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Thread: Progressive troubleshoot

  1. #1
    Master OptiBoarder OptiBoard Silver Supporter Jubilee's Avatar
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    Progressive troubleshoot

    I have a patient that is having a hard time with her new progressive lenses.

    Her latest rx is: +1.25 -0.50 x 135 / +1.00 -0.50 x 108 150Add OU

    Previous rx: +1.00 -0.25 x 132 / +1.00 -0.50 x 108 150Add OU

    New frame is the same as her old "doesn't like change"

    She originally came in for a disp and immediately took the glasses off and declared they "weren't right"

    When talking further, she was unhappy with swim, distortion, and a narrow field of view. The lens we used was a poly Physio. Fitting cross was right in center of pupil horizontally, and bottom of pupil. Seg height was 21.5 and PD was 31 / 28.5

    Double checked old pair (I didn't fit her initially) Her segs in old pair were at 17 fitting at bottom of lash line. The old lenses, I thought were Kodak, (+) symbol, (the nasal edge had one markign completely cut off, the other was beveled just to the side of the identifier)and poly... I remade lenses at 17 and in the Kodak Concise instead.

    Picks them up yesterday, and back in office today. Lenses don't work as well as old at work. Field of view is more narrow, and computer work is much more laborous. Checked face form, tilt, BCs,vertex, etc. Compared heights, OC's etc.

    The only thing I noticed was the monocular pd was opposite. IE they measured 28.5/30.5 The fitting cross in the right eye was fit at the nasal edge of the pupil. The left was a bit to the temporal edge.

    She claims the periphery is clearer in old, including the temporal edge. Now I could understand the left eye possibly having a wider zone to the outside, but I would think the right would have less....

    I called the previous dr and they couldn't tell me squat. They claim to have been using Kodak only the past two months, so the lenses must be a different manufacturer. I did notice on the concise, that the add was represented as 15 and on her previous pair as 150. Could this be a navigator? The previous place was a bargain chain using their own materials for Davis vision. We of course are using davis labs. When I called to ask for additional information and faxed them the patient release, I got they were poly, yep the rx was neutralized right, and they had a pds of 58/55 and could give me monocular or tell me what progressive it was. No prism prescribed and no notes for the low fitting. That info is stored at the labs and it wasn't possible to call them.

    There wasn't much change in the rx at all... I remeasured her pd's both manually and using a pupilometer and ended up with 30.5/29 ... I know some people are sensitive... but geesh.. I am at wit's end here.

    Cassandra
    Last edited by Jubilee; 10-17-2006 at 04:27 PM. Reason: Clarification
    "Some believe in destiny, and some believe in fate. But I believe that happiness is something we create."-Something More by Sugarland

  2. #2
    Master OptiBoarder OptiBoard Silver Supporter Barry Santini's Avatar
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    Danger Will ROBINSON!!

    0.25D change monocularly...and she instantly disliked it?

    She may be out of accomodative balance...

    Put -0.25D over the *changed* eye in the new pair...

    or +0.25D over the *unchanged* eye

    If she likes either, you have your answer...

    Barry Santini, ABOM

  3. #3
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    Buyer's remorse

    Barry has a good point, I would try it.

    I would also think about buyer's remorse. I have had patients make all sorts of vague complaints when they want their $ back. With only a 0.25D change and no increase in the reading power maybe she is disappointed that her vision isn't better w/ new lenses. Listen to her language closely, if she wants you to help she will work with you. If it's buyer's remorse, you won't be able to do anything right and her complaints won't be specific enough to for you to help.

    BTW, My lab told me that they have had zero non-adapts with the Physio. I haven't used it much my self, though.

    MarcE, ABOC

  4. #4
    Master OptiBoarder OptiBoard Silver Supporter Jubilee's Avatar
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    I have her scheduled to be rechecked with the doc on Monday.

    As for buyer's remorse, they have a Davis plan where all she paid was a $10 copay. I wouldn't think she would put me through the rack for $10. That is another patient's wife :) But that story belong's in another thread...

    Cassandra
    "Some believe in destiny, and some believe in fate. But I believe that happiness is something we create."-Something More by Sugarland

  5. #5
    Allen Weatherby
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    Same power

    Total power is the same and axis is with 3 degrees in one eye and exactly the same in the other. I'll bet if she see three other doctors they will all be within a similar range.

    It could be the design of the corridor is enough different that and she is sensitive. Without an individual plot of the lens produced compared to the lens replaced it maybe almost impossible to guess. With this you could understand if the pd fit was wrong what differences she might be experiencing.

    If the patient has been wearing an incorrect fitted pair and has adjusted then you have alot of explaining to do without sounding like your bashing the last optician.

  6. #6
    OptiBoard Professional Ory's Avatar
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    For a +150 add to stay the same over more than 1 year is unusual. This may sound silly, but does she wear these specs as occupational lenses only, and goes without glasses most of the time? If that is the case, her old lenses may be an Office/Access style lens and that would explain why she hates a conventional PAL.

    Like I said, it sounds silly but I've seen stranger.....

  7. #7
    Master OptiBoarder OptiBoard Silver Supporter Jubilee's Avatar
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    Well this particular chain doesn't use occupational lenses such as Access or Office. Plus don't both of those have a different indentifier mark than the (+) sign?

    Does anyone know if the Navigator or Navigator Short has the full add under the mark or uses the first 2 #'s...

    She does however wear them primarily only at work. So that is a reason they maybe fitted lower than norm.

    I did explain to her the "best practices" for fitting a progressive lens and actually had a lovely dispenser's guide from 20/20 explaining how to fit to show her. Of course, that doesn't mean a hill of beans when she can't see (in her own words) out of the glasses like her old.

    I hate hearing patients say they regret switching docs cause we aren't "getting" it....

    Cassandra
    "Some believe in destiny, and some believe in fate. But I believe that happiness is something we create."-Something More by Sugarland

  8. #8
    Rising Star
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    PD is probably the issue. If you read it as Old: 31.0/28.5 and New: 28.5/30.5, it doesn't seem that big a deal. However, if you read it like this:

    Old OD - - New OD - - Difference
    31.0 - - - - 28.5 - - - - - 2.5 In

    Old OS - - New OS - - Difference
    28.5 - - - - 30.5 - - - - 2.0 Out

    That's 4.5 mm change in PD!! I'm no good at the actual equations, but isn't this doing something like .25 BI OD and .20 BO OS? You probably measured her PD correctly, but whoever did the last pair probably didn't, and she's now used to the incorrect measurement. You can go one of two ways with it: Redo it with the old, wrong PDs that she's adapted to, or tell her to suck it up and let nature take its course, only more politely.

    If it's my patient, I'm rechecking the PDs in the old glasses (and base curves, while I'm at it), and matching that exactly. I'd move the seg up a little bit, say bottom pupil instead of center pupil. And as always with dicey PAL redos, I'd keep slipping in, "Oh, this is going to work so much better, you're going to love this" comments as I'm remeasuring everything and dispensing.

  9. #9
    Master OptiBoarder Joann Raytar's Avatar
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    Quote Originally Posted by Jubilee View Post
    New frame is the same as her old "doesn't like change"
    Jubilee, did she use her own frame or order a new frame, same model? If it's a new frame, are the face form, vertex distance and panto the same? Did you try bringing the lenses closer to her face?

  10. #10
    Master OptiBoarder OptiBoard Silver Supporter Jubilee's Avatar
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    It is a new frame, but same model, size, color, etc.

    I did try to match the "bent up" (her words not mine) adjustment as far as face form, tilt, Vertex etc...

    I did confirm with my primary lab that the Navigator short does show the full add under their mark and can be fit 17 high...So I am thinking now that the Navigator short was what the previous office used...

    Cassandra
    "Some believe in destiny, and some believe in fate. But I believe that happiness is something we create."-Something More by Sugarland

  11. #11
    Allen Weatherby
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    hotsauce said:
    PD is probably the issue. If you read it as Old: 31.0/28.5 and New: 28.5/30.5, it doesn't seem that big a deal. However, if you read it like this:

    Old OD - - New OD - - Difference
    31.0 - - - - 28.5 - - - - - 2.5 In

    Old OS - - New OS - - Difference
    28.5 - - - - 30.5 - - - - 2.0 Out

    That's 4.5 mm change in PD!!
    Is the PD actually that much different from old to new? If so this is the problem. I just glanced at the PD info but a 4.5 change would make a big difference. You need to figure out if the old were made incorrectly, then like I said before explain that she will have to let her brain now adjust to the correct version. Unless she was in an accident between PD checks I think the old was just a mistake, that she has adapted to so now the correct fitting PALs are not comfortable to her. Good Luck

  12. #12
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    I'm Baffled too

    I read all the posts and have been thinking about this for a couple of days. I am still baffled, but here are my thoughts.

    Her complaints (swim, distortion, narrow range) are what Physio are supposed to be best at. Something is fishy.

    If she was fit wrong before and adapted to it, she might complain of some swim with the new lenses. However my guess is that she would be thrilled with her new fit because it would have a much larger corridor and reading area.

    How does a person who immediately rips of the specs and says they aren't right ever get adapated to lenses that are off by 4.5mm total? Again, something is fishy.

    I would try her to put her old lenses back in the frame, but don't let her know. See what her comment is.

    If she only has $10 into it; you are right, it isn't buyer's remorse. But at this point, you have more invested than she does. I would be tempted to send her on with her old lenses. With such a small change in Rx, her acuity won't be noticeably better anyway, so what's her motivation?
    New style? No. Same frame.
    Better vision? No. And I would hope the Dr explained that to her.
    Less strain at near? I guess not the add didn't change.

    Why DID she come in for an exam and new Rx?

  13. #13
    Bad address email on file Rich R's Avatar
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    Just a thought, did you check the amount if any prism thinning, should be about the same, however some labs may differ from others
    Rich R

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    Base curve?

  15. #15
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    Be nice but....

    Offer to adjust her old pair, take them in the back and break "em,-- badly! Tell her you'll try to order a replacement frame but it will take a "week or two". Please wear the new pair in the meantime-- problem solved, by then she'll be fine. :D

  16. #16
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    Hot Sauce, the tolerance chart gives you 2/3 dioptor prism due to PDs. So, even with all that changing, you're within tolerance.

    I will say that I've dispensed about 80% physios since they came out, and one thing I've noticed is that almost everyone likes it sitting about 1-2mm lower than my normal progressive placement.

  17. #17
    One eye sees, the other feels OptiBoard Silver Supporter
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    Quote Originally Posted by Jubilee View Post
    Her segs in old pair were at 17 fitting at bottom of lash line.
    There's the answer. No swim, no peripheral blur, fit so low there's no progressive.

    Sorry, I missed that you made a second pair at 17mm.

    My Concise's show all three numerals for the add power. The lens could also be the Precise. Please note that the Concise and Navigator fitting cross is 2mm above the 180 line, the Precise is 4mm above. The Concise is a very aggresive short corridor design, poor distance periphery and narrow intermediate- if the fitting cross is 5mm below the pupil she *will* be reading through the intermediate where there is less inset compounding the problem. Good luck.

    Regards,
    Last edited by Robert Martellaro; 10-19-2006 at 04:24 PM.
    Science is a way of trying not to fool yourself. - Richard P. Feynman

    Experience is the hardest teacher. She gives the test before the lesson.



  18. #18
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    I don't have a problem remaking a patient's lenses, if and only if I am 100% sure it will sove the problem. Generally if the PDs are correct and seghts, increasing faceform and panascopic tilt make no difference and the Rx is verified as not the problem, then I punt. Guessing and re-making only to find the patient still un-happy never helps. You know 99.9% of your patients are happy after you dispense, chances are if you can't figure it out you would'nt be alone. Here's your 10 bucks back take the Rx to another Davis provider sorry we were'nt able to sove your visual needs.

  19. #19
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    try this stupid idea

    put a pair of sv lenes in to check distance swim or near for close up she HAS to respond some how

  20. #20
    OptiBoard Professional Ory's Avatar
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    Another silly question. How good is your lab at cutting lenses to the exact size? If the lens was just a titch large (yes, titch is a precise technical term!;) ) and forced into place it could cause some warpage of the lens.

  21. #21
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    with the kappa we have no problem ok very little problems

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