Best Choice of Lenses For a Patient, Given Rx/Cost/Desired Performance?

[Lelarep]

I'm a medical student currently on an ophthalmology sub-internship and I was looking for some feedback on what lenses I can point my patient towards after being asked for some suggestions. He tried asking the attending, but the attending was apparently uninterested/didn't know, so he told me to "deal with it", and I told the patient I'd research the subject and call or e-mail him if it was too complicated to explain over the phone.

The Rx (converted to - Cyl):

OD: +3.50 | -4.50 x 076

OS: -1.50 SPH

Wavefront mapping produced the expected "bowtie" appearance of astigmatism for the right eye, so nothing out of the ordinary, as far as higher order aberrations.

The patient had apparently done some research on his own and asked about the Seiko 1.67 Super MV. From what I can tell, they seem to be a good choice for his Rx. He told me his three major criteria, in order of importance are 1) Optical performance, 2) Minimal Minification/Magnification of the right eye, 3)Lens weight/thickness. Are there any other choices, given the Rx above, for a similar cost, that would provide the same or better performance then the Seiko 1.67 Super MV he mentioned?

Also, what additional information, if any, should be provided along with the script if he decides to go with the Seiko 1.67 Super MV? We usually only provide monocular PD, but I read somewhere about a third measurement that is recommended for this lens, fitting height? (I've only heard of this with regard to progressive lenses). Are there any other measurements that should be provided?

[braheem24]

Are VAs 20/20 ou?

Aniseikonia as well as off axis prism are 2 issues, Are contacts out of the question?

It takes experience to fit this rx not an index of refraction or brand name, no matter how many adjectives they add to the lens.

[Lelarep]

Are VAs 20/20 ou?

With the provided Rx, yes.

Are contacts out of the question?

According to the record, the patient has absolutely no interest in contacts whatsoever. Looks like it has been brought up a handful of times over the years and the response has consistently been the same.

It takes experience to fit this rx...

I'll make sure to mention that to the patient. I'll have to talk to the office staff and see if they know of anyone in the area that has the experience to handle this Rx.

[shannon]

This is definatley a single vision correct?? No bifocal needed ( I know the add wasn't listed, just checking :)

[Lelarep]

This is definatley a single vision correct?? No bifocal needed ( I know the add wasn't listed, just checking :)

Yep, single vision. No ADD listed for this Rx, nor any previous Rx's in the chart.

[Robert_S]

2) Minimal Minification/Magnification of the right eye, 3)Lens weight/thickness.

A little tip for you.

A biaspheric lens will reduce the minification/magnification the most. It will also produce the thinnest and flattest finish possible.

[Uncle Fester]

In your interaction with patients you may want to routinely ask if they are happy where they got their previous glasses. You will find some dispensing opticians in the area who shine above the others for rx's like this.

We have a nearby ophthalmic group practice who post a list of local business cards next to the reception desk that they refer patients too .

[Robert Martellaro]

Also, what additional information, if any, should be provided along with the script

The script is all we need (you can leave it in plus cylinder form).

It takes experience to fit this rx not an index of refraction or brand name, no matter how many adjectives they add to the lens.

True.

Lelarep, the lens design and fitting must be handled, face to face, by the optician. The primary concerns are VI and asthenopia. Ask your associates who they recommend.

[sharpstick777]

When there is extreme divergence between the RX's, there are few things I look at.
How long has the patient had this condition? Since childhood? The longer they have had anesekonia I have found the better they can adapt, and even merge images. If its recent, its more likely to be difficult. I had a 5 D patient who could still merge once.

With the OD RX you listed, I would consider them a Kerataconus suspect. Do they have have a thin cornea OD? If they do, consider RPG contacts now since they will be in them eventually. Was topography done? If not, its probably warranted.

Is the refractive difference due to the axial length or is it corneal? Is the patient supressing the OD eye, or do they have fully binocular vision? If they are supressing I would highly consider the... The Shaw Lens. Its made especially for anisekonic patients like yours.

Another option is to have the OD surfaced Free-form, but modify the Base Curve OS for better merging (you can't specify BC in all FF lenses). You will gain enormous clarity going free-form OD with an Atoric surface. Opticampus.com has an anesekonic formual for power adjustment and base curve. Most FF lenses DO NOT automatically modify for Anesokonia in their software, however, the Zeiss FF SV might with a manual override. Darrell Meister would be able to answer that if you PM here on Optiboard. As well, I think Dr. Shaw posts here occaisionally. Good luck, and please let us know what you do and how the patient responds.

[Lelarep]

...How long has the patient had this condition? Since childhood? The longer they have had anesekonia I have found the better they can adapt, and even merge images. If its recent, its more likely to be difficult...

According to the records, for 10 years OS had no correction, and OD was +2.25 | -3.00 x 077. Then, starting 7 years ago, there was a slow progression to the current script until 2 years ago, when it stabilized. So, going by the record, it has been at least the last 7 years.

With the OD RX you listed, I would consider them a Kerataconus suspect. Do they have have a thin cornea OD? If they do, consider RPG contacts now since they will be in them eventually. Was topography done? If not, its probably warranted.

According to the record, a wavefront analysis was done to r/o higher order aberrations and other potential issues, with the result being a classic "bowtie" shape for OD, indicating astigmatism. I have the image in front of me and it definitely looks like a bowtie, rotated 90 degrees so it's vertical rather than horizontal. Nothing in the record regarding a thin cornea.

Is the refractive difference due to the axial length or is it corneal? Is the patient supressing the OD eye, or do they have fully binocular vision? If they are supressing I would highly consider the... The Shaw Lens. Its made especially for anisekonic patients like yours.

According to the notes, my attending believed the patient was suppressing the OD eye until 7 years ago when the vision in the OS eye started to shift. Patient indicated a difficulty with judging distances and depth perception going back to his childhood from the present. Never heard of the Shaw Lens before. My attending didn't seem to know what it was either. I'll have to research that further. Sounds like it might be a good choice for a referral regarding this patient.

...Good luck, and please let us know what you do and how the patient responds.

Thank you. Hopefully once I discuss things with my attending we'll have an answer, or at least a referral for this patient.

[sharpstick777]

Given what you have told me, I would try the Shaw lens first as the best hope in improving depth perception,
If you have contact info you could PM me, I will give it to Dr. Shaw to give you call.

http://shawlens.com/

Failing that, the Zeiss FF offers the best 2nd option, if they will let you choose base curves. It sounds like its worth trying to get some improved binocular vision. Strangely if is OS VA continues to degrade faster than OD there is chance he could gain better binocular vison over-time.

You may want to measure corneal thickness for the record to see if it changes over time later.

According to the records, for 10 years OS had no correction, and OD was +2.25 | -3.00 x 077. Then, starting 7 years ago, there was a slow progression to the current script until 2 years ago, when it stabilized. So, going by the record, it has been at least the last 7 years. According to the record, a wavefront analysis was done to r/o higher order aberrations and other potential issues, with the result being a classic "bowtie" shape for OD, indicating astigmatism. I have the image in front of me and it definitely looks like a bowtie, rotated 90 degrees so it's vertical rather than horizontal. Nothing in the record regarding a thin cornea. According to the notes, my attending believed the patient was suppressing the OD eye until 7 years ago when the vision in the OS eye started to shift. Patient indicated a difficulty with judging distances and depth perception going back to his childhood from the present. Never heard of the Shaw Lens before. My attending didn't seem to know what it was either. I'll have to research that further. Sounds like it might be a good choice for a referral regarding this patient. Thank you. Hopefully once I discuss things with my attending we'll have an answer, or at least a referral for this patient.