Spectacle Non-Tolerance: When the Glasses Look Right, but the Patient Still Struggles

The patient is back. The glasses look right. The prescription appears reasonable. But something still feels wrong.

For optometrists and dispensing opticians, spectacle non-tolerance can turn an ordinary appointment into a difficult conversation. The patient may already have returned several times. Your team may have tried adjustments, explanations and a remake. Confidence is slipping on both sides of the dispensing desk.

Where do you go next?

In my conversation with optometrist, author and educator Jason Searle on The Optician Show, we explored what happens when straightforward answers run out. His message offers a useful starting point: listen carefully, investigate methodically and work together.

“The most important thing is listening to your patient.”

What is spectacle non-tolerance?

In everyday practice, spectacle non-tolerance describes difficulty wearing or functioning comfortably with supplied spectacles. It is a presenting problem to investigate, rather than a complete explanation of the cause.

The patient might report blur, distortion, discomfort, an unusual sense of balance or difficulty with a particular task. Different complaints can require different investigations. A prescription issue, lens design, fitting problem and an underlying clinical concern should not automatically be treated as interchangeable.

The first useful distinction is between what you have verified and what you currently suspect. “The lenses match the order” is a finding. “The patient just needs longer” is a hypothesis that needs justification.

1. Start with the experience, before defending the spectacles

When someone says their glasses are wrong, the temptation is to explain why they should be right. Start by understanding what “wrong” means to that person.

Ask them to describe a specific moment when the problem occurs. Walking downstairs? Reading a label? Looking between two monitors? Turning their head? A concrete example is often more useful than another general question about whether the vision is clear.

• What can you do comfortably in your old glasses that is difficult in the new pair?
• When did you first notice the problem, and has it changed?
• Does it affect distance, near or a particular working distance?
• Is it constant, or linked to movement, posture or a particular activity?
• What would a successful outcome look like for you?

These are suggested consultation prompts, rather than quotations from the episode. Their purpose is to turn frustration into information you can act on. Record the patient's own words alongside your interpretation.

The College of Optometrists' communication guidance supports listening to patients, considering their concerns and providing understandable explanations.

2. Revisit what the patient actually needs

“Take a good history with them”

A familiar record does not remove the need for a fresh history. The task may have changed. The patient may now work at a different screen, spend longer reading or use the spectacles in circumstances nobody discussed at collection.

Jason brings the conversation back to a practical question:

“What they want from their glasses.”

That matters because a technically acceptable result and a useful everyday outcome are related, but they are not identical. Establish what you are trying to improve before deciding what to change.

For a patient with several previous rechecks, summarise the story aloud. Explain what has already been tried and invite corrections. This can reveal misunderstandings while reassuring the patient that they do not have to start again from the beginning.

3. Check the supplied spectacles systematically

A practical investigation should consider both the appliance and the prescription. Verify the spectacles against the order, review relevant measurements and assess the frame as worn. Compare the old and new pairs where available, including lens design and how the patient uses them.

In the episode, Jason and I discuss high cylinder prescriptions, changes in axis, trial frames and the effects of frame position. The useful lesson is to investigate individual circumstances. There is no universal shortcut for deciding which change a particular patient will tolerate.

A trial frame may help explore a clinical question, but it does not reproduce every feature of the finished spectacles. Equally, matching the ordered powers does not establish that every aspect of the dispense meets the patient's needs.

Avoid repeated speculative changes. Record what you checked, what you found and why the next intervention is reasonable. That makes a subsequent review more informative.

4. Make the optometrist–dispensing optician handover count

“It's really important you do work with the dispensing optician”

One of the most useful parts of our discussion concerns observations that stay inside the consulting room. Jason describes how a patient's head position can affect the experience being reported. If that observation never reaches the dispensing team, useful context disappears.

Make the handover specific. Share the task causing difficulty, relevant clinical findings, what the patient demonstrated and the question you need your colleague to investigate.

For example, the team could establish whether a reported improvement with a different head position is reproducible and relevant to the dispense. The aim is a shared investigation, with each practitioner working within their competence.

For an outside prescription, the College's non-tolerance guidance advises contacting the prescriber with the patient's consent and agreeing a course of action with them and the patient.

5. Keep the clinical picture open

Some patients need more than a spectacle adjustment or prescription recheck. Our conversation includes dry eye, cataract surgery and a patient whose visual dissatisfaction involved several possible contributing factors.

That does not mean every difficult dispense needs an extensive new investigation. It means the history and findings should determine the next step. Avoid assuming that symptoms reported after collection must have been caused by the spectacles.

New or concerning symptoms need appropriate clinical assessment and triage. A routine adaptation discussion should never delay the assessment of a possible eye health problem. Seek advice or refer with appropriate urgency when the findings fall outside your competence or scope, following relevant local pathways.

“Understanding your limits.”

Recognising those limits is part of sound clinical judgement. It helps the patient reach the right professional without another unproductive cycle of appointments.

6. Adapt the appointment to the person

Complexity can involve communication, anxiety, disability or several health conditions alongside the optical problem. A standard appointment structure may need adjustment.

Ask what helps the individual. That might mean clearer explanations, additional processing time, an agreed pause or an appropriate alternative method of obtaining information. Involve a parent, carer or supporter where appropriate, while respecting the patient's preferences and consent.

Jason discusses adapting examination methods when the usual approach is not producing useful information. The principle is relevant across practice: remain focused on the clinical question while considering how best to obtain reliable answers.

Do not infer someone's needs from a diagnosis alone. Ask, observe and document. The College's communication guidance also encourages practical arrangements to meet patients' communication needs.

7. Finish with a clear plan and a named owner

A patient who has attended repeatedly needs to know what happens next. Before they leave, explain what you have established, what remains uncertain and what the next step is intended to resolve.

1. Summarise the problem: use language the patient recognises.
2. Explain the proposed action: connect it to your findings.
3. Agree follow-up: identify who will review the outcome and when.
4. Give appropriate safety-net advice: explain when and how to seek further help.

Where adaptation is a reasonable working explanation, make the advice individual and explain the review plan. Avoid an open-ended instruction to keep trying despite unresolved symptoms.

A better question for the next difficult case

Before asking, “What prescription should we try now?”, ask, “What have we not yet understood?” It might be the task, the fitting, the clinical picture or something the patient has struggled to explain.

For practice owners, this is also a process issue. Give the team a clear route for escalating concerns, sharing findings and allocating suitable review time. Good communication should be supported by the appointment system.

“I'm always ready to learn.”

That attitude is a useful foundation for managing spectacle non-tolerance: stay curious, respect the patient's experience and make the next decision explainable.

Listen to the full conversation with Jason Searle

For the clinical stories, professional reflections and wider discussion behind this article, listen to my full conversation with Jason Searle, founder of The Eye Care Advocate, on The Optician Show.

Listen to the full Optician Show podcast with Jason Searle

About the author: Garry Kousoulou, FBDO, is a dispensing optician, founder of Loving Social Media and host of The Optician Show.

This article combines discussion from the podcast with practical editorial suggestions for optical teams. It is professional educational content, rather than a patient-specific prescribing protocol.