Some patients see glasses as a hot fashion accessory. They will fake their VA’s or exaggerate tests in order to ascertain them. Some will do anything to avoid them! Other patients have differing agendas for their exam and often think they’re smarter than we are. However, they don’t often know that we have objective testing that can call their bluff. Here are a few SNEAKY ways to call your patient out (don’t be mean!):
The Trial Frame
Kids especially will try to lie to get glasses. Oh, how times have changed – it might be the pink sparkle and Spongebob frames they have now that they didn’t 20 years ago. Often they will complain that the letters are “too small” after a certain point. Try switching to Lea symbols. If they see through that, and even after refraction you don’t see much in terms of an Rx, pop +/- 0.12 or 0.25 (the smallest sphere you have) in a trial frame. Tell them it’s their new glasses prescription. Immediately (if they’re faking it) they will be able to read down to 20/20. This trick often works for adults too!
The Toys/Light CVF
Children or adults who are uncooperative during confrontation fields can be redirected to toys or lights. If they say “I can’t see it” (or count them incorrectly or keep looking at the peripheral hand), use something interesting as a central target to keep their attention. For kids, use a sticker or age appropriate toy on or near your nose, bring another toy in the appropriate quadrant, and notate whether they notice it as a + response. Change toys as often as needed for children. For adults that claim they can’t see the fingers – before moving onto difficult HVF testing – use a penlight near your nose as a target, and use another tool (I like my cover paddle or fixation stick) to “wave” in the quadrant-almost to sort of startle them and see if they notice it, like the kids. That way it only requires them to respond, but not use math. Recruit a friend to help if needed. Mission accomplished.
OKN, +APD
If a patient comes in telling you they can’t see ANYTHING, and you think they may be exaggerating (per the history), grab your penlight and the OKN. If they claim to be BLIND (like NLP blind), check their pupillary response. It’s anatomically impossible to have a blind eye with no +APD. If they have a normal pupillary response, they’re exaggerating. If they come in and you are getting a VA of 20/400 or worse, try the OKN drum at 2-3 feet. By nature of the gratings, a person who follows the grating (slow pursuit with saccade back) should have 20/200 vision or better. If they don’t follow the grating, they may have vision that matches their complaint.
The Pinhole
Occasionally, you’ll have a primary care patient in their late 50’s-60’s who has developing cataracts, but had been deemed unfit for surgery. Generally, the eye in question has to have 20/40 vision or WORSE (best corrected!) in order to have Medicare and most insurance companies pay for the surgery. If they have been told this in a previous visit, they may remember it and use it to their advantage. They may remember what line is 20/50 and say that’s the line they can see, when only a month ago they were 20/25. This amount of rapid progression is unlikely. Use the pinhole trick. A pinhole without any correction will tell us whether a decreased VA is due to refractive error or pathology. If our cataract surgery-seeking patient is faking the 20/50, pinhole will show us a better VA since the pinhole only allows minimal light in, and diverts it straight to the macula. I like to combine this with the following trick (using numbers or switching the letters) to get an accurate and not memorized VA.
Change the Charts
Just like some people will lie through their teeth in order to get glasses, some people (often emerging presbyopes) are desperate to avoid them. Some people will try to cheat on the charts by walking up closer to them or turning to see the mirror as they walk in the room, pulling the near card closer or farther away, or if they can hear someone in the next room reading letters and getting told they’re correct. If even for a split second, they will memorize letters and use that to their advantage. Some patients even have lines memorized between visits if they come to the clinic often. If you have computerized charts, utilize them, they’re a fabulous tool to keep patients on their toes and discourage cheating. If you don’t have computer charts and you suspect this, use the number charts (on most standard projector slides) or tumbling E’s. Anything to throw the patient off that they can’t memorize.
Disease Malingerers
Some patients may come in with a non-refractive complaint. This is often a little more “teasing out” what they are really after. Often they won’t come out and immediately say what they want if it’s slightly embarrassing. Does an older patient complain of trouble driving but really want a recommendation for ptosis surgery? The balding cancer patient who come in for a “routine exam” but mentions her grandma had longer, darker lashes on her glaucoma medications…maybe she’s looking for Latisse. The patient who is complaining that their eye is in SEVERE pain and yet has only mild injection with no corneal findings or photophobia…did they come in just to get some narcotics? These are the kind of scenarios where we need to be intuitive, a keen historian and know your patient. Observe well as you examine to help the patient as best you can, and to the fullest extent of your scope.
With any of these tricks, try to be sneaky at first. If I catch the patient red-handed, I may try to play it up: “I know what you’re doing!! Let’s try that again!” Kids tend to laugh when you catch them, so make their exam into a game. Shyer patients may just need you to have them try reading another line, or to tell them GENTLY that there’s no way they can be blind since their pupil was normal. Judge your patient’s personality appropriately and don’t make them uncomfortable. Above all else, make sure the patient knows you know what they want and you will do your very best to help them.
Have any other tips or stories? Share in the comments below!
