Progressive Len Problems

[Dpcbb]

Okay, I have seen patients over the years that can't adapt to progressives. I can't seem to give this patient a satisfactory answer as to why they can't see out of them.

Patient has been wearing 7x28 in a small frame. Tried PALs years ago, couldn't use them. Dr. said things have changed and she wanted to try again. I didn't think it was a great idea, but I have had a number of patients try again with new technology and they work fine.

Fit her in an Ellipse at 16mm. She says distance is okay but narrow. This she gets. But she is having more trouble up close and says she can't see anything near out of her left eye no matter where I move the lens on her. Everything checks out though.

I have checked and rechecked PD (binocular and isolating each eye for both distance and near), segs, Rx, ec, etc, etc. What gets me as weird is when I watch the patient read with them on, it appears as she may be looking "inside" of the segs, perhaps converging much more than the seg inset. Does that make since, is it my imagination, or is it merely an illusion on my part?

To test this, I drew the reading area with the layout chart and colored in the circles with a blue marker. She tells me the circles barely even touch when she tries to read, which leads me to believe there is a convergence problem.

In all my years, I have never had this much trouble with a prog fit.

Old Rx (New patient. Rx at least 2 years old)
7x28
OD +1.50 OS +1.00 Add +225

New Rx
Ellipse
OD +2.00 OS +1.75 Add +225


As a side question, how do you all explain to a person that is a non-adapt why they can't use progressives?

[VHB]

You gave us her Rx for the right eye, but she's having trouble with the left eye. What is the OS Rx?

If her distance pd is more than 5mm (2.5 ou) wider than her near pd, you may need to remake the lenses, using her near pd as the starting point. I know that lens manufacturers (especially Essilor) say that the inset varies, but if you look at a progressive with its original factory markings on it, you'll see that the near is decentered 2.5 mm from the distance.

[Dpcbb]

Let me post the rx differently. I can see where it would be confusing.

Old Rx (New patient. Rx at least 2 years old)
7x28
OD +1.50
OS +1.00
Add +225

New Rx
Ellipse
OD +2.00
OS +1.75
Add +225

I actually measured the near pd 4mm different after seeing how she was looking through them because it looked odd. And the distance as made sits directly in front of her pupil. Would starting with near affect this?

[Uncle Fester]

Here's a thought.

Mark up the lenses by hand drawing with a Sharpie (or similar pen) where you see the outer edges of the channel when held up to a grid such as a screened window.

Put pieces of opaque cellophane tape along and outside the channel so the vision is occluded except along the progressive pathway. Have her put them on and see if any reading becomes visible. If not then I'd go back to the tri and chalk it up to a non adapt.

Looks like the reading material now has to be held 6 inches closer as well.

[VHB]

Oops! Sorry for misreading OS as Cyl. I was up all night with a sick kitty. (She's okay today, but I'm not!)

I actually measured the near pd 4mm different after seeing how she was looking through them because it looked odd. And the distance as made sits directly in front of her pupil. Would starting with near affect this?

Four mm different compared to your original near pd measurement? And yes, I think if you take her near pd (for the length she likes to hold reading material), and add 2.5mm ou as her distance pd, she may be able to use it. I've found (usually with myopes, though) that some people are more comfortable holding material closer than 14".

[Dpcbb]

No. I measured it 4 mm different than her distance PD.

Interesting suggestion. If she insists on staying in PALs, I will try that.

[judyseyes]

She probably got used to holding her material out a little bit with old RX. Now she needs to bring it closer. Plus, I would never consider a short - fit PAL a non- adapt without trying a full PAL like Zeiss GT2, minimum height of 17mm. Good Luck!

[Freedom]

In this case is simple Rx. (not complicate,no cylinder)

Valilux ellipe is can handle this case.
From your fitting high 16 mm. I think ... It small frame

Please remake this lens by
1. reorder and erase yellow marking and remark by yourself.
2. use monocular near PD and plus 2.5 mm. each side of lens
for used it ... for used in distance PD.
3. If frame high is 25-26 ... try used fitting high 17 mm.
If frame high is 27-30 ... used fitting high 18 mm.
If you can used fitting high at 18 mm. It will perfect fitting high.
4. adjust nose pad wider a little when tou change fitting high from 16 to 17
5. adjust pantilt to 8-12 degree
6. adjust face form angle to 5 degree
7. adjust vertext distance to 10-12 mm.
8. educate client about Pals ... and manage the client hope.
Frist Pals wearer need time to adaptation If client need instance adaptation or short time adaptation ... should be used freeform Pals.


"No Pals lens in the world that wider than single lens"
"No Pals lens in the world that wider than Bi-focal lens"

Good Luck.

[DragonLensmanWV]

My policy is that when they have trifocals, never put them in progressives.
UNLESS they are HIGHLY motivated for progressives.

[Dpcbb]

Hey Dragon,

That is my policy as well. This was one of those patients, however. I know the benefits of doctor's recommending things in the exam room, but it doesn't ALWAYS turn out for the best.

:hammer:

[chip anderson]

You might look into an old proverb:
Don't fix things that are not broken!
If the patient is happy with a 7/28 he is seeing better and not complaining about the lines. Why screw that up for him?
For higher comissions or to comply with the last CEC sales pitch you heard?

Chip

[Dpcbb]

Hey Chip,

Read the posts RIGHT BEFORE yours.

[MarcE]

We have always been disappointed when a client is removed from a TF and moved to a PAL.

Why would someone all the sudden be concerned about the lines when they have had them for years (decades??)

[MicheleS]

I've had this happen a few of times after switching someone from TF to PAL. We now have a rule that we never put anyone in a short corridor PAL if thier add is above +2.00, those folks need and appreciate their intermediate view and the short corridor does not work for that. I have had 1 or lens companies disagree, but our proof is in the patient's. Each that we have switch to 18mm or above have not come back with a non-adapt.

[Dpcbb]

MarcE,

Great question. In this case, the patient originally wanted PALs years ago, they didn't work. SHe had heard there had been big improvements and wanted to try again because she never actually wanted the tri's. I did inform her that things had improved, but there was still a limited field of vision, etc., etc.

MicheleS,

Interesting suggestion about the adds. I will certainly remember that for the future.

[TLG]

Not all PALs work great for plus powers such as your patient. I think the last lens I might consider for a patient coming off of a 7X25 would be an Ellipse (I'm not trashing the lens in general, just for this application). There are not many areas of clarity in an Ellipse. I would strongly suggest since you are fitting 16 high to try a Piccolo by Shamir. It not only is my lens of choice but is also my favorite lens to wear and my Rx is nearly identical to your patient's.

[Andrew Weiss]

My guess is that even if you switch the patient to a Piccolo or GT2 or Accolade Freedom, and follow all of "Freedom"'s suggestions, you would still find your patient unhappy. Making the transition from TF to progressive is challenging because of the intermediate/near width and peripheral clarity the patient is giving up. Unless the patient is highly motivated and willing to put in 2-4 weeks of steady effort, without going back to the old familiar TF, I'd say it's not likely to work.

Fester's suggestion is a good one. It'll give you a good idea of whether a progressive will work at all.

[For-Life]

Okay, I have seen patients over the years that can't adapt to progressives. I can't seem to give this patient a satisfactory answer as to why they can't see out of them.

Patient has been wearing 7x28 in a small frame. Tried PALs years ago, couldn't use them. Dr. said things have changed and she wanted to try again. I didn't think it was a great idea, but I have had a number of patients try again with new technology and they work fine.

Fit her in an Ellipse at 16mm. She says distance is okay but narrow. This she gets. But she is having more trouble up close and says she can't see anything near out of her left eye no matter where I move the lens on her. Everything checks out though.

I have checked and rechecked PD (binocular and isolating each eye for both distance and near), segs, Rx, ec, etc, etc. What gets me as weird is when I watch the patient read with them on, it appears as she may be looking "inside" of the segs, perhaps converging much more than the seg inset. Does that make since, is it my imagination, or is it merely an illusion on my part?

To test this, I drew the reading area with the layout chart and colored in the circles with a blue marker. She tells me the circles barely even touch when she tries to read, which leads me to believe there is a convergence problem.

In all my years, I have never had this much trouble with a prog fit.

Old Rx (New patient. Rx at least 2 years old)
7x28
OD +1.50 OS +1.00 Add +225

New Rx
Ellipse
OD +2.00 OS +1.75 Add +225


As a side question, how do you all explain to a person that is a non-adapt why they can't use progressives?

Simple, they are happy with the 7x28 and do not want to change.

I remember playing golf last year with an older fellow whose woods were actually made out of wood. He was satisfied with his old, bent up clubs. Probably, because he just did not want to buy new ones. So he tries a new driver. A big titanium bertha. He hit it 20 yards further, and straighter. We got back to the clubhouse and he told everyone that it was his old woods that he hit better with.

No use arguing with him, he is happy. He plays a good game with the old stuff, so he does not want to learn the new stuff.