 going home. My name is Bob Christensen. I have a private practice over at LDS Hospital. I also work in low vision here at the brand of 1990. Joy Vision Rehabilitation and what that represents. We call it vision rehabilitation because we feel you have the same responsibility in vision care that you have cardiac care or in orthopedic care. So it would be unheard of to give somebody to do cardiac surgery and not give them cardiac rehab. It would be unheard of somebody to have a hip operation but not go to orthopedic rehab afterwards. And we feel we changed in 1994 from calling it low vision to calling it to calling it vision rehabilitation. The devices we prefer calling them devices because you know AIDS is bad enough but having low vision AIDS is even worse than having just regular AIDS. So we call them devices. I'm grateful you're here. I did all the great deal of fear on Friday after listening to your presentations. They were incredible and wonderful and I thought my goods, goodness, these folks are geniuses. Why do I even bother coming? They already know all this stuff. But I'm here anyway and I hope that I can prevent you from thinking. Congratulations on wonderful presentations on Friday. Today's presentation will be a little mixture of some research, a little mixture of some basic science and a whole lot of practical knowledge that I'd like to share with you. Enjoy it. Let's go ahead and get started. This was a patient. This was a patient form that I received in my office from one of my patients and I was especially interested. You can't read the bottom. So I brought it up for you. I've especially appreciated the list of family history problems that they had and it was a little mackerel degeneration. Oh my goodness, you know, I don't think you want to have mackerel degeneration. It just seems like that would be a terrible thing to have. Does it have all those mackerels swimming inside of your eye? So that dreaded mackerel degeneration. Are you familiar with the term where the term macula comes from? The term macula, we talk about macula in the eye, means spot. The early anatomists had no idea what the macula did when they opened it up. They did see a dark spot in the back of the eye so they naturally named it the spot in Latin. So it's called the macula. We use the term in English today when we talk about it in the negative. We talk about a person keeping their house perfectly clean. They keep it on an immaculate spotless. We talk about in Christian theology, we talk about the immaculate conception of Christ. So macula means spot. So I'm grateful to be here. I enjoy what I do very, very much. This is a delightful patient with a terrible vision, about 2100, who functions perfectly normal in our society and does everything she wants to do and is very happy with her life. She uses a magnifier to read her phone and she just enjoys what she's doing. She has, she's happily married, has a very active life, travels on the bus with no concerns. Vision rehabilitation for everyone is the title or how can asking which is better change a person's life. And I really do mean that by simple refractions and by using some simple principles of optics, you can change people's lives. I have no financial interest in disclose. I make very little money doing this so there's certainly no financial interest in this. I'd like to start out by talking about what our responsibility is in regards to our patients and when does that responsibility and when does that responsibility and does it end after after the after the opera board is dictated? Does it end after the second postoperative visit or still have a responsibility to our patients after those things are completed? I would contend that we do. I would contend that we have a continuing responsibility to our patients to make sure they are completely ready for life after we've cared for them. I hate to say but so many times we'll see patients who have who have who have said this is not a criticism. It's really commentary who have been who've received admitted the retina guy, the retina guy says we need to have the counteractory moved. The counteractory is moved. They go back to the retina guy and they look at it and say yeah okay they do some treatments and so many times a refraction is not done. So many times the correction for their monovision is not done. So many times their visual acuity is not totally realized and I see sometimes patients after a year or two years after they after the surgery and they're still not where they should be as far as optical refraction is concerned. I think we have a responsibility to mourn with our patients that are mourning. Comfort those that need comfort to help them bear their burdens and so vision rehabilitation is designed to help people who vision is subnormal still be able to function. So Dr. Patel I'd like to ask you since you're the only one I really know very well here so would you mind reading this for us that the power the phenomenal power of the human oops go ahead would you mind reading that for us no just go ahead and read the phenomenal power the rest can be a total mess that you can still read it without problem I disagree with that I had just used the word. Isn't that incredible? Do I think that's incredible? We don't read words from first to last letter we read the first letter and the last letter and we grab something in the middle to be able to get the words that we need to read. The human mind is incredible and it's able to do that. One of the principles of vision rehabilitation is that we don't need to see the whole word just the first letter and the last letter and we can often fill it in the middle. So I patient about three weeks ago with a prescription of plus five and reading glasses I said my goodness someone's been paying attention to these lectures that I've given since 1994 and they had been given up I said where did you get these glasses and I said well I got them here at the Moran from my doc and I said who is your doctor I am so impressed and I said Dr. Olson is my doctor and my goodness is the boss is willing to do vision rehabilitation and give somebody a plus five reader then we all should be willing to give them a plus five reader. Low vision optics by definition a low vision patient is generally a person with decreased vision whose needs are not met cannot be helped by further conventional medical or surgical needs. I think when we contemplate surgery we need to wait at benefits and the risks of surgery sometimes I think we're not doing a great favor to people with subnormal vision who have minimal cataracts by removing their cataracts and I think we just evaluate whether we can meet their needs some other way than going ahead with surgery we need to assess patients needs in regards to daily life and surgical intervention. Low vision optics the goal here is to utilize the patient's remaining vision in order to accomplish the patient's goals I can't give anybody more vision I can't change their macular status can't change their peripheral field but I can take what vision they have and make it so it works better and I'm here this morning to plead that you as Dr. Olson did are willing to help people utilize their remaining vision just in your normal everyday practice whether you're going to be a retina doc or whether you're going to be a pediatric ophthalmologist whether you're going to be a colcoma doc to utilize the vision which they have. Realistic goals need to be set obviously some people are not going to be able to read everything they want to read or be able to fly the airplane that they want to fly but we can help them to function in society activities of daily living need to be considered. Our goal needs to be to use to maximize use of maximize the use of the patient's remaining vision I'd like to talk about magnification in low vision for just a couple of moments. Magnification increases the size of a retinal image often that is done simply by bringing things closer. My hand appears much larger when it is here than when it is here and so does the reading material appear much larger when it is here than when it's out here so we may have increased the size of the retinal image. It may be beneficial for certain diseases not for all ophthalmologic diseases and processes that may not be beneficial for other processes. For example in retinitis pigmentosa and other non-macular vision limiting diseases we may choose to do other things than magnification. One of the tricks we use is to use a telescope in reverse as a field expand and so that just as an example of this this is a simple telescope it has a large exit pupil, a large entrance pupil so it makes it easier to use. Similar to the thing that you have in the door in your home so you can tell who's coming up and when they're knocking you can look out and it's a reverse that's a reverse telescope and we use this telescope in reverse as well to be a field expander and so a person with RP walks into a room they've lost their pen they have no way of finding it except by searching as you would plant plant grain in a field by going just along back and forth in order to find where their pen is or we give them a field expander. We have to return around the telescope and use it backwards so that their field is better. But in general when we talk about vision reovotations we're talking about macular diseases. We can't get rid of the central scatoma in macular disease. The goal of magnification is to make the size of the retinal image large enough so as to minimize the effect of the scatoma. Let me just sort of demonstrate that with some very simplistic slides. This is an example of a macular disease with a scatoma centrally in the macular and the word Utah totally disappears because it can't be seen at all. It falls into the hole. Macular degeneration is Swiss cheese vision. It has holes in the vision where if something falls there you can't see it. However, if we choose to enlarge the image where it says Utah on there the effect of this scatoma is much reduced and the image is able to be read. This is easily read by a patient. They see the U, they see the H, they can see part of the T and the A and they know that that says Utah. The goal of magnification in low vision rehabilitation is to make the size of the retinal image large enough as to minimize the effect of the scatoma. Our responsibility I feel as ophthalmologist is to provide the most careful refraction we can. Do you guys still learn how to do refractions? Yes, you do. Yes, remember that's the which is better one or two thing, that funny machine that hangs in their offices. Okay. Our responsibility is to provide the most careful refraction we can. Our responsibility is to provide needed magnification through an increased ad. Our responsibility of provided needed magnification otherwise, if not through an increased ad. So if we can't get them where they need to be with an increased ad, then we need to find some other way to help them. That might just simply be making an appointment with us and vision rehabilitation on Tuesday afternoon, Tuesday mornings and Thursday afternoons. Refraction, some thoughts on refraction. Even a slight improvement in refraction can make a major difference for a patient. You might have done a surgery that patients recovering and you're really disappointed that their visual acuity came out to 8060. Previously they were 80, 20, 2060. Previously they were 2100. I want to commend you because of what you've done. You've increased their vision from being 2100 to 2060. It's now a usable level where we can make it beneficial. You might be disappointed but you need to be able to recognize that you can change that 2060 vision into being 2020 vision. You've gotten them back so that they can drive comfortably. You've achieved a great deal. Changing someone from 2200 to 2100 can be very beneficial. We live by driving a 2100 in the state of Utah. If by the way, if I can ever help you with driving privileges for the patient, please let me know. One of the other hats I wear in life is I'm on the executive committee of the Utah Medical Advisory Board for the driver's license division. So if somebody is having a problem driving and you want them to be able to drive, you can drive up to 2040 with or without correction and unlimited from 2040 to 2100. You can drive with limited license, limited to time of day, limited to speed, limited to area. We have chosen not in the state of Utah allow the use of bioptic telescopes. Our concern with a bioptic telescope is a loop, basically, which is set for distance. A loop like you would use in pediatric surgery. It's a loop set for distance and mounted in the top part of your frame so you can dip your head down and read the sign on the freeway. Our concern is that the time you take to find the sign, move the loop to where it needs to be and read the sign at 70 or 80 miles per hour is much too long to be safe. You've traveled hundreds of feet, literally hundreds of yards during the time that you've been searching for that sign. That's too long to have your eyes off of the street. So instead, we have a very liberal policy of helping getting everyone who's even near at 2100 or better than they can drive. I personally think it sounds incongruous to say that somebody is legally blind at 2200 but yet they can get a driver's license. It just doesn't make sense to my mind. How can you be legally blind and still be driving? So your patients will ask about using bioptic telescopes. We don't allow them in the state of Utah. They do allow them in other states but we don't allow them here. A large character chart may be beneficial. Be careful about astigmatism and check old glasses. I think if somebody comes in and you're having a concern as to what their refraction should be, looking at their old glasses, looking at their preoperative glasses can often be very beneficial to detect. Looking at their preoperative refraction, you'll know if there's astigmatism, which may be residual in spite of our best efforts. We do a foreoptor refraction. Sometimes we do a trial frame refraction. Many times we'll actually do keratometry. Look at the corneal analysis in order to determine if there's an astigmatism that I'm not knowing about when I'm trying to refract somebody. My vision is blurry. Dr. Wilson talked about this briefly on Friday. If I say my vision is blurry when I read, they're probably a presbyopia. They're probably hyperopic. My vision is blurry when I read. My vision is blurry when I look far away. They're probably a myope that's having concerns there. When they say my vision is blurry all the time, Dr. Wilson, since I remember made the point on Friday, we're talking about myopic astigmatism or hyperopic astigmatism. Because no matter where they look, the astigmatism is affecting where they see. Stigma means point. Astigmatism means without a point focus. Instead, it's a linear focus that they have. Listen to the patient as they read the eye chart yourself. I often get some good hints by listening and seeing if they're having trouble with reading some letters very easily. If E's and T's and I's are very easy for them to read, but O's and D's and C's and letters which are not straight up and down or straight horizontal are difficult to read. So I often will just listen to how they're reading and what letters are missed and where. I'd like to give you an idea of just a visual acuity and estimate. I've learned from experience that if someone is about 2050 and they're straight myope, they'll be either a minus five-sphere or a spherical equivalent. So if somebody comes in, a kid comes in and they're 13 and they read the eye chart and they're 2060, I'm saying in my mind they're going to be minus 75 or minus one in both eyes. It's straightforward, no problem, or the spherical equivalent of that. If someone comes in and they're reading 2060 and yet I'm giving a refraction of minus 250, I'm saying to myself, there's something wrong here because that's just not optically appropriate that someone would have that level of vision that would require a minus 250, a 2200, that's going to be either a minus two sphere or a minus two spherical equivalent, just a rough estimate. Some people say cylinder is for sissies, I have an older brother who's an ophthalmologist who says that jokingly. I'd like to comment on what I call supplementary astigmatism and I'll show you, I'll demonstrate that in just a moment. Supplementary, complementary means an angle that adds up to 90 degrees for complementary and supplementary adds up to, in your basic old geometry class, supplementary angles add up to 180 degrees. I'd like to demonstrate that for just a moment. Talking about parallel astigmatism, the cross cylinder is so helpful. With the real astigmatism of course means the stigmatism at 90 degrees, against the real means at 180. I think we always have to remember to balance the cylinder as there's an atmosphere, as we're increasing the cylinder we need to increase the myopic power of the sphere. I hate it when I'm chasing axes with people. That's the term I use for it. They just keep moving, moving, moving this direction until they get to a certain spot and then they stop and then they just keep moving back and forth, back and forth like I hate that, can't stand that and so that's been it. I have no simple answer for that other than just being patient and recognizing that you just need to be patient to find where that axis is. I will always check axes at 0, 45, 90 and 135 and everyone just to get an approximate idea if everyone's where they should be. So this is what I'd like to talk about when I say supplementary symmetric cylinder and this has become such an important part of my practice in that I just don't even, I'll do retinoscopy on one eye and maybe not even the other one because notice the axis so here's somebody, this is their final refraction. The axis here in the right eye is at about 10 degrees. The axis in the other eye is at 170 degrees. 10 plus 170 equals 180 so it completes that supplementary angle. This is another refraction but the opposite so this in the right eye is at 175 degrees in the left eye they're at five degrees so once again that'll add up to 180. 45 in the right more often than not it's going to be 135 on the left. If it's 85 in the right more often than not it's going to be 95 on the left adds up to 180 degrees and that's made my life a lot easier a lot of times. Change in refraction. When does refraction change? Teenage myos and hyperopes. Nearsighted kids are going to be more nearsighted. To my experience girls seem to started about age eight or age nine boys started about age 12 and boys and girls could stop changing their myopia at about age 18 or 19 boys stopped changing at about 21 or 22 and they'll continually increase. Are there any hope to keep that from happening? No, I don't think there is. Can you keep the kid from reading? No, I don't think that's a good idea. Can you actualize both eyes for their entire youth? Yeah, but what mother would be stupid enough to do that. So I encourage so kids that are myopes I'll often look at them and I'll say you know what do you like to do and they'll say I read books. I read books all the time. That's my favorite thing is to read books. If you could play baseball or read books which would you do? I'd read books and I think to myself did their myopia caused them to uh did their reading books cause them to be myopic or did the fact that they play lousy baseball cause them to read books. I don't know the answer there but it so often happens. Any nearsighted folks here? Shrazy show of hands? Yeah, yeah, yeah, most, yeah, you're looking a law school class most of those folks are going to be nearsighted as well because they've been reading so much. Pregnancy, does nearsightedness change in pregnancy? To my experience it does. I can't prove that. Large studies have shown that it doesn't change but to my practically experience it changes all the time. So someone comes in I don't know whether it's growth hormone I don't know what it is it's causing increase in nearsightedness. I don't know whether you're simulating being in puberty again because of the growth hormone maybe goes transplant steadily I'm just making up all that stuff but pregnant women will come in two months after pregnancy and they'll say my vision has changed. Happens after the first pregnancy doesn't necessarily happen after a subsequent pregnancy. Law school, boy, law school is a killer. I have a patient who's a lawyer now who came in throughout law school and every six months he was coming in and he was more nearsighted. I thought to myself this really can't be happening he's 24 years old but we just kept increasing his nearsightedness so you can see the board and keep going on. I think he was in permanent ciliary spasm. The ciliary body was so overwhelmed by law school that he just was in constant ciliary spasm. He's now 10 years out of law school he's no longer wearing glasses and he's doing fine. I was increasing his nearsightedness every six months and he was just not happy because he couldn't see the board. So I think that there's a tremendous amount of reading they do at law school. In fact I advise I advise kids starting law school to wear reading glasses whenever they're reading or certainly to take out their contact lenses or to take off their glasses when they're studying because they study so much. Diabetes, diabetes changes it all the time. How does diabetic, how does diabetes change refraction? Anybody? Not big as well. And how and why is that? Smelling of the lens. Sorbiture. Yeah I think it's all of those things coming up but I think it's smelling of the lens. I think the lens increases as our glucose increases and they become more nearsighted. Guy comes in to see me numbering and I won't mention the name of the restaurant but he's the owner of a large restaurant chain and he comes in and he says hey doc I gotta tell you I am 45 years old and the best stuff has just happened. I said what's that? He said I used to have to wear reading glasses for three years and now I don't have to wear reading glasses anymore. I'm thinking this is not good. This is not good. 45 is not the age when you normally develop myopia and he says this. I say this is not good and he says and I say well how's your distance vision? He says you know that's kind of funny because I really can't see well the drive anymore. So I say oh okay here and we keep your intestine strips in our office. I said here this cup, put it in the bathroom, come back out, we test it and sure enough he is dumping sugar into his urine in considerable amounts and I say okay we need to fix this. He comes back and sees me three months so he said I don't like you anymore. I said why is that? He said well I have diabetes and now I can't now I have to wear my reading glasses again. So he had become very nearsighted because of the cheese fries, oh we mentioned it, because of the cheese fries at the restaurant and he was diabetic he was now wearing reading glasses and seeing better far away but his reading vision had disappeared. Cataracts, nuclear sclerosis is real, people become more nearsighted and you know that already and you have the choice either to correct their nearsightedness or to do surgery. I have a tendency to wait until people no longer can drive before recommending surgery just because I think they're benefit in doing that. Presbyopia, presby means elderly. Okay the Presbyterian Church, anybody Presbyterian? Tell us about Presbyterian Church, who runs the congregation in the Presbyterian Church? Oh I don't know about Presbyterian Church. I'm just saying that I call Presbyopia disease of short terms. Disease of short arms, yes it is, it is, we do an arm transplant or we give them bifocals. Presbyterian Church is a church that each congregation is run by elders. So it's the church of the elders, so Presby means elders, elderly, elder vision is Presbyopia. I seldom explain that to patients though in the office. We're all aware that a combination of amplitude decreases with age and it reaches a critical stage at age 42 reaches another critical stage at age 50. At 42 we no longer can read here, at 50 we no longer can read here. Presbyopia is real, you folks are going to say it's not going to happen to me. It is real. Why does Presbyopia happen? Lens loses ability to change the curvature. That's right and why? Because it loses the fibers and it's become more hard. Okay it does, why did and so Presby, the lens of the human eye is made out of epithelial cells. And like epithelial cells throughout the body they grow, they die, they flake off, however in the eye they know a lot they don't flake off and drop into the vitreous, they get compacted tighter and tighter and tighter inside of the lens and the lens even though your ciliary body may remain just as strong as it's always been, the lens becomes more and more rigid and no longer is it as elastic and flexible so that it can round up in order for us to read. So the process of combination is accommodated by letting the lens round up and become more thick so that we can read up close and that no longer happens as easily. Symptoms of Presbyopia. Difficulty with reading, of course, need for bright or light, of course. Okay, I gotta tell you the first time I knew I was Presbyopia because I was sitting in a wonderful library and I was having just a great time reading this wonderful book about my family history and I glanced up and I looked and I thought oh gosh I can't read the clock. So my first symptom of Presbyopia was having been an accommodated spasm because I was trying to read so hard and I couldn't see the clock. So that happens to a lot of people. Blur distance vision after reading, headaches, age 44 and higher. I've actually gotten referrals from docs who sit from primary care docs who say you have got to see this patient this afternoon. This morning they could read and at lunch they could no longer read and you have to see him. So they came in and they they become Presbyopic and it really just didn't actually happen between morning and afternoon but they they thought it had and they said this was an emergency and it was just simple Presbyopia but it's real and it's really sort of a shock what it happens to you the first time. We can treat it using readers, bifocals, trifocals, progressive lenses and we have to increase the power. So this is a progressive lens. We prescribe these all the time but you need to recognize though is that there are areas in this progressive lens which do not work at all, which are totally worthless. And so when you're going to a progressive lens the trade-off is there's no line, it's cosmetically better, you can adjust your reading distance wherever you are back and forth but there are parts of that lens which don't work at all. For example it says this blending region, this purple area is the blending region okay doesn't work there at all and in the top in the top is an area which is terrible vision and so when I'm using my computer and I'm using my wearing my progressive lenses, yes I am wearing progressive lenses I'll confess to that, in order to see the upper left head corner of the screen I have to move my head like this and go up to see the left corner. I come back to the center, I have to then move my lens and go up to move my whole head and go up to the right corner because I need to bring those corners into this area where the intermediate is. I am not simply able just to glance and see the edit menu, I'm not simply he's able just to glance and see the right corner to close my screen I have to physically move my head and during the day when I'm sitting here using me I actually have to tip my head back and kick my neck so that I can see this screen. Progressive lenses are great but they're really hard on your neck and it's very difficult. I think each one of us has a responsibility to you to recommend computer glasses. I love computer glass so I mentioned there are two big changes one happens at 44 that's when we lose here one happens at 50 when we lose here because of loss of accommodation you will bless the lives of so many people if you recommend computer glasses to them. I use I use regular old-fashioned d-shaped bifocals and I take and I hold up a book one of my texts holds up a book and we we put in plus power until they're happy maybe plus 150 125 and they said whoa that's great I'd love to have that I would love to have that vision so I can see my computer without tipping my head back you say okay great and then I said you have to read texts as well read letters as well and I say yes I need to read letters so I need to read a letter here look at my computer screen and so I give them an old-fashioned pair of d-shaped bifocals on the bottom for reading and the whole top part becomes plus 125 or the plus 150 over their basic refraction and now they are as happy as they can be more people so many people are using two screens now in their work and I have to go back and forth and then they have their laptop on the side and they're sitting there and they're moving back and forth from screens and computer glasses really make life so much easier for those folks and makes it for possible for them not to go home with a headache at the end of the day I think you just do great things for giving people to give people a pair of computer glasses not very expensive you know progressive lenses any idea how much progressive lenses cost they're expensive 600 bucks 800 bucks for a pair of progressive lenses I think you can get regular d-shaped bifo me get this computer glass or maybe 300 and it makes it so much better excuse me you still take them off yes my hopes can still take them off my hopes can still take them off when they need to keep the same effective ad power so when you increase myopia you need to remember to increase the bifocal power where they're not going to like you be careful with presbyopic IOLs with macular degeneration you know I just I just caution you that if someone has bad macular degeneration they have enough macular pathology as well the throwing in a progressive throwing in a bifocal to bifocal interocular lens may not be what you really want to do to them I think that's just really a difficult thing to be able to manipulate the the scatoma of your macular degeneration at the same time you're trying to find that place in the lens where you can use it for distance vision versus reading vision I call this occlusion the seconds maybe not that's the appropriate that's not the appropriate term but with my experience I've noticed that for example a challenge is a teenager who wants to drive and with occlusion drops below legal limit so this is characterized to be seen in albinism so I'll have people who are albino they'll come in and they'll read the chart and they're reading 2060 and they can drive then we cover the one eye the nystagmus increases I don't know why it increases but nystagmus increases and then they drop to 2100 then they cover the other eye and they drop to 2100 and nystagmus increases but with both eyes open they're at 2060 so what I would suggest is when you're when you're refracting a albino that you use plus sphere to blur rather than occlude the other eye and that seems to work very well I'm not sure if that's other people's experience but I will just simply crank I'll be sitting there at the foreopter and I'll just either crank in the plus three if I turn in the major major my major spherical change dot I'll either put in plus three or plus four and now I know that they can't read with their with their blurred eye but they can read with their other one and now I can refract them to 2060 in both eyes and get them their driver's license have a great patient who's gone on to graduate school teaches drives she's 2080 with both eyes open but she drops to 2200 when I was covered and for many years she was not allowed to get a license because nobody would let her drive at 2200 when they tested vision avoid over minusing pay attention to how much minus is really needed started out by saying if someone's 2060 they're really only going to be minus 75 or minus one and if you're getting them a minus 150 that's not going to be the right prescription for them watch for small winner and darker we all know that reading bottom line versus reading next to the bottom with 2020 rows we have multiple on the old charts we had for 2020 rows and you have a number of as many 2020 rows with the computers that you want to have we use those for refining their nearsightedness and also for malingerers tell you just love doing that with malingerers is just put up the 2010 row on the bottom and you say can you read that they go oh no no I can't see that at all anyway 2015 can't see that one and so they've decided they're only going to read the third row from the bottom so they end up reading the 2020 row it's just such a great moment when that happens have you ever followed a malingerer into the parking lot that's even another great experience it's just a great experience just a great experience I was at the national chamber here the Boy Scouts one year and there was this kid that came in and he said I was called over to the tent to the emergency field hospital because he had gone blind suddenly and this 12 year old I said you really and he said what did the story say it just left just after I left home I said to kind of miss your family said I really missed my mom I just really miss her and I but I'm really blind now and I can't do anything and so I said okay um so I did the old trick of walking out of the exam I said you just come with me to this other room okay and I pulled the chair into his pathway and then I walked on and he walked carefully around the chair so I knew where we were this kid was a malinger he just wanted to go home to his mom but then field hospital docs and we're in the army and they said yeah we got to evacuate any person to serious problems I said okay you can evacuate him but it's not going to be good so this kid 12 year old kid got on this jet helicopter and he had to face the challenge of whether he was going to continue to be blind and not enjoy the airplane or helicopter trip or whether he was going to be cured went back the next day they said oh yeah as soon as we got off the ground he could see just as fine as he ever gets not going to miss that jet helicopter ride so what's happening I like I like saying blurs blurs more so what am I doing when I say that the last step in my refractions is always bringing the image into correct position on the retina where I think it should be and I enjoy refraction because it's sort of like a physics experiment in real life so I'll get to the back I'll have the image where I think it should be on the retina and then I down click one click I say does that blur and they'll say no that's actually about the same ooh I was not at the right place I clicked down another one they said oh yeah that blurs I clicked down another and I said oh that's really blurry so if I could so I found that blurring by half a diopter doing in quarter steps will really tell me whether I have the image on the retina or whether I'm not having an image on the retina uh estimating prescription hold lenses up and look at something rectangular do you ever do this just to see what their prescription really is so somebody will come into my office I get their glasses and I'm just going like this I'm going okay and I go like oh yeah there's cylinder there and then I move it up and down there's a progressive lens there so what does this really mean I like to look at the patient's face and see if I can see the shadow and they see their eyes behind so are the bottom ones nearsighted classes yes absolutely they're minus lenses so they're making things look smaller so right away I know that um that person is nearsighted so this works best when I'm taking care of a teenager and I turn around and look at mom and I see this is what mom's face looked like this lower picture and I say well they're just sort of nearsighted like you are ma'am she looks at me like how did you know I'm going oh that was an easy one okay so I'll hold glasses lenses up and I'll look at a square object and decide what they really are someone's not getting to 2020 vision I think you have a responsibility to figure out why maybe it's a post-op you don't know if they were ablyopic before you don't know what as a child now they're post-op now they're pseudo-faking and they're still ablyopic and you're not getting good vision there I think we need to look at that our responsibility is provide needed magnification through an increased ad so focal length and magnification are all associated with somebody help somebody can help me remember the how you calculate the focal length of the lens best so based on this biopic power anybody plus two lens focuses at what distance 50 centimeters so it's the inverse of the focal length expressed in diopters plus three lens focuses at 33 centimeters plus four lenses focuses at 25 centimeters and so forth so a plus eight if this guy's put in a plus eight it focuses at 12.5 centimeters which is about five inches away and so I need to encourage people when they're using an increased ad to hold things closer I usually say this is like dancing at the closer the better and they sort of chuckle and um and we tell them to hold it closer from 2030 to 2040 if someone's best corrected vision is 2030 to 2040 I will give them a plus 350 if someone's best corrected vision is 2050 to 2060 I will give them a plus four if someone's vision is 2070 to 2080 I will give them a plus 450 Dr. Olson and I will give them a plus 450 or a plus five ad and that allows them to bring the material close enough that they can use it using increased ad power is the best thing you can do for people it's so easy and so simple you give them you test it in the four after you say is it okay will you be willing to hold things that close if you can see them that well and I say well sure and then I look at their spouse or the person with them and say would you remind them of that when they get these new glasses so they have to hold things close sometimes I physically grab the back of their head and I grab the reading material and I shove them forward shove them together as much as I can in order to show them that they have to be able to hold things close this is such a crucial essential thing if you're doing nothing other than what we from what we talk about today this is so crucial let me just pass around a set of high-plus reading lines I'm going to use these all the time and I just want you to test just for a moment the effect of increased ad on focal length so these are prismatic lenses these have base in prism because nobody can converge easily at my love age to six inches to three inches and so let me just pass these around the bigger powers are here on the right the lower power of the problem let me just pass those around let me just pass it as we continue to talk so this is a very interesting lady this is a PhD student in engineering who comes in to see us her prescription is minus two and a quarter plus some cylinder which is not very significant and so aha this is going to be very interesting for you yeah yeah yeah but it's very large isn't it sometimes we have to do nose surgery so this is a lady stargardt's disease she's a PhD student up until now she's been fine but no longer can she read so her accommodation is already decreased she takes her glasses off and the minute she takes her glasses off she's her minus two glasses the minute she takes them off she's now two diopters worth of nearsightedness but really that's adding two powers of two diopters of reading power but the problem for her is two diopters of reading power is not enough for her to be able to read so we give her a pair of plus six diopter reading glasses like you're passing around and now she can read just fine now she can go to go to class she can look up at the board to then look at her notes and hold them right here and she can read so it seems crazy to give somebody who's nearsighted and minus two already to give them a pair of plus reading glasses but they when they take off their glasses they're not minus two they're plus two and now they're plus eight because they put on a pair of of plus six reading glasses so change this lady's life just by a pair of plus six reading glasses our responsibility to provide needed magnification if we don't through through an increased ad we need to do it in other ways this is a guy very interesting guy maybe he's a patient that you have actually seen patient here at the Marat 58 years old he has a central retinal artery inclusion and he comes in he has a refraction which is minus 125 which gives him 20-20 vision okay and he's doing pretty well with minus 125 and getting 20-20 vision but he can't read anymore he says i can't read and so i'm not going to wear these glasses i said will you be willing to wear a bifocal and he goes no i don't want to wear a bifocal cheapest way to take care of this guy is to give him tell him to go to the grocery store and pick up a pair of plus 250 readers take your glasses off he's now plus 125 instead of being minus 125 and put on a pair of plus 250 dot readers he's now almost a plus four he can read very well and he's back to doing what he needs to do reads with his glasses on puts on his readers in order to read it's one of those folks who has enough nearsightedness that it blurs the distance but not enough that he can take his glasses off and read easily this is a guy with bilateral retinoblastoma he's been walking around with a 20-diopter lens which he carries in his pocket and he is just just doing fine we instead decided to give him plus 20 pair of plus 20-diopter glasses and so now he's hands-free he doesn't have to pull the lens he just brings things up to 20-diopters and what would be at 20-diopters if you were playing no before is one over 20 it's five so he's at five centimeters he's really at about two inches away but he's as happy as can be glasses off for myopes we give reading glasses even in myopes and we give prescription high power readers like you're looking at oh this isn't really the lady that's happened to but it's to remind me to tell you this great story this lady's in my office similar to this lady and she says you know about 10 years ago i was visiting the eye doctor and i was really having trouble with my reading and i needed a very powerful magnifying magnifier and so i noticed that there was this magnifier laying on the doctor's desk when he stepped out i said yes and she reached in and she said so i just picked up that magnifier and i slipped it inside my shirt and i've been using one of those ever since she stole she stole the 20-diopter indirect lens off to the doctor's desk and put it in her in her shirt and walked out she said you know ever since then i've gone to doctor's seeing if i could find one at such a low price again and i'm thinking she'll stay out of my office i don't want you here that's that's too expensive 20-diopter night on one additional principles of low vision optic magnification positioning illumination ability to use the stronger the magnifier the shorter the focal length we've talked about that already the stronger the magnifier the smaller the smaller depth of field you have very little depth of field when you're using a plus six or a plus eight but you just need to recognize that stronger the magnifier the smaller the apparent field the stronger the magnifier the smaller the less so this is a 14x right this is a 4x you're never going to be able to find a 14x that's this size does it exist becomes so difficult to make the length the center thickness becomes so thick so you can always tell how strong the magnifier is just like lansing at the size i recognize we need to get going so let me just finish up the stronger the magnifier the smaller the physical size the electronic magnification is really fine this is an electronic magnifier over here this is a close circuit television system patient places the image places the thing i want to read on the reading stand down here magnifiers turned on they can slide things for about 30 for about 2,800 bucks you can get one of these that does text-to-speech and they're wonderful my mother-in-law has macular degeneration and she loves she reads the newspaper every Sunday reads the paper daily just by using a close circuit television system like that the text-to-speech it's expensive but it changed it's changed her life all the reference difference of arbitrary 25 centimeters traditionally has been assigned to this value so a 4-diopter lens equals a 1x magnifier therefore the label magnification for a 20-diopter hand magnifier is specified as 5x as we usually communicate with other health professionals we usually include both the diopter value and the label magnification so this is a 5x magnifier this is a 20-diopter lens and it's a 5x magnifier so if i'm going to specify for this for you when i'm writing to you i'm going to say we used a 5x 20-diopter magnifier in general that's the relationship between x powers and diopter powers quality of vision that we look at typically our acuity field and we also need to look at contrast sensitivity so many times you may do a counteract operation and you're not satisfied with the result what you don't realize is that their contrast sensitivity has decreased tremendously we measure contrast sensitivity i'm not sure we have that down here nope we use just a simple hand chart and what we did a huge study in my office at our clinical study which showed as the contrast sensitivity was good glided magnifiers were not necessary and the contrast sensitivity became poor people wanted to have a light in the magnifier that they were using you know folks so in reality i haven't given out an unlighted magnifier in the last 15 years because so so many people like additional light we now have halogen lights that are excellent we have excuse me have led lights which are excellent and they last forever and the batteries last a long time and so 99 percent of the time we'll use a lighted magnifier no matter what their level of visual acuity is or no matter what their contrast is this dis-magnification can be accomplished with telescopes loops and binoculars the goal of magnification and low vision rehabilitation is make the size of the rebel image large enough so as to minimize the effect of the scatoma that's what we're doing so we're making the retinal image larger so that so that the effect of the scatoma is not as significant um vision rehabilitation for everyone or how can asking which is better change a person's life i really believe this i really believe you can change people's lives by taking responsibility for them even after the surgery is complete even after your last post-op visit you can change their lives by giving them a high plus magnum high plus bifurcum presbyopes i always give at least a plus between 60 and 70 i always give plus three dial up your progressive lenses i'm really cuffs 350 plus four the optical shop will make you a plus four 50 at if you want it it's kind of fun to enjoy refracting but i would suggest that if you're having a really bad day you can always try asking which one is worse rather than which one is better thank you so much for being