Anisometropia Case for PALs

[standarduck]

Hello world.

Had a juicy looking rx across my desk just now, and the patient has gone away to think about it (she's got an appointment next week).

I need to run her prescription past everyone to find out if I'm opening up a can of horrible worms in trying to make this up with a progressive lens.

NB. THIS IS A FIRST TIME PAL wearer....

RX is:
-5.50 / -0.75 x 20
+1.00 / -3.50 x 105

just re-reading it is making my prisms hurt.

She's obviously going to get large amounts of differential prism through the NVP (which i've estimated at 10mm). I can get around some of this with a shorter corridor, but it may still be an intolerable amount.

Has anyone had any luck with this sort of issue? Or is she to be forver unable to use progressives?

Ta,
Duckie

[Robert Martellaro]

Shorts answer: probably separates, maybe a PAL and SVNO, or SVDO and SVNO. Throw in BCVAs and status of the habitual glasses when you get a chance. It's Miller time.

[Robert_S]

You certainly need a lens that utilises sophisticated binocular vision calculations. To my knowledge the best on the market for that is the ID Mystyle from Hoya. On a lower budget, I might try an entry level Zeiss lens, or not attempt at all.

[Sphinxsmith]

I would look into the Seiko Surmount also.

cs

[Uncle Fester]

Ryser's Rule- "The success of a progressive is directly proportional to the motivation of the patient to wear a progressive."

If you must--- Another vote for Seiko!

[Robert_S]

Why Seiko?

[Uncle Fester]

Zero drop to the corridor. Seiko starts the progressive on the PRP.

Post #6

http://www.optiboard.com/forums/show...gressive-wear?

[Nobody77]

I had best success with the MyStyle V+ from Hoya as it does compensate vertical prismatic effects (among many other things). Of course physics still does apply, but so far with customers who could directly compare two pair of PAL's Hoya had the edge.

As Uncle Fester said, a lot of it is motivation of the client, picking the "more suitable" lens will help the adaptation tho.

Is the customer willing to invest into suitable PAL's with the risk that it can also end up with the lenses in the trash can and you will have to solve the problem via other lenses?

I had good experience by telling to the people "Look, if we do not try we will never know. There is a slight risk to it, due to your prescription, but this is the lens that could be the only one I would even try it with, this is it's price... I am willing to try and I will not let you down in the case that it would not work."

So far *knocks on wood* I had people with approx. 3,00 - 3,50 D differences R/L getting really good results with the MyStyle V+.

The prescription you posted makes me shiver, but hey, I am often into crazy stuff :) If you don't try, you will never know ;)

[Robert Martellaro]

I had best success with the MyStyle V+ from Hoya as it does compensate vertical prismatic effects

The Hoya lens doesn't compensate for vertical imbalance. No PAL can do that without a slab-off, press-on prism, etc.

[PAL_Guru]

I would talk to the doctor about over refraction. You are not going to get her VA to 20/20 anyway because she is most definitely amblyopic. But, if the doctor is willing to talk to the PT about correcting OD with CL, than I would be willing to make her PALs. But as for the 6D difference, it isn't even worth trying, even if you could put something like an MyStyle iQ with a cambered blank.

IF I was the doctor, I would try to over refract so that the Rx is as follows:

CL RX:
OD: -4.50 sph.

PAL RX
OD: -1.00 -0.75 x20
OS: +1.00 -3.50 x 105

Outside of that, Robert is right. Not even worth trying, you cant compensate for the induced vert prism between powers.

[Robert_S]

I had best success with the MyStyle V+ from Hoya as it does compensate vertical prismatic effects (among many other things). Of course physics still does apply, but so far with customers who could directly compare two pair of PAL's Hoya had the edge.

As Uncle Fester said, a lot of it is motivation of the client, picking the "more suitable" lens will help the adaptation tho.

Is the customer willing to invest into suitable PAL's with the risk that it can also end up with the lenses in the trash can and you will have to solve the problem via other lenses?

I had good experience by telling to the people "Look, if we do not try we will never know. There is a slight risk to it, due to your prescription, but this is the lens that could be the only one I would even try it with, this is it's price... I am willing to try and I will not let you down in the case that it would not work."

So far *knocks on wood* I had people with approx. 3,00 - 3,50 D differences R/L getting really good results with the MyStyle V+.

The prescription you posted makes me shiver, but hey, I am often into crazy stuff :) If you don't try, you will never know ;)

I like your philosophy!

[drk]

You need to know what the deal is with this patient. You have no information, and that's not your fault.

Really the prescriber should have dealt with this, but that's what you get with ophthalmology, apparently...

Is this a post-surgical case, maybe a post radial keratotomy? I'm not thinking this looks like a congenital refractive error.

[DanLiv]

I don't think progressive design is going to have much of an impact here. Vertical diplopia is going to obliterate any effort you put into progressive design unless you slab off.

Last week I dispensed this Rx, also to a first time progressive wearer:

OD -1.00 -3.50 x176 +1.00
OS -8.00 -2.25 x002 +1.00 SLAB OFF

Primarily CL wearer, but all I went with was Comfort Enhanced 1.67. Pt immediately saw 20/20 DV and NV with no diplopia.

However, nothing overcomes this truth:

Ryser's Rule- "The success of a progressive is directly proportional to the motivation of the patient to wear a progressive."

[opticurtis]

Of course, all aniso's are likely to accept any changes in their mechanics differently. Similarly to any pt with prescribed prism, some people can jump in to it and enjoy it and immediately see 20/20 or at least 20/happy but other patients, who obviously need the correction, may not enjoy it. I have had luck with an Autograph 3 on several patients with aniso varying from 4-7D but have also had a few with more trouble. I'm lucky enough at my office to have the liberty to play around and not worry about refund limitations or remakes or changes so I would start hoping for the best and downgrade the lens options from there until you found something that works

[optical24/7]

I don't think progressive design is going to have much of an impact here. Vertical diplopia is going to obliterate any effort you put into progressive design unless you slab off.

Last week I dispensed this Rx, also to a first time progressive wearer:

OD -1.00 -3.50 x176 +1.00
OS -8.00 -2.25 x002 +1.00 SLAB OFF

Primarily CL wearer, but all I went with was Comfort Enhanced 1.67. Pt immediately saw 20/20 DV and NV with no diplopia.

However, nothing overcomes this truth:

Your pt. must have amazing accommodative abilities to overcome 7% image size discrepancies. (with no Iseikonic design.)

[DanLiv]

Your pt. must have amazing accommodative abilities to overcome 7% image size discrepancies. (with no Iseikonic design.)

Yes I was worried about that, but with a very forward placed bevel on the high minus lens (and some adjustment) I was able to achieve ~5mm less vertex for closer to 4-5% size difference. But she is also very accommodating (clinically and socially).

[standarduck]

Just to follow up on this, and apologies for not thanking all of your input more recently - went for separate pairs...

the decision was out of my hands, as the progressive lenses were 'too expensive'. I very nearly responded with a 'thank god for that then'.

Thanks again,
The Duck

[AngeHamm]

Just to follow up on this, and apologies for not thanking all of your input more recently - went for separate pairs...

the decision was out of my hands, as the progressive lenses were 'too expensive'. I very nearly responded with a 'thank god for that then'.

Thanks again,
The Duck

Usually cost concerns result in the patient getting a less-than-desirable result. This time, it's the reverse. Glad you didn't have to deal with that, but what a great discussion!

[standarduck]

I was over the moon to be quite honest.

And for those interested - she was not amblyopic, but had had some medical issues with a corneal ulcer which leads to a large discrepancy (which used to be a smaller one). So she would have had two very clear images potentially, but at very different sizes, and in very different places.

As Hamm said, great chat!

[obxeyeguy]

You need to know what the deal is with this patient. You have no information, and that's not your fault.

Really the prescriber should have dealt with this, but that's what you get with ophthalmology, apparently...

Is this a post-surgical case, maybe a post radial keratotomy? I'm not thinking this looks like a congenital refractive error.

My thoughts also. What are the acuity's? How long like this? What caused it? Just simply throwing a "brand" of progressive at this Rx does nothing without a more detailed history.

[standarduck]

My thoughts also. What are the acuity's? How long like this? What caused it? Just simply throwing a "brand" of progressive at this Rx does nothing without a more detailed history.

Answered above mostly now, but it's an open and shut case anway.