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Thread: Progressive nonadapt

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    OptiBoard Apprentice Fabian Corio's Avatar
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    Question Progressive nonadapt

    Hi everyone, I was wondering if you could help me out with this one.

    We have a 72 years old patient that has worn progressives in the past (in the 80īs) but now was wearing trifocals and wanted to try progressives again. On 08.02.2011 we put him in a Rodenstock PureLife and he came back one week later complaining about poor near vision.This is his rx:
    OD -0.50 -1.25 x 006
    OS +0.25 +0.25 x 170 add +2.75

    He told us that he had to turn his head to his left if he wanted to read comfortably with his right eye, otherwise the left half of the line was blurred. He inquired if we had fitted his lenses inhouse and even accused us of fitting them poorly, he told us they were off center. We checked the rx, pd, heights, panto and vertex distance and everything was fine. To make a long story short, he walked away.
    He came back yesterday (09.29.2011) with a new pair of Varilux Comfort Poly that he bought elsewhere "because we had poorly fitted his previous lenses inhouse and they were off center" and guess what...
    "He has to turn his head to his left if he wants to read comfortably with his right eye"
    I checked his new glasses and they are right. I thought that maybe he is experiencing some horizontal prismatic imbalance when he reaches the reading zone.The OD is a minus so there is base in, base out for the plus OS. He has no problem when looking at the distance.
    Whatīs your opinion and what should I do next? I would really appreciate your input.
    Thanks!

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    The most likely cause of this is vertical imbalance. What is the monocular IPD, and has this person had cataract/implant surgery?

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    OptiBoard Apprentice Fabian Corio's Avatar
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    Hi uncut, thank you very much for your answer.
    The monocular PDīs are OD: 33,5 mm.; OS: 32,5 mm and no, he hasnīt had any cataract/implant surgery.
    I have just called his doctor and he says no retina nor macula issues as well.

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    And he didn't feel he had to do this at all with his trifocals? Is he turning his head a large amount to the left or just a little?

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    Patient has been spoiled by trifocal wear, his brain has learned what it's like to see clearly. Will never accept the abberation in progressive again.

    Sorry,

    Chip

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    EyecareRich is probably correct in saying he probably did this with his trifocals, but, of course, they created a wider field of view, and the reading/intermediate sweet area was more accessible higher in the lenses. This person would probably be a candidate for: an old style (hard) progressive with a wide intermediate corridor and a bicentric on the right eye.

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    OptiBoard Apprentice Fabian Corio's Avatar
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    Hi EyeCare Rich, uncut and Chip, many thanks!

    "And he didn't feel he had to do this at all with his trifocals? Is he turning his head a large amount to the left or just a little?"

    No, he doesn't need to turn his head at all with his trifocals but that Rx is old and has nothing to do with his actual requirements. With the progressives he is turning his head about 30 degrees.
    Trifocals
    OD -0.75 sph.
    OS +0.25 x 020
    Add1: +1.25
    Add2: +2.50
     
    "Patient has been spoiled by trifocal wear, his brain has learned what it's like to see clearly. Will never accept the abberation in progressive again."

    Definitely not. He is not complaining about aberration, he can see clearly with his progressives but needs to twist his head. He wanted to improve his vision but didn't want to deal with segment lines, that's why he asked for progressives.
     
    "of course, they created a wider field of view, and the reading/intermediate sweet area was more accessible higher in the lenses. This person would probably be a candidate for: an old style (hard) progressive with a wide intermediate corridor and a bicentric on the right eye."

    Maybe the wider field of view is disguising the twist? Would it be wise to re-fit trifocals? If not,which progressive would you suggest?
     
     
     
     

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    Maybe you can move the right lens out 1-2 mm further out? I dont think changing lens style will help because your client is having problem on just one side. It sounds to be is the position of the inset is causing this problem. I actually see this problems very often and is usually solved by moving the PD on that one side that is having problem. Just my 2cents. Good Luck!!!

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    One eye sees, the other feels OptiBoard Silver Supporter
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    Fabian,

    This thread has some helpful hints...

    http://www.optiboard.com/forums/show...6-PAL-PD-issue

    Your client may be a head turner. Use the "Mirror Trick" to determine the real near PD. Try doing that with a Digital Video Centration device!
    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.



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    Master OptiBoarder optical24/7's Avatar
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    Robert, excellent thread for future reference! Thanks for sharing!

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    Quote Originally Posted by optical24/7 View Post
    Robert, excellent thread for future reference! Thanks for sharing!
    Great information in that thread! This should help Fabian solve his situation.

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    OptiBoard Apprentice Fabian Corio's Avatar
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    Hello everyone, thank you so much for all your great help!
    And thank you for reminding that Robert, I have never tried the "mirror trick" but I'm pretty sure I've seen it in an old Zeiss booklet. The mirror had to be laid flat on the desk, though. I'll try to find it and post a picture.

    I also remembered that I once had a conversation with a colleague who was a great fan of Zeiss and he told me that he always used near PD as reference when centering progressives. Iīll try the mirror trick and Iīll possibly end up adding 1 or 2 mm. as CalCal suggested.
    By the way, this may sound dumb but how do you search for similar posts? I can never make the "Advanced Search" feature work!

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    Betcha either end up with an unhappy patient or a trifocal.

    Chip

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    OptiBoard Apprentice Fabian Corio's Avatar
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    Quote Originally Posted by chip anderson View Post
    Betcha either end up with an unhappy patient or a trifocal.

    Chip
    Sure Chip, Iīd be better off watching him walk away but unfortunately he lives next door, his return was just a matter of time and yes, I guess the trifocal is still an option.

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    Master OptiBoarder RIMLESS's Avatar
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    Having to turn his head to the left to see out of the right would not be a vertical prism problem. Assuming the mono PDs were measured correctly and the script was made correctly it's probably a near PD issue, which is difficult to compensate for with a PAL. I'd also be curious to know if he got the comforts for a cheaper price which could also be a factor "per se". After 25 years of this stuff, I can say that putting a BF or TF wearer into a PAL is somewhat akin to sailing into the Bermuda triangle.

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    One eye sees, the other feels OptiBoard Silver Supporter
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    Quote Originally Posted by optical24/7 View Post
    Robert, excellent thread for future reference! Thanks for sharing!
    It's more like pointing to, than sharing with, but you are welcome!

    What's really special about that thread is Darryl Meister's contribution. Maybe I haven't said it enough in the past, but here it is- advanced level opticians (or all opticians really) should read everything this man has written pertaining to ophthalmic optics.

    Quote Originally Posted by Fabian Corio View Post
    Hello everyone, thank you so much for all your great help!
    And thank you for reminding that Robert, I have never tried the "mirror trick" but I'm pretty sure I've seen it in an old Zeiss booklet. The mirror had to be laid flat on the desk, though. I'll try to find it and post a picture.
    I always measure the client's reading distance and depth with the card held well away from the dispensing table, guaranteeing that the card is placed in a realistic position. I would do the same with the mirror. Once the client assumes the position, angle the mirror towards you so that you can see the client's eyes.

    I also remembered that I once had a conversation with a colleague who was a great fan of Zeiss and he told me that he always used near PD as reference when centering progressives.
    This will generally bring forth poor results, for the reasons stated in the above thread.

    Iīll try the mirror trick and Iīll possibly end up adding 1 or 2 mm. as CalCal suggested.
    I wouldn't deviate from the text book lens position unless there is prescribed prism.

    By the way, this may sound dumb but how do you search for similar posts? I can never make the "Advanced Search" feature work!
    Use a major search engine like Google. Make sure to include "+optiboard" in the your search terms.

    Quote Originally Posted by RIMLESS View Post
    Having to turn his head to the left to see out of the right would not be a vertical prism problem.
    I must have missed that part of the discussion! Regardless, I agree with you.

    Assuming the mono PDs were measured correctly and the script was made correctly it's probably a near PD issue...
    Sans prescribed or induced prism, the near PD at 40cm will be 94/100's of the distance PD.

    After 25 years of this stuff, I can say that putting a BF or TF wearer into a PAL is somewhat akin to sailing into the Bermuda triangle.
    Or into the whale's stomach! The OP did say his client wore PALs 30 some odd-years ago, but that most likely would've made it a +1.25 Add. OTOH, if he could adapt to a +1.25 VIP/VAL2, why not a stronger Add with with one of the more optimized, latest generation PALs?

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~

    Fabian,

    Time to troubleshoot.

    Let's firm up that Rx for starters. Is it written in minus or plus cylinder? If the Rt cyl is +1.25, and he's over plused (old Rt sph equiv -.75, new +.12), then a turn to the left will decrease the plus power improving his near vision. Check the right eye distance and near vision with a trial frame or hand helds over the eyeglasses.

    If that's not it, then supply the true seg height (fiiting cross to the bottommost part of the eyewire using your best guess for the inset), describe how the client is so sure that the problem is the right eye, why a +2.75 Add (instead of +2.50), which eye is dominant, and pathology, if any, beyond the usual haze in 72 year old lens.
    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.



  17. #17
    What's up? drk's Avatar
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    Quote Originally Posted by Robert Martellaro View Post
    Sans prescribed or induced prism, the near PD at 40cm will be 94/100's of the distance PD.
    This is true optical gold.

    As an older, balder OD since 2005, I believe that, while the problem still escapes explanation, the solution is either a short corridor lens (lending credence to Robert's "not looking through the stabilized near zone and instead only looking through the intermediate zone" theorum) or simply a widest possible near zone lens design.

    I too think that an improper refraction may have the patient liking random unwanted astigmatism powers outside the viewing zones, so I would always check refraction on these.

    Bottom line, though, could be something a stupid as an artifact: monocular testing of near vision through a binocularly inset zone may simply be invalid; as Robert has said before, "you don't read with one eye closed, so don't do it to test your vision". I think this has validity and a little salty reply is more useful the more seasoned you get as a dispenser.
    Last edited by drk; 10-03-2011 at 08:57 PM.

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    OptiBoard Apprentice Fabian Corio's Avatar
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    Quote Originally Posted by RIMLESS View Post
    I'd also be curious to know if he got the comforts for a cheaper price which could also be a factor "per se".
    Hi RIMLESS, he actually complained about what he had paid for the comforts, he got them for almost the same as the PureLifes.

    Quote Originally Posted by RIMLESS View Post
    After 25 years of this stuff, I can say that putting a BF or TF wearer into a PAL is somewhat akin to sailing into the Bermuda triangle.
    Then we might have been lucky, many of our happy PAL wearers once switched from BF and TF.
    Funny comparison BTW, I started my day with a laugh
    Last edited by Fabian Corio; 10-07-2011 at 03:49 PM.

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    Master OptiBoarder RIMLESS's Avatar
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    As a side note I have observed that many problems with PAL adaption complaints tend to increase directly as the add power increases.
    Obviously related to corridor restriction (compared to their old lenses) or peripheral distortion issues. I am curious if anyone dispensing alot of freeform PALs can chime in and comment if this is less of an issue with the newer lenses.

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    Many progressives have had (I think some still do) a non-adapt warranty which allows a NC remake in bifocals (pity it isn't trifocals). The reason isn't that the optician may be incompetent at measureing for progressives. The reason is that many patients cannot accept the inherent abberation (and it is abberation no matter what progressive lens sales people call it) that must be present to blend the curves.

    Of course this is only a one time option because for the most part a patient that non-adapts will continue to non-adapt no matter how many progressive designs are tried.


    Chip

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    OptiBoard Apprentice Fabian Corio's Avatar
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    "I always measure the client's reading distance and depth with the card held well away from the dispensing table, guaranteeing that the card is placed in a realistic position. I would do the same with the mirror. Once the client assumes the position, angle the mirror towards you so that you can see the client's eyes."


    Compared to the mirror laid flat on the desk, I agree that your method has improved ergonomics.


    "Use a major search engine like Google. Make sure to include "+optiboard" in the your search terms."


    Thatīs what I usually do, I just wondered what was the "Advanced Search" button for.


    "The OP did say his client wore PALs 30 some odd-years ago, but that most likely would've made it a +1.25 Add. OTOH, if he could adapt to a +1.25 VIP/VAL2, why not a stronger Add with with one of the more optimized, latest generation PALs?"


    Thatīs exactly what I thought!

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~

    Fabian,

    Time to troubleshoot.

    Let's firm up that Rx for starters. Is it written in minus or plus cylinder?



    OD written in minus cylinder, OS written in plus.


    "If the Rt cyl is +1.25, and he's over plused (old Rt sph equiv -.75, new +.12), then a turn to the left will decrease the plus power improving his near vision. Check the right eye distance and near vision with a trial frame or hand helds over the eyeglasses.
    If that's not it, then supply the true seg height (fiiting cross to the bottommost part of the eyewire using your best guess for the inset), describe how the client is so sure that the problem is the right eye, why a +2.75 Add (instead of +2.50), which eye is dominant, and pathology, if any, beyond the usual haze in 72 year old lens."

    I will check all of the above and post the results.

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    One eye sees, the other feels OptiBoard Silver Supporter
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    Quote Originally Posted by Fabian Corio View Post
    OD written in minus cylinder, OS written in plus.
    Fabian,

    Are you dealing with more than one Doctor? Some of the larger clinics might have one lane for a doctor that prefers a plus or minus cylinder phoropter, but that's not too common I think. I would red flag the Rx if it's is on a singular Rx form, calling the doctor to confirm the Rx before proceding. 99.9% of the time this is simply a typographical error. Keep in touch!
    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.



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    OptiBoard Apprentice Fabian Corio's Avatar
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    Quote Originally Posted by Robert Martellaro View Post
    Fabian,

    Are you dealing with more than one Doctor? Some of the larger clinics might have one lane for a doctor that prefers a plus or minus cylinder phoropter, but that's not too common I think. I would red flag the Rx if it's is on a singular Rx form, calling the doctor to confirm the Rx before proceding. 99.9% of the time this is simply a typographical error. Keep in touch!
    Hello Robert, many thanks!
    I called the doctor last Friday and there is no typographical error. He told me the patient has no pathology, no retina nor macula issues.
    According to his TF -that he also bought elsewhere 3 years ago- he already had a myopic OD (though without astigmatism) and hyperopic OS. I have already called him and he is probably coming in the afternoon so wish me luck!
    By the way, I havenīt found the Zeiss booklet yet but I googled a little and found this:

    http://www.idol-lb.com/Library/Guide_EN.pdf

    This pdf has a picture and the explanation of the mirror method.

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    OptiBoard Apprentice Fabian Corio's Avatar
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    Quote Originally Posted by drk View Post
    "you don't read with one eye closed, so don't do it to test your vision". I think this has validity and a little salty reply is more useful the more seasoned you get as a dispenser.
    Hello drk, thank you very much.
    I totally agree with all of the above but this patient has used progressives in the past and he knows that he shouldnīt be turning his head to his left to see out of the right.
    Thatīs obviously why he thought at first our progressives were off center.
    Last edited by Fabian Corio; 10-05-2011 at 08:41 AM. Reason: typo error

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    I suspect that when : "The patient wore progressives before." he had not worn any other type of bifocal. He became acustomed to the type of vision one gets with progressives. Now his brain knows there is something better. His years in trifocals taught him what it's like to see and now he can't accept the abberration.

    Chip

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