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Thread: Highish Plus dilemma

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    Highish Plus dilemma

    Hey all,

    Got a highish plus Rx the other day. Here's the Rx:

    +12.00 -0.75 x 170
    +12.25 -2.75 x 173

    It's a VSP Sight for Students job, and they said it was only available in a Spherical Mid-Index 1.56. (Out of power for range for 1.67, 1.74, etc) I'm thinking a supermod will look better, and I'm looking for support in my decision.:hammer:

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    ATO Member HarryChiling's Avatar
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    Quote Originally Posted by Pell View Post
    Hey all,

    Got a highish plus Rx the other day. Here's the Rx:

    +12.00 -0.75 x 170
    +12.25 -2.75 x 173

    It's a VSP Sight for Students job, and they said it was only available in a Spherical Mid-Index 1.56. (Out of power for range for 1.67, 1.74, etc) I'm thinking a supermod will look better, and I'm looking for support in my decision.:hammer:
    Spherical is gonna have horrible optics, you need asp[heric whenever you go above a +8.00 so that could be your saving grace.

  3. #3
    Underemployed Genius Jacqui's Avatar
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    Aspheric is the way to go. This should not be beyond the range of higher index materials, check around. We've done up to +17.00ish in 1.67 (double convex style).

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    opti-tipster harry a saake's Avatar
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    plus

    also make sure you have a frame pd that matches the patients pd, very critical in these type rx,s, also wire frames will give you a lot more adjustment room. seems to me that there is alens out there for this rx thats aspheric called a super modular, but i cant recall who makes it

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    Quote Originally Posted by harry a saake View Post
    also make sure you have a frame pd that matches the patients pd, very critical in these type rx,s, also wire frames will give you a lot more adjustment room. seems to me that there is alens out there for this rx thats aspheric called a super modular, but i cant recall who makes it
    Yes, the frame pd vs pt pd is critical. Thanks for the reminder. And the super modular is what I planned to use. As far as I know, Essilor makes it.

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    Quote Originally Posted by Pell View Post
    Yes, the frame pd vs pt pd is critical. Thanks for the reminder. And the super modular is what I planned to use. As far as I know, Essilor makes it.
    Supermodular is the way to go. As little dec as possible and as round a frame shape. (If the b is narrow it will cut into the thicker part of the lens.)

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    I can't believe that I beat Chip to this:

    How about fitting a contact to this youngster?

    I know that the $$$ is a major concern with this patient and it probably is not an option, but worth mentioning.

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    ABO-AC, NCLE-AC, LDO-NV bob_f_aboc's Avatar
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    In a small frame with PD to FPD close, I have had luck with aspheric Trivex up to +11. The benefit is that there is no extra charge for aspheric mid index on VSP where poly or higher index lenses will incur an upcharge.


    My 2 cents.
    A lack of planning on your part DOES NOT constitute an emergency on mine!

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    Quote Originally Posted by Fezz View Post
    I can't believe that I beat Chip to this:

    How about fitting a contact to this youngster?

    I know that the $$$ is a major concern with this patient and it probably is not an option, but worth mentioning.

    Not our patient...yet. But the best idea yet! Less work for me!:cheers:

    Thanks everyone for your input!

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    Quote Originally Posted by Fezz View Post
    I can't believe that I beat Chip to this:

    How about fitting a contact to this youngster?

    I know that the $$$ is a major concern with this patient and it probably is not an option, but worth mentioning.
    I can't believe that FEZZ beat me to it.:bbg: I was going to say the same thing. Why get separate brains when we can share one?

    On a job like this through VSP, you probably can get authorization for contacts. Just my guess and I think it is worth a try. Of course not just for the aesthetics, but the effective field of vision will be so much larger.

    I think the reason that you were told that 1.56 was the only choice is because of thickness. 1.56 comes in an extra thick blank. If you choose a small eye, then you have more material choices. Right? I think many other materials come in an +12 or higher BC. Someone tell me if I'm wrong.

    For specs, they have some great shapes for this in the John Lennon collection. 42 eye w/ a 22 bridge.

    I had this great little frame from Neostyle that was a 36-25. I sold half a dozen for these high Rxs. We did a -10.50 in Asp Trivex w/ a 1.1mm CT that had an ET of less than 3.5mm!! Sadly it's now discoed.

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    aspheric poly from BCD (Bristolite) is in SV and FT 28 and can handle this well.

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    In terms of contact lenses, if we are dealing with economics and budget, the highest power in disposable is Precision UV by Ciba at +10.00.

    What I would do is prescribe that and over refract the pt and prescribe gls along with the CL.

    Of course the patient's parents would have to pay for the CL fitting unless the VSP will allow the necessary contacts and preapprove in this instance, then it would be no problems.

    I did take a look at both AV Oasys and Cooper's Biofinity and +8.00 is the highest.

    Normally this patient would need +14.00 contacts and that is in the province of aphakia...

    It would be possible that with +10.00, this patient could tolerate his vision without glasses for occassional times...as he is young and he has high accommodative level...of course the doctor would have to check his phorias and make sure he is not esophoric.

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    Psaturn: How come you stick with these brands. Why not use a CL that fits the patient's needs? In fact you will find that for aphakic patients a well fitted, well managed PMMA lens is really the best thing you can do.

    Can't immagine why you are limited to brands that only go to 8 or 10..

    Chip

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    Quote Originally Posted by chip anderson View Post
    Psaturn: How come you stick with these brands. Why not use a CL that fits the patient's needs? In fact you will find that for aphakic patients a well fitted, well managed PMMA lens is really the best thing you can do.

    Can't immagine why you are limited to brands that only go to 8 or 10..

    Chip
    If I was going to use Hard CL, I would use RGP like Boston XO or Boston XO2, but many young patients prefer the comfort of soft contact lenses.

    I have fitted several young children with RGP lenses and they are usually because they have smaller lid apertures or if they have extreme astigmatism.

    We have not fitted PMMA lenses in our offices, specially in young children...our feeling is that since we have RGP's available that function as well as PMMA, and has safety factor of oxygen permeability, specially when you have thicker center thickness due to high plus, you need every oxygen you can get for the young patient whose eyes are growing.

    I like the Boston XO and the XO2. The DK (Oxygen permeability) of XO2 is 141 while XO is 100.

    The DK of PMMA lens is 0 (ZERO).

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    I knows bout dem DK's but there will never be a soft or HGP lens that performs anywhere near as well as PMMA on an aphakic patient.

    Chip

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    I was not aware it was an aphakic patient but either way, I do think RGP is better for corneal health to prevent corneal edema and endothelial diseases, especially in young patients who we presumably think have a long life ahead of them...

    And I do think RGP's are performing very well...I have patients who have the same RGP's for 3 yrs or more...and cornea looking good, not too many neovascularization or superficial punctate staining or Descemet's breaks.

    I do have Aphakic patients who have Precision UV +10.00 and may have some residual prescription but find that the performance and vision of the disposables to be good enough for his needs considering the cost. Some patients are cost sensitive, especially they are older and retired and have fixed income and have high energy cost because they live here (where temperatures can reach 125 degrees in the summer!).

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    I'd hate to have my practioner tell me I have "good enough vision." I want and will always want every damn bit of vision that can be squeezed out out my visual system. I have aphakic patients wearing PMMA some times for up to 10 years per lens and up to 60 years per patient. Many of these were PMMA prior to surgery and were PMMA afterward. Do not ever recall one having any surgical compliation from polymegathism. RGP's are not nescessiarily "healthier" as the collect deposits that in my opinion (and yes I do usually fit new non-aphake(s) with RGP's or soft lenses) cause more corneal problems and dangers than the oxygen depriviation of PMMA. Aphakic patients for some reason do not seem to be as needy of oxygen transmission through the lens as myopes and low hyperopes.
    In fact I really doubt that any lens of aphakic lens thickness has siginficant permeability of anything in sufficent amounts to be of any benefit to the contact lens wearing cornea.

    Chip
    Last edited by chip anderson; 01-19-2009 at 07:34 PM. Reason: More off the wall theory to expound.

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    In regards to RGP Contact Lens deposits, I do find that Lobob Extra Strength cleaner works wonder on deposits and of course periodic enzymatic bath helps a lot and so does polishing. And of course the fact that there is more silicone in the RGP formulation, means less deposits.

    In terms of "good enough" vision...It is my patient's determination that they get satisfactory vision with the contact lens they get...each person has different criteria and each person knows the budget they are in. I try to fit it within that expectation and desire to the best of my ability.

    Some patients choose not to have hard lenses, and so the soft lenses being the only choices, then we work with it accordingly.

    And if the patient is Aphake and has Medicare, they usually get contact lenses provided by Medicare anyway, up to a certain amount.

    Chip, I am glad you are expert at PMMA and you had great success at it...but PMMA CL is not used in our office at all except for measuring corneal curvature if the patient had LASIK and needed cataract surgery.

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    Don't kid yourself about silicone. If you had ever been in a dental lab when a silicone lined dental prosthesis was being cleaned and buffed you would know that a crew of 20 would drop to the one doing the work. Talk about stink! The stuff not only attracts protiens, it imbibes them and grows bacterial within itself.

    Chip

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    Wink

    Imagine they use silicone material for bakeware and cookware! I have not used my silicone Madeleine molds yet...they claim it will not absorb odors and it is easy to clean...

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    hi

    If you choose a small eye, then you have more material choices. Right? I think many other materials come in an +12 or higher BC. Someone tell me if I'm wrong.

    Lisa11

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    If your silicone cooking moulds go in the oven with the food, chances are they will get pretty sterile while in the oven.

    chip

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    VSP has done amazing things for special needs patients on occaision, but they have tighted up in recent years. I have seen them cover Progressives for children, and 2 pairs for near vision convergence disorder, and even combo glasses/contacts for high RX's in kids.

    If you use their "Prior Authorization Form" once you have figured out what you want to do, VSP could consider special benifits.

    I would suggest figuring out 2 options, send the "Prior Auth" form to VSP for your first choice and keep the 2nd choice as a backup if they say no.

    Send the form in with the patients chart, and a seperate letter signed by you and the Dr explaining why this choice is the best for the patient. I think I have about a 60% approval on special benefits.

    Sharpstick

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