Help with a patient

**EdgeOptical** · 03-30-2010, 06:17 PM

Ok, im at a loss on this one... i hope im missing something...

Old RX
0.00 -1.50 X 180
-.50 -.75 X 015
1.00 add ou

Poly Definity fit at 20 mm

grooved rimless

New RX
-.25 -1.75 X 180
-.75 -1.00 X 015
1.50 add ou

Trivex Auto II fit at 22 mm

Drilled rimless - almost identical size and shape

There has been one RX check and adjustment to get us to the current RX, the initial problems are pretty much gone.

Complaining off intermediate issues mostly. also problems with horizontal alignment (best way to describe it) in the right eye. PD is the same in both. I would expect the Auto II to have less distortion, even with the increase in add. but maybe i am hoping for too much?

Distance is good, reading is good, going from int. to reading is a problem, patient has to completely reposition to be straight on with what they are doing, not just turning his head.

loves the frame, lenses and everything else, so there is no chance of remorse.

he does seem to be more sensitive then most... adjustments look good and similar to the previous pair. im out, i have no more ideas.

plan so far.

a few years back we did have an SRX check that was presented similar to this time also, changes made were similar (seems to like to be over minuesed) but his PD was also changed, i dont know if it was an error but the os only was brought in 2 mm.

my thoughts are to put him back into the definity, change the PD to 34 33 (remeasured) and see if that does it... could he really be used to the progressive design that much? but with a .50 increase in the add, is it going to be similar enough?

help!!

Thanks

**obxeyeguy** · 03-30-2010, 06:29 PM

Another reason why I have moved slowly into these "new improved" lenses, as we keep seeing more and more of this. We seem to be up-selling to "better" lenses to solve problems which don't really exist. After 2 pairs of Auto's,($$$) put him back in Definity, up-grade to trivex vs. poly, and watch the problem go away. JMHO

**Uilleann** · 03-30-2010, 06:32 PM

OK, so first off, the obvious stuff. A half diopter increase in add is gonna affect just about anyone. The corridor will narrow, to a greater or lesser extend depending on lens design and patient awareness, but it will be narrower. You're also likely to have more of our favorite friend - marginal astigmatism pushed up towards the dist. areas as well. I've had very mixed luck with the Definity on the whole, and really poor luck with the Definity Short. We're more comfortable fitting the Physio designs if you're looking to stick with an E lens. The ol poly vs. Trivex argument hold no water or weight for me. Poly works perfectly fine.

What is your patient doing all day? Lots of computer use? He might benefit from on occupational/computer lens like the Office. But he should be well educated that any progressive is likely to exhibit that compressed intermediate as his eyeballs get older and his accommodation gets weaker in time.

Let us know what you find. Best of luck!

Bri~

**Happylady** · 03-30-2010, 07:36 PM

Definity has a great intermediate area and it comes in Trivex, too.

**bigeyejim** · 03-30-2010, 08:52 PM

As they said, sometimes people get used to something and it is hard to get them out of it. Case in point: I have a bunch of "retired engineers" in the Percepta for cryin' out loud that cannot come out of that lens. Any changes have freaked them out!!! I eventually said, "Look, this thing is going away, and you have to change!" And they do it grudgingly.

Sometimes, it doesn't pay to change!

**EdgeOptical** · 03-31-2010, 09:55 AM

Changing back might be my best option then... seems weird though.

what about doing a fixed seg auto II? say an 18 fit at 22?

think the corridor changed so much from a 1.00 add to a 1.50 that he couldnt adapt, so maybe step the add down to 1.25 and work him back into where he should be? is it that drastic of a jump?

**WFruit** · 03-31-2010, 11:39 AM

You have two choices:

1) Put him in a fixed Auto II 18 (which I would have done in the first place (see this thread http://www.optiboard.com/forums/show...plications-etc... for a good discussion on the Variable lens).

2) Put him back in a Definity. I've never liked the Definity since J&J introduced it, but I'm not the one wearing the glasses. If the patient likes them, that's what matters.

**Ginster** · 03-31-2010, 12:11 PM

Could it be a converence issue? take the mono near PD as well and see how the difference is between both far and near pd's. One or both eyes might not be converging, that could be why the other PD worked best. If you find this to be true let the lab know the near pd as well as the far pd,. Be sure to do the near at mono, the lack of converging may only be in one eye. I also agree to find out the Pt's occupation and hobbies to determine if a progressive with more intermediate is the issue. I have a plus proscription and did not find the intermediate in the Autograph, I didin't have one. Shamir couldn't figure out why either. I have a high plus asthigmatism prescription. Hopefully with the Autograph 2 they have resolved the issue for some of us.

**EdgeOptical** · 03-31-2010, 03:11 PM

Originally Posted by WFruit

You have two choices:

1) Put him in a fixed Auto II 18 (which I would have done in the first place (see this thread http://www.optiboard.com/forums/show...plications-etc... for a good discussion on the Variable lens).

2) Put him back in a Definity. I've never liked the Definity since J&J introduced it, but I'm not the one wearing the glasses. If the patient likes them, that's what matters.

Thats what made me think of trying it with an 18 fit at 22. but what would that gain?

Going back to definity is the easiest answer, but i want to be sure its the correct one. I havent been a huge fan of the definity also, the optical manager before me was, so we are dealing with the people he fit.

so yeah, im kind of at a loss. im not 100% on putting him back, but not more then 30% on any other option either.

**flexonman** · 03-31-2010, 04:03 PM

Similar problem here. Patient was a refraction redo...to much plus in the add area. Recommend a refraction or place -trial lenses over to see if that resolves the issue.

**Whidbeyeyes** · 03-31-2010, 05:06 PM

Quick question- Which Auto II did you use for this patient originally? We have problems in the past going from whatever PAL the patient was used to into a variable design. The variable designs actually work better for first time PAL users than those who are already in progressives. Check the corridor length of the Definity and use the fixed design that most closely matches that length without going shorter. The Defnity looks like an 18mm which would make the most comparable Autograph II to be a fixed 18 as well. I would also double check the PD issue. We have had very few patients who have not adapted into the Auto II lenses, AS LONG AS WE USE THE CORRECT DESIGN. The fixed designs seem to be much easier for patients to adapt into than the variable designs. YOu may also need to add abit of pantoscopic tilt. It can be tricky with the drills but you may find that helps.

**EdgeOptical** · 04-01-2010, 03:26 PM

ok, so i just ordered the new lenses.

going back to the definity, going with a little lower ADD to make it an easier progression for him, and also slightly changing the PD, 1mm in one eye.

lets see how it goes. I know the definity worked for him before, and i couldnt say that for a fixed auto II.

**Mr. Finney** · 04-01-2010, 06:00 PM

Not trying to be argumentative here, but you'll never know if you really solved the problem or not with the lens change and PD change, if you also change the add. IMO, big difference between a 1.25 and a 1.50 add. Unless an over-refraction proved otherwise, I would have left him in the 1.50 and made the other two changes. Just my $.02 Good luck!

**EdgeOptical** · 04-01-2010, 06:06 PM

im trying more to guarantee success then continue trouble shooting and going through more lenses then i have to.

i want to try a fixed auto II, but i want to be sure whatever we do will work instead of dragging this out further and making the patient wait again. the lab and my patient have been more then patient (ha) through this process and i dont want to push that any more then i have to, not for the sake of experimenting.

i know you arent being argumentative, i have had a very hard time deciding which direction to go on this one, thats why i have waited nearly 2 days to put the order through.

**Mr. Finney** · 04-01-2010, 06:09 PM

I totally understand. You might want to remind your patient that emerging presbyopes often need more frequent Rx changes, that way he/she will understand if they need that 1.50 six months from now. :)

**EdgeOptical** · 04-01-2010, 06:24 PM

That is a conversation I had with him this last time around, his very first pair was prescribed at a 1.75 add. he didnt adapt to that and it was backed down finally to a 1.00. even this time around he is refracting with a much higher add then he can actually use.

at some point what works and what he needs will collide.

when i dispense this pair i might steal his old glasses from him too.