The doctor (or for purposes of this topic, the refractionist) must be educated enough to make proper assessment of the patient’s responses. To understand why, we must be willing to consider the human factors. The central concern is that mankind is a visual creature:

•   Years ago, a physiologist noted that the entire design of the human body appears to be solely to support the eyes and the brain in an upright position.
•   Between 25% and 50% of human neuro-anatomy is dedicated to vision directly or indirectly.
•   With the eyes open, two-thirds of the brain’s electrical activity is related to visual processing.
•   The visual creature in our chair is manifesting his/her adaptations to his world as he/she sits before us. Head torts, slouched posture, bodily motor overflows, visual tics and even language and tone of voice – all reflect ocular, torso, and neck tensions.
  Vision dominates perceptions so greatly that as physiologist Samuel Renshaw demonstrated, strong yoked prisms base right or base left change spatial perceptions so dramatically that vertical edges not only look distinctly curved, but for most people, they actually feel curved. How does the technician integrate this dominance of central visual processing into their results? How can a subjective refractor device know how loose or how tight the patient’s visual system is?Leonard Press, optometric author of a significant visual therapy text,1 illustrated the point this way: if, on the positive relative vergence tests, a patient breaks fusion every two prism diopters but recovers until a final break occurs at 22^, how does the mere recording of that value differ from a patient who broke at 22^ the first time? Both final values read 22^, but it would be an unwise prescriber who treated both with the same treatment plan.

  Does the question of delegated or automatic refraction boil down to patient- centered care versus something less? Is not pathology/medically-oriented optometry more important? The question is somewhat moot. No one would argue that we should abandon our medico-legal responsibilities to identify, refer, or treat ocular medical conditions. Yet would we ignore our accountability to identify, refer, or treat the up to 30% of the population who manifest binocular or developmental visual dysfunctioning?

  To think of the refraction/visual analysis process as just “another piece of data” is to risk second-rate care to our patients. Are all refractions the same? Perhaps the more important question is looked at a bit differently, in this way:

  What is the nature of ametropia? If ametropias are strictly genetic in origin, or perhaps merely idiopathic, then we have no choice as care-givers but to follow and palliate the patient. However, if there is ever any functional component to ametropia, or any medical condition that can alter the refraction, then our focus, even our responsibility, to our patient is altered. We then ethically owe it to our patient to apply our scientific ministrations to either correct or prophyllactically intervene and interrupt the process.

  This brings up an extremely important question: does stress ever manifest itself in the refraction? Do medical conditions ever alter a refraction? Will a patient in emotional distress respond in a usual and customary way and render a valid prescription? How do black and white numbers or cryptic notes from a technician reflect the picture that the prescriber would see if they were personally involved in monitoring the quality of responses from the patient?