Help trouleshooting high cyl. progressiv

[Scooter224]

Customer has following prescription:
+3.00 -5.00 105
+4.00 -5.00 63
Add: 1.5

I tried the Varilux S 4D. No success. Now he is wearing the Ipseo NE. Distance view is ok, but intermediate and reading is difficult for him. Any suggestions?

[Randle Tibbs, ABOM]

He may be experiencing the oblique cylinder in the lower quatrants that have been made worse by the additional cylinder prescribed especially that prescribed for the left eye.

[sharpstick777]

Given his cyl's vary by more than 40 degrees, and his near zones alone are deteriorating, you have a lens design issue. Oblique cyls create prism imbalance that effectively moves the corridors out of alignment as the eye drops in the lens. In addition, 95% of progressives are designed for only myopes and your patient is a strong hyperope.

First step, verify distance visual acuity using a trial frame worn for at least 15 minutes, and compared the new lenses you made. Its highly possible it won't be 20/20 but both should match the refraction DVA from the chart. Then you know you have a good RX. If their DVA is 20/25 or better with the trial frame you have a chance.

Second step, you need a lens design that will improve near binocular symmetry, esp for hyperopes.

There are only a few choices: the Seiko Surmount (order with Near PDs!, fit on center) because it will take into account the both the oblique cyls and the plus power to realign the corridors based on effective prism off OC. The Zeiss Individual offers the same corridor compensations, but its more expensive. These are the only 2 lenses available in the US with a full redesigned corridor based on the RX/ near power as it changes from OC. The other choice is the Shaw Lens, the Shaw Lens will correct for dynamic anesokonia across the whole lens, not just the near zones. So potentially the Shaw lens could correct the visual imbalance enough the eyes will work well in the corridor without further compensations. I would definitely consider the Shaw lens to improve DVA first assuming all your patient astigmatism is regular, not irregular.

Right now Varilux doesn't not offer a product that has the features you need to improve binocular symmetry.

If your patients best corrected visual acuity is 20/35 or worse (not uncommon with this cyl) then hard contacts may be the best option because irregular astigmatism cannot be solved with anything other than contacts. Its my preference to recommend topography if any patient isn't acheiving a best corrected DVA of 20/30 or better. If your patients DVA is between 20\35 and 20\25 the Shaw lens might improve that, assuming they don't have irregular astigmatism. But again, that is why knowing DVA in a trial frame is so important to solving issues.

Its likely given his RX adaptation to any lens will be 4 weeks.