Spectacle correction of a presbyopic patient with a vertical deviation

[Elias Bou Obeid]

Patient has recently started losing track when reading and developed asthenopia.

Previous Rx:
R: Plano/-1.50x167
L: +0.25/-2.25x5

The patient has a left head tilt and left hypotropia. It seems as though they have a CN IV palsy affecting their RSO.

Current Rx:
R: -0.25/-1.50x170 (5.25 BD)
L: +0.50/-2.50x5 (5.25 BU)
Add: +1.50

The patient is suddenly requiring an add as well as vertical prism correction. They do a lot of computer work.

1. What is the best way to correct this patient?
2. Is a progressive lens suitable?
3. If so, should I set the heights with the eyes in their natural position in primary gaze, or when aligned by occluding the alternate eye?
4. Is it better to use a progressive design like the Sola Elan HDV or Shamir Freeframe where the corridor length is computed on the pupil height or should I use a progressive design with a set corridor length?

[rdcoach5]

Patient has recently started losing track when reading and developed asthenopia.

Previous Rx:
R: Plano/-1.50x167
L: +0.25/-2.25x5

The patient has a left head tilt and left hypotropia. It seems as though they have a CN IV palsy affecting their RSO.

Current Rx:
R: -0.25/-1.50x170 (5.25 BD)
L: +0.50/-2.50x5 (5.25 BU)
Add: +1.50

The patient is suddenly requiring an add as well as vertical prism correction. They do a lot of computer work.

1. What is the best way to correct this patient?
2. Is a progressive lens suitable?
3. If so, should I set the heights with the eyes in their natural position in primary gaze, or when aligned by occluding the alternate eye?
4. Is it better to use a progressive design like the Sola Elan HDV or Shamir Freeframe where the corridor length is computed on the pupil height or should I use a progressive design with a set corridor length?

Doc all I can tell you is I have made progressives successfully in similar Rx's to this. I always try to tell if both eyes are tracking together and occlude one at a time if necessary. Remember, you will have a bit of leeway in adjusting the coplanar alignment as the bevels will be difficult for the lab to perfectly align.

I used GT2 for home and Image for work.

[chip anderson]

And I can tell you that your (the patient's) chance of success is a whole lot greater if you don't use a progressive.

Chip

[fjpod]

You'll never know until you try. Low add is in your favor. Patients with high phoria/tropia are usually adapted to their situation vis a vis head tilt. Have they worn this prism before? I would try a progressive if their lifestyle and mindset support it.

[drk]

There is no significant lens-induced vertical component. See the vertical meridian on an optical cross.

You have to determine if the vertical phoria changes on downgaze or not (which is not part of Park's procedure). Barring that, progressives should be a "go", theoretically.

As a practical matter, that much prism induces a lot of chromatic abb. I'd consider a low index material and a cosmetically correct frame.

As to fitting height, I'd have to think about it! Suffice it to say that if you'd put a trial prism in front of each eye and measure it, you'd be fine.

Note though, the unbeliveably high amount of prism you're prescribing will be difficult to adapt to. It's difficult to do this much change all at once.

Also, people with +1.50 adds don't usually present with computer problems since they have enough accommodation.

I'd consider a separate pair low add +0.75 SVNO for the computer with the amount of prism for primary position. I'd titrate the prism and not go the full amount on the initial pair.

For a dress Rx, I'd eventually consider a progressive and prism, but use the adaptation information gathered from the SVNO pair as a guide.