Comfort Non-Adapt

[jhegyi]

My first post, so go easy on me.

I'm an OD who until recently worked for a regional chain where I didn't do any dispensing or lens selection at all. I own my own practice now and I'd like to get back into dispensing and understanding the best lens options again.

I have a patient with an Rx of +1.00 -1.25 x 90 / +2.00 Add previously wearing FT-28. We moved him into Comfort Short in CR-39 with a 17mm height at center pupil.

He's come back with problems of not being able to scan side to side without turning his head, both distance and near, compared to his FT bifocals. He also gets blurred watching TV while reclined in his EZ chair.

I know these are all common shortcomings of progressive lenses and I blame myself and staff for not educating the patient enough during lens recommendation. I want to learn from the situation and see what we could have done better.

What would you have done? Would a digital/free form design made a big difference? Larger frame size? Who wouldn't have recommended moving a longtime FT wearer into a PAL?

Thanks for your opinions and experience!
Joe

[Robert Martellaro]

What would you have done? Would a digital/free form design made a big difference? Larger frame size? Who wouldn't have recommended moving a longtime FT wearer into a PAL?

Welcome!

I keep most folks in a segmented multifocal, unless there's reason to change to a PAL. An optimized PAL would offer very little benefit with this Rx, unless there is an unusually wide or narrow PD.

Regarding your client, you could change the PAL design to a more moderate length corridor that has less distance peripheral blur, but continue to advise the client of reduced field of vision both vertically and horizontally at near. Avid readers may need an auxiliary pair of segmented or SV for extended near tasks, or computer lenses if applicable. It comes down to what's best for your client, and only you can sort that out after a detailed sit down and Q&A with your client.

[DragonLensmanWV]

We also know that he would have a hard time watching TV while reclining with his FT-28's too. Time to sell him some "task-specific" SVs for watching TV if he wants to recline. If he's an engineer type, ask him how he'd solve the problem of looking out through the bottom of his frame where the add has to go. It simply can't be done.
As for the progressives, most all short corridor lenses have less width and more distortion than conventional ones, so that's no surprise. I ask people sometime who complain about that (even with digital progressives) if they have some medical reason they are unable to turn their head a few degrees from side to side. I also would fit progressives a bit lower, say at bottom of pupil at highest. I usually split the iris and have a great acceptance rate.
If you want to use a good shorty, Younger's Adage has a sweet design that, IMHO is way better than the Comfort Short.
So, a larger B dimension would help because you can use a conventional prog, but it still won't be as wide as a FT-28.
The only cure is a selective time machine that will take his eyes back 20 years.

[jhegyi]

Thanks so much for your replies. It makes sense to be really careful in switching a longtime BF wearer into a PAL and after talking about his success with the BF I think that is truly the case with this patient.

I've been reading back through the old messages here trying to see what PALs people have been using. When I last dispensed we were using Sola VIP and Percepta! My god, I sound like an old man and I'm only 40!

[PhiTrace]

+1.00 -1.25 x 090 +2.00 add - looking at the script I would say yes a back side free form would have made a difference. Here is my reasoning why:

1. The power is a plus which makes for a reduced field of vision with a front side PAL especially.
2. The astigmatism is weighted at 1/2 the power, so figure a 1.25D of astigmatism is worth roughly 0.625D which is about 2/3 the strenth of the defocus power. Correcting optimally for both meridians can add a level of clarity to the Rx that could help.
3. The add power is a +2.00 which according to an older zeiss powerpoint I have and many of the older texts I have is a contraindication for new wearers.
4. Short corridor lens design is by definition harder than the comprable traditional corridor length designs which should be a bit more difficult for newer wearers to acclimate.

The two positives I see going for the script is that the axis is oriented so that the powers are aligned vertically and horizontally, this means that their is less compunded effects due to the torsion of the Rx so I would guess that the corridor remains fairly stable and properly oriented if the base curve is chosen properly.

My procedure or solution on dealing with this client is to start with a proper explanation of what to expect from PAL's and guage the patients motivation. If they are happy with their FT then I would be prone to staying in the design, however I would still recommend the PAL with the caveat that they go with a good FF design to help compensate for the issues that the Rx has with a traditional molded design and the late adoption of a PAL design. I would choose a frame with a deeper fit to ensure that the design remains as soft as possible for the +2.00 add power. If the patient chose to stay in a traditional design and the major complaint is the width of the zones then I would have the lab chose the base curve that corresponds to the horizontal meridian of power to try and optimize the clarity in the width of the zones.

[Barry Santini]

In ascending order:

Regular Comfort 2 (not short)
Comfort DRx (Atoric)
FT28IQ enhanced
7x28 Tri enhanced through Quest Florida
Round (name your size) optimized through Quest or Digital eyelab.

B

[PhiTrace]

In ascending order:

Regular Comfort 2 (not short)
Comfort DRx (Atoric)
FT28IQ enhanced
7x28 Tri enhanced through Quest Florida
Round (name your size) optimized through Quest or Digital eyelab.

B

Good list of suggestions I have enjoyed the Surmount especially for Rx's like this with mid to high adds. 3 Rivers also has a round seg that would suit. I might also suggest a secondary pair FT with inter/near or a computer PAL fit low for home TV viewing especially in a recliner.

[Java99]

If he was watching TV in his recliner just fine in his FT, it was probably set low and/or slid way down his nose most of the time. I would stick with the FT for two reasons: it doesn't sound like he wants to have to turn his head, and it also sounds like he was doing okay with his FT. Motivation is key here, and it doesn't sound like he has it.

[cocoisland58]

Who wouldn't have recommended moving a longtime FT wearer into a PAL?Joe

I wouldn't. Unless I really feel it would benefit them and that is not often. I deal with a lot of seniors who have been wearing FTs for 20 years and if they really want to try a PAL I'll do it and tell them exactly what to expect but I can almost count on a remake. I work with a dispenser who will put anyone and everyone in a PAL and tell them it's the greatest thing since sliced bread but it is not always the best lens choice for the patient.

[jhegyi]

Thanks for all the suggestions. I think in this case the key factor was motivation. My staff and I had more motivation to switch him to PAL than the patient. He was really content with his BF and the PAL's narrower fields outweighed the other benefits of PAL.

Just like with contact lenses (especially bifocals), its important to remember patient selection. I appreciate the other PAL suggestions as they will be helpful when considering other patients.

If he was watching TV in his recliner just fine in his FT, it was probably set low and/or slid way down his nose most of the time. I would stick with the FT for two reasons: it doesn't sound like he wants to have to turn his head, and it also sounds like he was doing okay with his FT. Motivation is key here, and it doesn't sound like he has it.