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When 20-20-20 Isn't Enough

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Why Optometry?

As a young girl, I was fascinated with going to the optometrist, and the older I got and the more questions I asked, the more interested I became. I graduated from Indiana University School of Optometry in 2007, and I’ve been practicing for 16 years. I opened Preferred EyeCare Center 15 years ago, where we practice general optometry, serving patients “from diapers to diapers,” which is why I love patient care.

Our patients are diverse, but whether they are executives, schoolteachers, or students, they all spend part or all of their day on an electronic device. Computers and mobile devices are part of our culture. As a result, we all struggle with digital eye strain, even though people often do not realize that they have it. They may think that they have dry eyes or tired eyes and not realize why. So, it’s satisfying to finally be able to give them some guidance.

Accurate & Precise Screening is Essential
The screening procedures in our practice have evolved over the last few years. Previously, we used the basic cover test and near point testing, but Neurolens has provided us with a screening tool, a short questionnaire that allows patients to rank the severity of their symptoms. That information is entered into the Neurolens Measurement Device, Generation 2 (NMD2) to determine whether a patient has misalignment. Whereas the cover test measures misalignments in increments of three prism diopters, this instrument is accurate to hundredths of a decimal point, providing us with far greater precision than we ever had before.

We screen everyone at our practice, whether they’re symptomatic or not because this instrument is so precise that we can learn things that may not even pertain to a misalignment. For example, someone may have an eye that constantly turns in, and the NMD2 helps us to better understand the severity of the problem.

Some patients come in complaining about symptoms like head and neck pain, and they may not understand that these problems are ocular-related. Other patients are so busy that they accept their chronic symptoms as normal. I can use myself as an example. I used to have a daily headache, and I actually didn’t realize how chronic or severe it was until it was alleviated when I started wearing contoured prism lenses. Headaches had become normal for me.

Though the objective results of patient screenings may or may not conform to their self-reported symptoms, once they are diagnosed and receive proper treatment, our patients are surprised and pleased by the improvement in their quality of life.

When—and Why—20-20-20 Isn’t Enough

We’ve all heard the 20-20-20 rule: after 20 minutes of work, look away for 20 seconds to something 20 feet away. Back when I got out of school, we really stressed this rule, but not so much these days. We find that many patients are not aware of it and are excited to have something simple that they can do that helps relieve their symptoms of eyestrain. But I haven’t met a patient who’s completely compliant with the 20-20-20 rule, because people get so focused on what they’re doing, whether for work or entertainment, that they could be on their devices for an hour or two before remembering to look away. They would have to set a timer for 20 minutes, and I have yet to meet anyone who does that.

Moreover, adherence to the 20-20-20 rule cannot always alleviate symptoms because, if patients have excessive near misalignment, it generally takes much longer than 20 seconds for their eyes to relax. In addition, some conditions may not be alleviated by the 20-20-20 rule. An example is trigeminal dysphoria, overstimulation of the trigeminal nerve because of misalignment, which can produce discomfort or pain in the head, neck, and sometimes other body parts.

For patients who do comply with the 20-20-20 rule and still report symptoms, we may recommend vision therapy. For simple convergence insufficiencies, vision therapy is absolutely appropriate for the right patient, one who can afford it and who has the time for it. I refer appropriate patients to our local vision therapy practitioner.

But for patients for whom vision therapy is not appropriate, contoured prism lenses provide the kind of easy fix that patients appreciate. These lenses are unique in having more prism at near vision than at a distance. Back when I was in optometry school, you could only prescribe a static prism, so there was a different pair for distance and for near vision, and we were always warned about the risk of esotropia. That is no longer the case.

Contoured prism lenses correct both near and distance misalignment in one pair of glasses. These lenses can work together with vision therapy, like the rubber bands that orthodontic patients may wear with their braces to correct dental misalignment. As we are a primary care practice, these lenses allow us to treat our patients without referring them out, and our patients are happy because they love an easy solution.

Our Satisfied Patients Include Me
So many of our patients have benefited from contoured prism lenses. My accountant used to tell me that at the end of the day, his eyes would be red, and he would rub and rub them. Since wearing the contoured prism lenses, he says his eyes are whiter, he no longer rubs them, and his wife no longer comments about how bad they look.

My optician is another patient. When she first joined the practice, by mid-afternoon she would turn off the lights in the lab because they were bothering her so much, and she was having severe migraines almost weekly. Now, wearing the contoured prism lenses means that she can work on the computer all day without needing to turn the lights off. She’s had only one migraine in the last nine months!

And then there’s me. I have a little misalignment myself. Back in the 80s, there wasn’t a lot that I could do about it, except for some mild vision therapy exercises. But today, using contoured prism lenses, my headaches are gone, and I’m no longer experiencing symptoms.

Some patients have reported that their contoured prism lenses make things look sharper and crisper. Some of our child patients, who were not doing well academically, now get their work done on time and are less distracted in the classroom. Those are our fun cases because those kids are at risk of being mislabeled and misunderstood. It feels so good to be a part of something that can potentially improve our patients’ lives. For me, this aspect of my profession is tremendously fulfilling.

Read more here in Ophthalmology 360.


Rachael Click, OD

Rachael Click, OD

Dr. Rachael Click received her Doctor of Optometry from Indiana University and then moved to South Carolina. She opened Preferred EyeCare Center in 2008 to provide complete visual healthcare services, including annual eye exams, contact lens exams, diabetic exams, glaucoma treatment, misalignment problems, and more. Today Preferred EyeCare is a thriving practice, with plans to grow.

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