The role of noise-cancelling devices during the neurovisual exam

And its symbolic significance to the patient

Generally, the patient suspected of having a binocular vision dysfunction comes in with symptoms for which no definite cause has been found. Before the optometrist looks for a possible visual cause in the form of a visual misalignment, they instruct the patient to try on a series of noise-canceling devices, with the understanding that sound may be a contributing factor to their symptoms. This portion of the neurovisual exam is highly proceduralized, lasting about fifteen minutes and taking place shortly after the case history.

That sound should play such a prominent role during an eye exam may appear puzzling at first. But like many aspects of the neurovisual exam, the therapeutic effect of the noise-cancelling process goes beyond any organic cause — which is typically and somewhat ambiguously postulated as a reduction of overstimulation — and lies in its symbolic significance to the patient. It shouldn’t be overlooked, furthermore, that the patient has more often than not frequented medical specialists whose practice, in keeping with the general trend of modern health care, has all but abandoned this important aspect of the clinical encounter, a situation which only makes its positive effects more pronounced.

For most patients, wearing a noise-canceling device is a new experience, let alone during an eye exam. The optometrist introduces them to the process by saying “Our office is doing work with the connection between sight and sound”, a well-rehearsed line which accomplishes two things. First, it places the trialing of noise-canceling devices in the context of an ongoing project which, it is strongly implied, has been successful for other patients. Secondly, it relates the undertaking to the primary focus of the exam, which remains vision and eyecare.

Having fitted the patient with a noise-cancelling device, the optometrist encourages them to get in touch with how they feel, prompting their self-reflection with the following open-ended question: “Now that you’re wearing these, how do you feel?” In some cases, especially those in which the patient appears anxious or distracted, the optometrist will suggest that they take a deep breath and relax their shoulders, and a momentary silence constitutes an effective overture for the patient’s feedback.

That the patient is given the opportunity to introspect and express how they feel is no trivial thing, representing a therapeutic intervention in its own right beyond any specific improvement to mood or symptoms that might be caused by the noise-canceling devices. With a single question, the optometrist indicates to the patient that their feelings are not only worthy of consideration, but integral to the exam itself, constituting a major piece of data: during this time, the severity of their symptoms are ranked once again on a scale of 1 to 10.

In other words, during the process of trialing noise-cancelling headphones, the subjective experience of the patient, in contrast to the disease-centered paradigm which dominates modern healthcare, is brought to the forefront of the clinical encounter.

The primacy of the patient’s feelings is further developed when the optometrist brings them a variety of options for the sake of comparison. For each selection, they’re encouraged to assess not only the result of the device on specific symptoms, but on their overall mood and comfort level. By the end of this process, the patient has a favorite and least-favorite device, which the optometrist diligently notes.

In the event that the devices help to reduce some of the patient’s symptoms or have an otherwise positive effect, the optometrist asks the patient, “Have you ever made the connection between sound and your symptoms?”, typically giving the examples of avoiding crowded rooms or feeling that the world is too loud. In some cases, the patient will feel as though there was in fact a connection all along, enthusiastically recalling several past experiences in a newfound series of equivalences. In other cases, the patient will not recall anything along these lines. Either way, the patient is made aware of the existence of a previously unknown factor which may be a possible cause or contributor to their symptoms.

The optometrist begins closing this portion of the exam by using the often-repeated phrase: “It seems like sound is a piece of your puzzle.”The puzzle, of course, is the question that brought the patient to the exam chair in the first place — some poorly understood process, yet to be determined, which is perpetuating their chief complaint — and by demonstrating definite improvements during the trialing of noise-canceling devices, the optometrist leads the patient to believe that some progress is being made in identifying the problem and finding a solution. Furthermore, the patient is empowered to take their health into their own hands by using a pair of noise-canceling headphones themselves, if nothing else, to assess whether they will make any long-term impact on their symptoms. Some optometrists will phrase this as “Another tool in your toolbox”, emphasizing that this is one of many interventions which may alleviate the patient’s symptoms.

Finally, in the case that noise-cancellation provided significant relief to the patient, the optometrist will suggest a referral to an ENT physician or audiologist, with the understanding that further pursuing the connection between sound and the patient’s symptoms will be beneficial. This is typically expressed by the optometrist who says to the patient: “You’re a work in progress”, although this phrase is also used in relation to continual updates to a prism prescription.

We can summarize these remarks as follows. Towards the beginning of the neurovisual exam, sound is presented as a previously underappreciated factor which may be contributing to the patient’s symptoms, and by being brought to the patient’s attention, they frequently believe that they’ve gained a better understanding of their symptoms. During the process of trialing noise-canceling devices, the patient’s inner world and subjective experience are brought to the forefront, and the optometrist signals that they play a central role during the exam.

We find that all of these factors are aspects of patient-centered care. We can list them as the following:

• The importance of the patient’s comfort during the clinical encounter
• The importance of the patient’s subjective experience of their symptoms, as opposed to objective measures
• Contextualizing and providing meaning to the patient’s symptoms
• Empowering the patient with methods of taking care of their own health
• Providing the patient with resources for further care

How can sound play such a prominent role during an optometric exam? The question isn’t so difficult when we consider that, framed in the ways just described, the trialing of noise-canceling devices can contribute to the patient-centered character of the clinical encounter. An investigation into the influence of sound on common symptoms, then, is a procedure which, besides any organic validity, facilitates and contributes to a positive delivery of care when understood in its symbolic significance.