whacky patient or legitimate complaint?

[ilanh]

We recently saw the wife of a referring physician who ordered 5 pairs of glasses? Needless to say we wanted to make sure that everything went well. From her complaints about her previous experiences with optical we decided to proceed carefully.

I refracted her personally and then trial framed her to assure a correct Rx. We were cautious about vertexing etc. Her Rx was

OD: +4.50-0.75x90
OS: +2.00 add +2.50 OU PD 72

We suggested that we make one pair of glasses first and that if that worked out she would get the other 4. We made bifocals in Poly AR.

When the glasses came back she immediately complained of the thick right lens (which was rather thick). However, most importantly she complained that she couldn't read through the bifocal segments. I rechecked the Rx which was perfect. However, everything was "swimming" and she complained of monocular ghosting on reading thru the segs. She was reading about J5 with the glasses but J2 or better with trial frames. She told me at that point that in the past she had always had slab off; but I don't think that this is related. I have to say that I'm mystified and don't know how to proceed with the other 4 glasses.

[chip anderson]

For thickness: It is not written in stone that that the thickness of the weaker power can't be beefed up to match or come closer. One could (or at least der Meister could) go into lots of mathematics about the image sizes with 1 dio. giving aproximately .25 magnification you have about 50% bigger image here in the stronger lens. Proper ballances of base curves and possibly aspherics or even indices might help with this (a good orthoptist is hard to find now days).

Having said all of the above I would have made the glasses in similar materials (with possibly some thickness balancing, if I could get it across to the lab that it can be done) first without anticipating any problems.

Chip

[Excel-Lentes]

I assume this patient came to her exam wearing a pair of glasses. The first thing to do before making a new set is to check all aspects of the old set; Rx, Lens Style, Material, PD's, Seg Placement, Thickness, Base Curves. Also important is how the old frame fitted as well as if she was pleased with the performance and appearance of the old glasses. After going through these things it would guide you to the proper frame/lens combination.

Sometimes on Poly D segs there is a blur factor from the seg line to about 2mm above that can cause vision troubles but a simple frame adjustment should fix that.

Regarding the thickness. A rectangular frame shape would be a poor choice for this Rx due to excessive thickness at the upper and lower edges. I would recommend a rounder shape with very little decentration (shouldn't be a problem with her pd).

If the patient wore slab off previously then she may have had CR-39 Reverse slab off (easier and cheaper to make) so she may be poly-intolerant. Traditionally, a vertical imabalance due to anisometropia of 1.50 or more could present problems to some people when reading. It is a very under utilized option.

I would go back few steps and begin a close inspection of her last pair of glasses for more clues. Good luck and I hope you can make her 5 pairs of excel-lent glasses!:D

[Snitgirl]

was there a special reason for choosing Polycarbonate?

[spartus]

was there a special reason for choosing Polycarbonate?

I'm not a fan of poly in mid-to-high-plus situations like this. This thread is coming at the same issue from the other side--poly's main strength in making for a thinner lens is in minus powers, because of the thinner CT. Personally, I like mid-index for the +2.00 to +5.00 range. It's cost-effective, surprisingly thin and has a better abbe value than 1.60 or 1.66/7.

I had an octogenarian patient who was about a +4.50 OU who was nonadapt after nonadapt--1.67, 1.60, to say nothing of poly. Finally, my lab, probably as desperate to be done with this patient as I was, suggested 1.56. Perfect--no vision problems, patient's happy. It's not so hot for minus RXs (or drilling), but it may lend a hand in this case.

[drballen]

Chip,
I estimate the image size difference at 5%(had to make some base curve, vertex distance and thickness assumptions), not 50%, but considering that anything over 3% can be clinically significant I guess it really doesn't matter. You are right on with increasing the thickness of the left lens, and altering the base curves, but I think that the slab off is still necessary.
One could even reduce the image size difference by using a 1.56 for the right eye and a 1.6 for the left.
All I can say is that I hate making one pair of these, the thought of 5 pairs(and the possible number of redos) makes me cringe. The only thing that makes me cringe more would be calculating these magnifications by hand and memory, rather than cheating with a program.

[jtart2]

Just give her the slab off for the OD and see what that does!:D

[ilanh]

You guys may not have noticed that I mentioned that I tested her reading vision MONOCULARLY and she was squawking about how everything was ghosted, doubled, blurry etc. Therefore, this isn't an issue of slab off or image disparity(which is a binocular situation). Also, I raised the glasses with my hand while I was testing her so that she was staring right through the bifocal segment (this eliminates Excel-Lentes' supposition that perhaps it was a blur above the bifocal line. I would have loved to have her previous glasses but they were lost and she came in with other glasses which she hated.

I am intrigued by the reccomendation for using 1.56 for the +2 to +5 Rx's. I have always used Poly for this and will try out the 1.56. Thanks,

[Snitgirl]

You guys may not have noticed that I mentioned that I tested her reading vision MONOCULARLY and she was squawking about how everything was ghosted, doubled, blurry etc. Therefore, this isn't an issue of slab off or image disparity(which is a binocular situation). Also, I raised the glasses with my hand while I was testing her so that she was staring right through the bifocal segment (this eliminates Excel-Lentes' supposition that perhaps it was a blur above the bifocal line. I would have loved to have her previous glasses but they were lost and she came in with other glasses which she hated.

I am intrigued by the reccomendation for using 1.56 for the +2 to +5 Rx's. I have always used Poly for this and will try out the 1.56. Thanks,

Doc, I am curious and want to know the reason why you have always used poly for the +2.00 to +5.00 rx's... Also, do you own a pair of reading glasses? If so, what is your power if you don't mind me asking?

[walleye]

Another idea is to do distance and near phorias both horizontal and vertical. It is amazing how many older presbyopes have high exophoria at near. Also do a cover test without Rx and with present Rx. Even if no movement of the eyes are noted, ask the patient if the image shifts and if so how? Up, down, left, right. The objective and subjective muscle testing will give a clue as to what prism to prescribe if any.

[QDO1]

You guys may not have noticed that I mentioned that I tested her reading vision MONOCULARLY and she was squawking about how everything was ghosted, doubled, blurry etc. Therefore, this isn't an issue of slab off or image disparity(which is a binocular situation). Also, I raised the glasses with my hand while I was testing her so that she was staring right through the bifocal segment (this eliminates Excel-Lentes' supposition that perhaps it was a blur above the bifocal line. I would have loved to have her previous glasses but they were lost and she came in with other glasses which she hated.

I am intrigued by the reccomendation for using 1.56 for the +2 to +5 Rx's. I have always used Poly for this and will try out the 1.56. Thanks,

could be:

• early cataract
• bifocal line blur
• hardcoat run
• poor surfacing
• lack of AR coating
• casting error in seg

[shellrob]

Do you know what the difference between the 2 rx's is? That could explain alot. I too do not think it's a material issue at all or anything to do with not having slab off.


I agree with the other posters, see if you can find out the old rx.

If she didn't have a complete medical exam....get her one asap. (defintley could be cadillacs..hee hee...I had to say that.

[drk]

Ilan is an OMD, so I doubt he missed anything organic.

Ilan, I think it's chromatic aberration through the polycarbonate. Not a good move to use poly on mid to high plus. You'd be way, way better off with Sola's Spectralite. You didn't mention if you did aspheric lenses or not.

I doubt anisekonia is the issue. Anisekonia's symptoms are not close to what is described.

Remake to Spectralite and you'll look like a genius. BTW, good move to make a single pair first, trial frame, etc. You're pretty sharp.

(Younger's aspheric trivex in D-seg, yet?)

[ilanh]

I have asked the lab to redo in 1.67 aspherics with slab off. I will fill you in on what happens. By the way, last year I did cataract surgery on her husband (who happens to be a physician) and he came out 20/20 OU uncorrected. Believe it or not he complained for about 3 months because he couldn't "see the signs on the freeway", " you didn't tell me I wouldn't be able to read", "things are too bright now", "how come my eyes glint like a demon" etc etc. After endless complaints and making my life hell he referred his entire pain in the neck family to me. They're all just like him!:(:(:(:( (there were 4 of them).

[walleye]

I agree with drk and the Spectralite idea. Aspherics offer an amazingly thin lens across the board of Rx's.

Sorry to hear your misfortune ilanh concerning the family of whiners. Maybe there will be a happy ending like them referring all their non-whining neighbors.

[eyegoddess1028]

check the DESIGN of the progressive. is it hard or soft or semi soft. highr plus powers have worked best for me in soft designs with less induced cyl.

[jediron1]

We recently saw the wife of a referring physician who ordered 5 pairs of glasses? Needless to say we wanted to make sure that everything went well. From her complaints about her previous experiences with optical we decided to proceed carefully.

I refracted her personally and then trial framed her to assure a correct Rx. We were cautious about vertexing etc. Her Rx was

OD: +4.50-0.75x90
OS: +2.00 add +2.50 OU PD 72

We suggested that we make one pair of glasses first and that if that worked out she would get the other 4. We made bifocals in Poly AR.

When the glasses came back she immediately complained of the thick right lens (which was rather thick). However, most importantly she complained that she couldn't read through the bifocal segments. I rechecked the Rx which was perfect. However, everything was "swimming" and she complained of monocular ghosting on reading thru the segs. She was reading about J5 with the glasses but J2 or better with trial frames. She told me at that point that in the past she had always had slab off; but I don't think that this is related. I have to say that I'm mystified and don't know how to proceed with the other 4 glasses.

1. You said or wrote they were "rather thick" A pair of caliphers would have settled that issue and you should returned them to the lab, they could have reduced the thickness.


2. Swimming I can understand considering you used a poly. I think knowing her history I might have used a high index.


3. If you compute her RX out she really does not need a slab but I think someone else had the same problem your having and sold her on the idea it was because she needed a slab.


4. I would not make anymore glasses until you have this satisfied. I would recheck PD ( Taken by yourself and from Lab ) recheck curves, but since you used poly this maybe useless. I would also check retro and panascopic tilt, face form, are the glasses grossly curved? ( bent from the bridge to a face form fit, not good in hyperopes ) Also how far are they sitting from her eye's?
This may sound crazy but on this type of RX fitting the closer the better. One last thing, how much of a change did she have from her old to her new, I have found most hyperopes hate change even the smallest amounts. We had one that was just a quarter diopter, pd the same, curves the same and they swore they could not wear them, we finally ended up giving there money back
and asked them to go elsewhere because nothing we did pleased them, after three pairs they still said they like there old one's better. Just my 2 cents!

[icyou]

"we finally ended up giving there money back
and asked them to go elsewhere because nothing we did pleased them"

That's where my nightmare pt came from Thanks alot.
Just kidding!! I've had patients come in saying that they have been elsewhere and weren"t happy. If it was a reputable shop, I try and call to see what was done before (ie material used, lens type and any rx changes) Most of the time the other optical has tried everything with no luck, I'll advise the patient I can't do any thing else. Maybe not a wise decision for an "I can fix anything" optician, but a better financial one.

[SpecialT]

There are a fair amount of posts and I didn't read each one word for word so sorry if I repeat.

Probably smart refunding by the way!

I was thinking about this and I think the slab off could have really been the problem. If the patient doesn't suppress the higher plus eye and looks down even 10mm (which is reasonable considering pals are ~18mm) it would induce 2.5 prism diopters BU OD. I also agree that poly carb lenses classically give bad chromatic abberation (I recommend trivex as an alternative). The other problem with asymetric plus prescriptions is the base curve. Base curve changes cause alot of problems like this, but if the proble is really only at near then this is unlikely.

Hope this helps a bit in the future.

[jediron1]

There are a fair amount of posts and I didn't read each one word for word so sorry if I repeat.

Probably smart refunding by the way!

I was thinking about this and I think the slab off could have really been the problem. If the patient doesn't suppress the higher plus eye and looks down even 10mm (which is reasonable considering pals are ~18mm) it would induce 2.5 prism diopters BU OD. I also agree that poly carb lenses classically give bad chromatic abberation (I recommend trivex as an alternative). The other problem with asymetric plus prescriptions is the base curve. Base curve changes cause alot of problems like this, but if the proble is really only at near then this is unlikely.

Hope this helps a bit in the future.

ilanh Said:

When the glasses came back she immediately complained of the thick right lens (which was rather thick). However, most importantly she complained that she couldn't read through the bifocal segments. I rechecked the Rx which was perfect. However, everything was "swimming" and she complained of monocular ghosting on reading thru the segs. She was reading about J5 with the glasses but J2 or better with trial frames. She told me at that point that in the past she had always had slab off; but I don't think that this is related. I have to say that I'm mystified and don't know how to proceed with the other 4 glasses.


1. Maybe she or he needs a slab but what struck me is they complained about the thickness. ( look to above in blue )
2. I would do a reverse slab and not a regular slab to keep thickness down on OD.
3. From my experience of asymetric plus they see double not that they can't see at all but it's doubled, see two of everything in the reading. Just my 2 cents

[Andrew Weiss]

I agree with drk about using mid-index, and Spectralite in particular. When I saw you were redoing in 1.67, I cringed. Yes, it may be better than poly, but the Spectralite will give a cleaner image, which I believe is the problem here. Even in my Rx (+2.75-+3.00 with 2.50 add) I won't wear poly because of chromatic abberation issues. The combination of factors you describe point to chromatic abberation as the issue.

And VERY smart to do one pair first!

[ilanh]

The glasses were remade in Hi index 1.67 with slab off. The patient is still unhappy. Distance vision is 20/20 but she complains of things swimming and unclear when she tried to read. Even when I lift her bifocal seg and have her read through the center she complains it is unclear. She was refunded her money and promptly evacuated.

[Specs]

I believe the overpowering issue is the material, no doubt I'd be offering Trivex as my first choice material for this Rx. I think it would have eliminated the aberration factor and you're getting a lens w/ a higher abbe value which will help with clarity.

[jediron1]

could be:

• early cataract
• bifocal line blur
• hardcoat run
• poor surfacing
• lack of AR coating
• casting error in seg

QDO1 could be on to something. I have noticed over the years that some lenses after having the scratch cote applied offen look ( and you have to hold them, lenses at an angle to see this ) like they have waves across the lens
or more like they are dimpled, almost like they are distorted. Remove the scratch cote and all of sudden that wavyness disappears. Now I m not saying this happens on all lenses but I have seen it enough to know that it happens
about 2 or 3 percent of the time. Just my 2 cents

[chip anderson]

Can a very lightly polarized lens reduce the reflection?