glasses, she had the same reaction as this patient did. It was only when I insisted she return with her old glasses that I realized that I had never made the glasses she was wearing (and I proved it looking at all her orders over the past 15 years) and that her current glasses had a DBC that was off by 6 mm from her actual PD (and she's a -8.00!). I put her Rx into a trial frame, and moved the DBC slowly until her symptoms disappeared and that's what I used for the remake and she was happy. I told her that she has now become a rehab patient.

Paul G., MD Tucker, GA

A relatively simple, easy, and cheap solution could be press-on Fresnel prisms. Explain to the patient that he had induced prism with his old glasses, and that by tapering the prism over time, he would probably adjust to the new glasses without any prism.

Amber C. Glen Burnie, MD

Our practice model has the glasses checks begin in the optical with a recheck of the patient wearing the old glasses and the new glasses (when possible). We include a note of the patient's complaint and compare all aspects of the glasses, which hopefully would catch the prism. We may also trial frame the patient with the induced prism and the new Rx for comparison, notating for the doctor. Since we have already done one glasses check, and assuming both pairs of glasses were compared, we would again review our findings including the induced prism with the doctor (assuming it was missed initially). We want to be respectful of the patient's and doctor's time. The doctor will advise, which may include asking the patient to try over the next week or two without the prism, if the exam did not find it medically necessary. However, given these circumstances if it was found the patient did need the prism to comfortably see, we would then remake the glasses as a courtesy.

Rick R. Girard, PA

1. Camille cannot make another pair of glasses and induce the prism. She needs to explain the error on the part of the online glasses and reassure Doug that it will be a continual problem, in the future, if he doesn't correct the problem now.

2. Only if they decide to remake the glasses once again. Which they shouldn't. The online glasses are the mistake, not Camille's.

3. Since the online glasses were made incorrectly, creating the problem, then I wouldn't refund the cost difference because they have already taken a loss on the remakes.

Vlad C. Hackensack, NJ

I would not knowingly make a pair of glasses that will induce prism that’s not part of a patient's original Rx without the OK from a doctor. I recommend Camille explain what happened to the patient and give the patient more time to get used to the proper Rx first. If that doesn't correct the patient's symptoms, then ask the doctor if he's comfortable Rx'ing prism to match the patient's previous eyewear. As far as financials, I would wave additional costs if the patient is not a habitual offender. Assuming the patient brought his old glasses in with him during his initial visit, it's only fair to conclude that the prism error was not his fault, but an important lesson to learn for both the patient and the optician when dealing with online glasses.

Tami T. Cincinnati, OH

No you don't remake the glasses knowing that would be wrong. He needs to give his brain time to readjust to the correct glasses. It's an eye brain coordination that has to happen and that takes time.

Jeff R. North Sioux City, SD

It is our job to create a pair of glasses that most accurately represents the doctor’s Rx. If a patient purchased something in the past that counters that, it’s on the patient. Creating a pair of glasses with induced prism is no different than voluntarily changing the doctors script. Show the patient the optical center on the old glasses to help explain and inform that anything you do to attempt to duplicate is a random guess at best. Check with the insurance company on their frame change policy and fall back on yours if necessary. No refunds on downgraded frames, just like lenses. If the patient wants you to go forward, get your doctor’s inclusion and any recommendations from them. Full price, you have already made the correct pair twice. This is upon request of the patient. 

Leisa S. Newport Beach, CA

Camille should have done a more thorough assessment of Doug’s glasses from the very beginning. Why were the glasses slipping and how much time was he wearing them in the wrong fitting position. Unfortunately, once a patient has adapted to the wrong RX it really is not wrong any more it becomes the proper or tolerated RX. The practice is responsible for the remakes because of a lack of proper assessment. I would not charge the patient for the redo; allow him to choose a different frame at no charge but I wouldn’t refund any money to him directly. I would suggest he try a progressive again with the new RX because of what was stated initially from the doctor about his needs in very day life.

Bob EyeHelp LLC Florida

Quite a dilemma. How many remakes before you cut a patient loose? Everyone gave up on the PALs too quickly and now you'll lose a customer and who knows how many others when he shares his story. Remake one more time.

James Barnes, Boise, ID

I would make at half the prism so that it’s not such a shock. And then the next pair of glasses he gets reduce the prism again.


This article originally appeared in the September 2018 edition of INVISION.       

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