what up with that???

[eyes4u]

This is going to be a long one! Patient comes into optical shop and says I need a 22 bridge. No one seems to be able to help me. Now pt. is wearing a Rayban Aviator frame with progressives and one nosepad arm broken off. They are pretty much sitting on his face. They are 5 years old and really scratched up!! At first I try looking at what I have knowing I do not have a frame with a 22 bridge but will look anyway. I tell him that they are much harder to come by but that I can look for some frames for him. Then I realize that the Silhouette drill mounts come in a 21 bridge. So I start showing him the Silhouettes and he wants a aviator shape which I do have and we then proceed to custom make his glasses. He is very happy that I can do this for him. He has Davis Vision (ughhhhh) not a fan of Davis Vision!! Anyway, put him in a Varilux comfort 2 poly. He does not want any extra's. The glasses come in - he comes to pick them up. Blurred vision out of right eye at near. Everything else is good. So I double check all my measurements. Used the visio office for measuring. So I take manual measurements too. Get the same thing. Pt's pd is 36/36. Glasses pd is 36/36. So I try to check his glasses which are so scratched that they are really hard to check.But it looks like they may be a 34/34 pd. So I send them back to DV lab. He comes back in to pick up new lenses. Guess what? Its still blurry at near ! Pt says he doesn't see double but its like a shadow behind the letter. I asked him was it like a ghost image- yes that's it! Compared to his old Rx - the new Rx had .50 diopters cyl in that eye. That's pretty much the only difference. So I ask him to go back to his Dr and have RX checked. Kept all the markings on the glasses so the Dr could see them and maybe do rerefract with glasses and with out. Pt comes back next day with new Rx. The Dr changed the OD from : +.75-1.25x10 to +.50-1.25x10 - wow!!! Really!!! So I show pt what that will do to his glasses and guess what? NO Difference!! At this point I'm not sure what to do.I try explaining to pt. that it might be the fact that he wore his previous pair on his face and these actually sit where they are suppose to be. He does not agree with me. I've done something wrong - he's never had this problem before!! He's brought a book in with him and keeps looking at it and saying the letters are blurry- he then moves his glasses out towards his ear and says if he holds the glasses there its all clear. WHat???? The pd's are absolutely correct. He keeps doing and saying that its clearer. That's moving his pd in to 30.We're going from a 34 pd to a 30!! What the what??? Any ideas out there?? HELP!!!!!!!!!!!!!!!!

[Judy Canty]

Did you compare face form (wrap angle), panto and vertex distance from the original pair to the new pair?

[eyes4u]

Yes I did. We pushed them out,in,up down........made no diff. Remember pt's glasses sat on his face b4. Tried lowering,rasing.nothing helped except when he pushed the glasses out which made his pd shorter.

[mervinek]

Did his old glasses have any prism?

[Robert Martellaro]

eyes4u,

How does he know the vision at near is blurred at near in the right eye only? Subjective distance and near vision when dispensing new lenses should always be performed with both eyes. Self-testing will almost always induce parallax error, and possibly object distance error as the head turns.

Trial frame the near vision for the prescribed distance, usually 40cm, but verify.

Verify fitting cross position is center pupil using a light and marked fitting cross position (ink or template).

Check for pathology, convergence disorders, and fixation disparities.

Can't add much more without a thorough history.

Hope this helps,

[eyes4u]

Thanks for the info, but this pt did not see one of "my" drs. How can you explain to a pt that one eye will be blurry and the other one wont. The glasses he came in wearing he does not have that problem. I was thinking maybe astigmatism correction. But the Dr didn't change that. Does he need prism?

[Uncle Fester]

What was the old lens design?

[Robert Martellaro]

Thanks for the info, but this pt did not see one of "my" drs. How can you explain to a pt that one eye will be blurry and the other one wont.

As I explained above, if the client performs the test for monocular near vision, they'll probably get it wrong, resulting in poor vision in usually one, but sometimes both eyes.

The glasses he came in wearing he does not have that problem.

That could simply be due to a larger or higher near zone in the old pair that's more friendly to layperson self-testing. A change in add power would give the same erroneous result. But the add power remains a mystery, as well as the PAL designs, as Uncle Fester noted.

[finefocus]

This is going to be a long one! Patient comes into optical shop and says I need a 22 bridge. No one seems to be able to help me. Now pt. is wearing a Rayban Aviator frame with progressives and one nosepad arm broken off. They are pretty much sitting on his face. They are 5 years old and really scratched up!! At first I try looking at what I have knowing I do not have a frame with a 22 bridge but will look anyway. I tell him that they are much harder to come by but that I can look for some frames for him. Then I realize that the Silhouette drill mounts come in a 21 bridge. So I start showing him the Silhouettes and he wants a aviator shape which I do have and we then proceed to custom make his glasses. He is very happy that I can do this for him. He has Davis Vision (ughhhhh) not a fan of Davis Vision!! Anyway, put him in a Varilux comfort 2 poly. He does not want any extra's. The glasses come in - he comes to pick them up. Blurred vision out of right eye at near. Everything else is good. So I double check all my measurements. Used the visio office for measuring. So I take manual measurements too. Get the same thing. Pt's pd is 36/36. Glasses pd is 36/36. So I try to check his glasses which are so scratched that they are really hard to check.But it looks like they may be a 34/34 pd. So I send them back to DV lab. He comes back in to pick up new lenses. Guess what? Its still blurry at near ! Pt says he doesn't see double but its like a shadow behind the letter. I asked him was it like a ghost image- yes that's it! Compared to his old Rx - the new Rx had .50 diopters cyl in that eye. That's pretty much the only difference. So I ask him to go back to his Dr and have RX checked. Kept all the markings on the glasses so the Dr could see them and maybe do rerefract with glasses and with out. Pt comes back next day with new Rx. The Dr changed the OD from : +.75-1.25x10 to +.50-1.25x10 - wow!!! Really!!! So I show pt what that will do to his glasses and guess what? NO Difference!! At this point I'm not sure what to do.I try explaining to pt. that it might be the fact that he wore his previous pair on his face and these actually sit where they are suppose to be. He does not agree with me. I've done something wrong - he's never had this problem before!! He's brought a book in with him and keeps looking at it and saying the letters are blurry- he then moves his glasses out towards his ear and says if he holds the glasses there its all clear. WHat???? The pd's are absolutely correct. He keeps doing and saying that its clearer. That's moving his pd in to 30.We're going from a 34 pd to a 30!! What the what??? Any ideas out there?? HELP!!!!!!!!!!!!!!!!

He's gone to a 30 pd in one eye, and a 38 in the other. Does the patient's chin point right at you when he looks at you; or does he habitually look kind of sideways? The pupilometer will assume the patient looks straight ahead, normal posture. Maybe he's a head-turner, and leads with one side of his face, the one that likes a wide pd.

[CCGREEN]

[QUOTE=eyes4u;460344]Anyway, put him in a Varilux comfort 2 poly. Its still blurry at near ! Pt says he doesn't see double but its like a shadow behind the letter. I asked him was it like a ghost image- yes that's it!

Chromatic aberrations. That is the problem. Get rid of the polycarbonate material. Use CR-39, Hi Index, Glass. I don't care get rid of the polycarbonate and the trouble will go away. Been down this road myself and it worked for me.
I bet he finds it very very noticeable when he is looking at bold black letters on a white background. Black letters on a colored back ground not so bad. But the lighter the background the more noticeable the shadowing will be.

[SeaU2020]

This is where I usually go the progressive markings sheet and COLOR IN the reading circles. Have him put the glasses on and, with both eyes open, try to look as if to "read" with glasses. If he is seeing only 1 circle, you have done your job. Congratulate the patient on being able to find his dominant reading eye! If the he sees well with both eyes open, the glasses are a success. If he sees 2 circles, back to the drawing board. Very old school but works well for me!

[Robert Martellaro]

He's gone to a 30 pd in one eye, and a 38 in the other. Does the patient's chin point right at you when he looks at you; or does he habitually look kind of sideways? The pupilometer will assume the patient looks straight ahead, normal posture. Maybe he's a head-turner, and leads with one side of his face, the one that likes a wide pd.

Yup, and that's assuming the damn thing is calibrated! But it still doesn't explain why the old eyeglasses are okay. I assume that the lenses have been inspected on the bench (180 line is ±1.00°, proper inset, etc.), and on the face with ink lines or templates, which would indicate a head turn or fixation disparity, unless any fixation disparity is at near only, which can be measured in a variety of ways.

There's some indication of a cyl change in the rt, but the degree is unclear, although it does possibly match one of the symptoms (ghosting around text). It's also unclear if the client is occluding the left eye when testing the near vision.

I'm afraid there's still insufficient data to successfully troubleshoot this one.

[eyes4u]

Can't tell from all the scratches!

[eyes4u]

I watched this pt. looking at near with new glasses - he was not turning his head or chin. When he put them on initially he saw fine but then he starts comparing right to left and his old glasses don't do that and why do these? Round and round we go. Everything lines up perfectly - I have checked adjustment, tilt - all those things. It only clears up when he moves glasses out - that's why I was thinking astigmatism correction. But now I'm like maybe he needs prism.

[kelanor]

It's possible that the shape of the lens is cutting out reading power. Aviator and pilot styles have been known to do this before.

[eyes4u]

He actually has more reading area than he did with his Rayban aviators

[Robert Martellaro]

It's possible that the shape of the lens is cutting out reading power. Aviator and pilot styles have been known to do this before.

Good point, but probably not an issue with a 68 IPD.

I watched this pt. looking at near with new glasses - he was not turning his head or chin. When he put them on initially he saw fine but then he starts comparing right to left and his old glasses

So he's covering or squinting one eye?

It only clears up when he moves glasses out

This needs clarification- do you mean he pulls the eyeglasses away from his eyes? Before this, you said he had to move the reading card to the right.

...that's why I was thinking astigmatism correction. But now I'm like maybe he needs prism.

The Rx change needs to be analyzed. You'll get no more help from me if you don't post more data, including, but not restricted to the old and new Rx, the old PAL design, the new and old PAL positions i.e. vertex distance, fitting cross relative to the pupil center on both pair, and any other differences that you can see or measure.

[Wes]

It sounds to me like he got used to not having the nosepad (I'm guessing the left one, since you stated that he says he sees better when he pulls his new glasses to the right to see better out of them) on his frame, both lowering the lenses and offsetting the segs to the right, and has adapted to this situation. You will be amazed at what a patient will get used to, and then be frustrated when you make a perfect pair of glasses and have them rejected. You may have to fudge the pd some in that direction to satisfy him, and gradually work him back to what it should be. Remember, what a patient was wearing, and the difference between that and what you provide, may have a lot of impact on acceptance and adaptability.

[Robert Martellaro]

Nice hypothesis Wes, especially if he wore it that way for a couple years.

Here's another- the client is left eye dominant. Davis labs being what they are, uses two right lenses, resulting in the left eye near visual point that is outset instead of inset.

[Wes]

Well it is 5 years old, and scratched all to he11...

That's an interesting hypothesis, Robert, but it seems unlikely, considering the nose pad issue, as it would have been worse prior to the loss of the pad+arm and would likely have been rejected with prejudice at dispense.

[eyes4u]

Thank you!! That is what I tried to tell the patient. But you know they know everything!! So, I've gone from a 36 pd to a 34 and I actually measured 30 when he moved the glasses temporal.So maybe moving the pd to 32? I really don't want to go from 34 to 30 in one step.

[Robert Martellaro]

Wes,

The two right lenses scenario is for the new lenses, not the old. Remember, it's Davis labs, and it absolutely matches the symptoms. So would an off axis PAL as I mentioned above. But all this speculation is moot until we get a thorough history- for all we know the add went from +1.50 to +2.50...but the OP ain't talkin'.

One thing for sure...it's not possible to have a monocular IPD of 36mm at infinity and 30mm at 40cm with healthy eyes.

[Wes]

OH! That's what I get for posting after a trip to the Mexican beerfest.

[eyes4u]

Well Robert I was going to post his previous Rx, but then I decided not to because it didn't sound like you were going to be all that helpful. Maybe you need to change your verbage. I just wanted a couple of 2nd opinions. I've been an optician for 30 years and I work by myself so sometimes you just like to bounce things off other people to see what they say. Don't need to be talked down to. I got a thorough history on the patient just so you know. Thanks for your help.

[Robert Martellaro]