Best PAL for squeaky wheel high hyperope?

[Uilleann]

Original glasses came from I-conveniently-forgot-optical. PAL of unknown origin due to scratching over the etchings and a pretty messed up A/R job. Were able to see enough to pick out the circles on the 180, and check alignment at least.

Old power read as:
OD: +5.75 -1.00 x 140
OS: +6.75 -0.75 092

New SRx:
OD: +5.50 -0.75 x 120
OS: +7.00 -0.75 x 090

Old VA's hovered around 20/30--, with the new 20/25. No known medical Hx, no medications, and the heath of her eyes looks as clean as can be expected from a 60 yo female pt. No cataracts either.

We've made two sets of lenses for this pt already, 1st was a Seiko Surmount (soft, not the ws design), and then again remade into an Auto III. Both times material was 1.70 I believe (I didn't send either order through myself), with the house A/R from Digital Eye Lab.

She hates everything we've made to date.

It runs the gammut of "near is good, but mid and distance are completely unusable", to there is so much swim and distortion they make me sick.

We've checked all the usual suspects, done two SRx checks (both showed either no or utterly miniscule Rx change), material, base curves, meticulously matching alignment and POW from old to new pair, etc etc. Were she a first time progressive wearer, I might understand some of the push back, but particularly with the high pedigree of the new lenses and the validity of the SRx verified, we're left scratching our heads.

Any thoughts? She's coming back in again in a couple hours to talk to the doc about her options. We'd like to try one last remake if needed as a courtesy, but we'd really like to nail it down this time. Are there any other lenses we're missing that you think might be viable options in this case?

Thanks in advance.

[optical24/7]

Stop using totally backside PAL designs on high hypers. (I prefer split designs)

[Uilleann]

These two lenses were specifically recommended to us for high hyperopes. Is that bunk? As it happens, the plot thickens. She's in office now, and presented with yet another set of glasses - these apparently from Costco (if one can believe the glasses and case belong together.) These are an Essilor SmallFit...wait for it...in poly. And the story today is that these work better. Set at a seg of 14, with very little reading area left when plotted out on a layout chart.

We've had beyond atrocious luck fitting the Definity series - any other lens you might happen to suggest with a split design?

[Paul Smith LDO]

This may sound odd given the advancements in lens technology but I put a patient with similar parameters into the Surmount and the Auto III HI-1.67 AR just as you did, along with some Essilor. Pt not happy with any lens, solution Younger Image Trivex. Swear to G--, a HI-1.67 may have worked but by that time I was deep in debt and grasping at straws for any solution.

[Uilleann]

I may well end up going that route Paul - as counter intuitive as it seems to logical thinking, it's crazy enough it just might work! ;) Thanks for the insight.

[LENNY]

Leave her in Small fit or give her naturals/ovations whatever she is used to depending on the fitting height!

[Barry Santini]

This may sound odd given the advancements in lens technology but I put a patient with similar parameters into the Surmount and the Auto III HI-1.67 AR just as you did, along with some Essilor. Pt not happy with any lens, solution Younger Image Trivex. Swear to G--, a HI-1.67 may have worked but by that time I was deep in debt and grasping at straws for any solution.

Never ever complain about money spent in methodically discovering what works for your clients.

I view this money spent as the same as taking a class to learn how to solve the problem involved. You don't stop paying for an education just because you are no longer in a classroom.

It's the path toward becoming a master Sherlock, and adds a lot to your creds.

B

[Barry Santini]

These two lenses were specifically recommended to us for high hyperopes. Is that bunk? As it happens, the plot thickens. She's in office now, and presented with yet another set of glasses - these apparently from Costco (if one can believe the glasses and case belong together.) These are an Essilor SmallFit...wait for it...in poly. And the story today is that these work better. Set at a seg of 14, with very little reading area left when plotted out on a layout chart.

We've had beyond atrocious luck fitting the Definity series - any other lens you might happen to suggest with a split design?

interesting, Definity is my ultimate goto progressive: I go to it when all else fails, and it works...every time!

B

[Barry Santini]

Original glasses came from I-conveniently-forgot-optical. PAL of unknown origin due to scratching over the etchings and a pretty messed up A/R job. Were able to see enough to pick out the circles on the 180, and check alignment at least.

Old power read as:
OD: +5.75 -1.00 x 140
OS: +6.75 -0.75 092

New SRx:
OD: +5.50 -0.75 x 120
OS: +7.00 -0.75 x 090

Old VA's hovered around 20/30--, with the new 20/25. No known medical Hx, no medications, and the heath of her eyes looks as clean as can be expected from a 60 yo female pt. No cataracts either.

We've made two sets of lenses for this pt already, 1st was a Seiko Surmount (soft, not the ws design), and then again remade into an Auto III. Both times material was 1.70 I believe (I didn't send either order through myself), with the house A/R from Digital Eye Lab.

She hates everything we've made to date.

It runs the gammut of "near is good, but mid and distance are completely unusable", to there is so much swim and distortion they make me sick.

We've checked all the usual suspects, done two SRx checks (both showed either no or utterly miniscule Rx change), material, base curves, meticulously matching alignment and POW from old to new pair, etc etc. Were she a first time progressive wearer, I might understand some of the push back, but particularly with the high pedigree of the new lenses and the validity of the SRx verified, we're left scratching our heads.

Any thoughts? She's coming back in again in a couple hours to talk to the doc about her options. We'd like to try one last remake if needed as a courtesy, but we'd really like to nail it down this time. Are there any other lenses we're missing that you think might be viable options in this case?

Thanks in advance.

try the double aspheric Seiko, made in Japan. Thinnest too!

B

[Craig]

Barry,
What is the upper range on the Seiko aspheric; last time I tried it was only up to a +5.

Thanks and who do you order those from?

[Jason H]

Backtracking a bit, this doesn't sound like lens design to me. Was there a big jump in add power? I still think that is the #1 factor for people who have difficulty with int & near. My reccomendations would have been what you have already done - mabye the problem is elsewhere? Outside the box a bit?

[Jason H]

Make her a single vision pair in near and intermediate powers. You'll be out $5. But her reaction to them might send you in a new direction to see what's really bothering her.

[becc971]

These two lenses were specifically recommended to us for high hyperopes. Is that bunk? As it happens, the plot thickens. She's in office now, and presented with yet another set of glasses - these apparently from Costco (if one can believe the glasses and case belong together.) These are an Essilor SmallFit...wait for it...in poly. And the story today is that these work better. Set at a seg of 14, with very little reading area left when plotted out on a layout chart.

We've had beyond atrocious luck fitting the Definity series - any other lens you might happen to suggest with a split design?

I will say that previously this had been my luck as well with the Definity, BUT after some prompting from the rep I have fit a few patients in it recently (within the last few months) and they have actually been very happy. Not sure if they have improved the design or what. i would give it a shot :) i feel like i used to have only non adapts and now the people i fit in it love it.

[optical24/7]

We've had beyond atrocious luck fitting the Definity series - any other lens you might happen to suggest with a split design?

Regular Definity if the add is +2.00 or lower. Definity III if over.

[Uilleann]

I think we're going to go with her beloved Essilor short corridor ancient lens. Same Rx. (Amazingly, she can't use the old pair at her computer, and that was one of her main initial complaints...go figure!) Though the doc wants to use 1.67 instead of poly to minimize thickness and magnification. She's also reverting to an even narrower B frame.

At this point, its the doc's money. What could go wrong?!

[ak47]

I think we're going to go with her beloved Essilor short corridor ancient lens. Same Rx. (Amazingly, she can't use the old pair at her computer, and that was one of her main initial complaints...go figure!) Though the doc wants to use 1.67 instead of poly to minimize thickness and magnification. She's also reverting to an even narrower B frame.

At this point, its the doc's money. What could go wrong?!

I think the frame change is quite possibly the key here...the patient quite possibly just did not LIKE THE NEW FRAME and had you chase your tails until she could conveniently change it when you were willing to do anything to make her happy.

[Uilleann]

I think the frame change is quite possibly the key here...the patient quite possibly just did not LIKE THE NEW FRAME and had you chase your tails until she could conveniently change it when you were willing to do anything to make her happy.

Perhaps - though in this case, she was actually quite happy with the new frame style and fit. She mentioned that she didn't want to give it up, just to find the "same thing - only smaller". After reiterating the hows and whys that wouldn't work, she chose something else. And, wanting to do all we can to achieve 20/happy isn't something we just do when a patient squeaks - it's a company ethos. Yet there are always those who push even our skill, patience and sanity to the limit.

[NCspecs]

...Yet there are always those who push even our skill, patience and sanity to the limit.

Don't. I. Freaking. Know.

[optilady1]

Leave her in Small fit or give her naturals/ovations whatever she is used to depending on the fitting height!

This made me laugh because I was thinking the same thing. Also, if there is anyway she was previously in a dreaded panamic, the darn ovation is the only thing I've ever had success fitting in immediately after for all patients who are:
hyperopic
myopic
high add
low add
have eyeballs
do not have eyeballs
are picky

Best of luck. It's like another beautiful day in my wonderful neighborhood.

[Robert Martellaro]

Original glasses came from I-conveniently-forgot-optical. PAL of unknown origin due to scratching over the etchings and a pretty messed up A/R job. Were able to see enough to pick out the circles on the 180, and check alignment at least.

Old power read as:
OD: +5.75 -1.00 x 140
OS: +6.75 -0.75 092

New SRx:
OD: +5.50 -0.75 x 120
OS: +7.00 -0.75 x 090

Old VA's hovered around 20/30--, with the new 20/25. No known medical Hx, no medications, and the heath of her eyes looks as clean as can be expected from a 60 yo female pt. No cataracts either.

A BCVA of 20/25 seems a bit soft for healthy eyes (in this case I assume no amblyopia).

As Jason pointed out, this is the age when we're probably going to see a bump in add power. That shouldn't be a problem though unless the power has changed more than a quarter.

We've made two sets of lenses for this pt already, 1st was a Seiko Surmount (soft, not the ws design), and then again remade into an Auto III. Both times material was 1.70 I believe (I didn't send either order through myself), with the house A/R from Digital Eye Lab.

As Optical24/7 pointed out, high plus/high add PALs perform better when the progressive optics are on the front.

I'm surprised that she found the near vision 'good' with the Surmount- they use a "trick" (reversal of curvature) to thin the lens, but the near optics take a hit (amongst other disadvantages). Just like with the old cataract four and five drop aspheric lenses- too much asphericity for the best peripheral optics, but a modest to substantial reduction in weight, thickness, and magnification.

It runs the gammut of "near is good, but mid and distance are completely unusable", to there is so much swim and distortion they make me sick.

A long, somewhat linear power change corridor is usually desirable for this Rx. Definity comes to mind since it's mentioned in the thread by a master optician, and because I've blind tested it. There are other good choices.

We've checked all the usual suspects, done two SRx checks (both showed either no or utterly miniscule Rx change), material, base curves, meticulously matching alignment and POW from old to new pair, etc etc. Were she a first time progressive wearer, I might understand some of the push back, but particularly with the high pedigree of the new lenses and the validity of the SRx verified, we're left scratching our heads.

Any thoughts? She's coming back in again in a couple hours to talk to the doc about her options. We'd like to try one last remake if needed as a courtesy, but we'd really like to nail it down this time. Are there any other lenses we're missing that you think might be viable options in this case?

Use for a frame that leaves at least 19mm of usable fitting height to accommodate a longer corridor PAL.

[MikeAurelius]

Stop using totally backside PAL designs on high hypers. (I prefer split designs)

I'm going to toss this out there as a wild card...

Many years ago, we had a local patient who was a very crochety 70+ years old, and could not, would not, wear any lens design EXCEPT plus cylinders. As I recall, he was somewhere in the neighborhood of a +4.00 OU with probably a +1 or thereabouts cylinder. Had to have ultex (of course).

The kicker is that he was the church organist, and he was about the most gawd-awful organist it has ever been my misfortune to listen to. People would comment that they could always tell when he had an Rx change because his playing went from miserable to horrible.

Anyway, my point is, given the apparent age of the patient, could this be a non-adapt from a plus side progressive to a minus side progressive?

I toss that out only as an outsider looking in.

[Paul Smith LDO]

Never ever complain about money spent in methodically discovering what works for your clients.

I view this money spent as the same as taking a class to learn how to solve the problem involved. You don't stop paying for an education just because you are no longer in a classroom.

It's the path toward becoming a master Sherlock, and adds a lot to your creds.

B

Barry there is certainly some value in what you say however, there are going to be occasions when one is searching out a solution when you have to explore the basics. That fact that any optician and the patient would be willing to continue to try multiple PAL designs; in my case it was 10, should speak volumes to said individuals tenacity as a dispenser. As to whether nor not you would try an additional lenses material after you found one that worked, that of coarse would be at the discretion of the optician. Kudos to you, Moriarty

[bill2020vision]

This patient has been pretty much wearing single vision lenses. You mention that you measured the height of 14 on the small fit, but don't mention what height you get when you measure her in that frame. Is it possible that her segs are so low (and she is so used to them) that they are primarily single vision? You mention that she complained about her near and intermediate coming in. Although I usually fit hyperopes on the high side, this patient thinks she's been wearing a progressive when at best she's wearing poor fitting occupational. I'm sure her intermediate and near are better with her new lenses. She will have to readapt to progressives. Explain the situation and that you can make her comfortable by fitting low. But she will have better intermediate and near with a proper fitting RX (her original complaint). Sometimes the squeaky wheel gets too much oiling and not enough talking to. If all else fails, fit her artificially low in the small fit and continue the poor fit she has been wearing. Most patients will suck it up and readapt once you pont out the improved int & near. Good luck
Bill

[sharpstick777]

Old power read as:
OD: +5.75 -1.00 x 140
OS: +6.75 -0.75 092

New SRx:
OD: +5.50 -0.75 x 120
OS: +7.00 -0.75 x 090


Any thoughts? .

The Zeiss Individual 2 is probably the only lens for this Rx. Use all measurements, but especially the near PDs, fit on center.

[sharpstick777]

Stop using totally backside PAL designs on high hypers. (I prefer split designs)

Split designs start to make sense over a +5.00 sphere.