Kinda Stumped...

[Slim]

Ok I have a PT that came to me on my suggestion. Her complaint from going to a chain store, that her progressive had a VERY VERY narrow distance.

I put her in a Surmount and at dispense it was night and day for the better, but ended up with a recent rx change.
Now she tells me after the remake that its back to very narrow in the distance.
If I have her focus on the clock across the room, straight on, its great. But if she looks about 8 foot left of right its blurry. Even with her head tipped down.

Here is a quote from the email she sent as well.

"The left eye seems ok but the right lens is still blurry and it appears to be off center. When I am looking at something to read, I close my right eye and I can see it but when I try to look at it with my right eye, I actually have to move my head over to the left to see it. And everything seems out of focus just like it does when I am in the Drs chair and looking at the letters on the wall. When I am looking at those letters, they never get clear enough during the exam. So, I was wondering if the Varilux 4ds lens would be my only option. I would like to actually see clearly and see more in my peripheral. I can tell my eyes are straining. I am feeling frustrated and hoping this is not how I am going to have to see things. Do you have any ideas? "

I did tweak the PD's a lil (wider 30mm to like 31ou) than the orig pair as we picked up a digital measuring system and slightly raised the seg. from 20 to 21

Surmount 14
hi-index 1.67
trans grey

Came in with

OD -7.00 -0.75 095 +2.50
OS -8.00 -0.75 115 +2.50


Our RX First round...

-6.75/-0.75/090 add 1.75
-7.75/-0.75/115 add 1.75

RX for 2nd round...after recheck

-6.75/-0.75/090 add 2.25
-8.00/-0.75/115 add 2.25

Refraction was
OD -6.75 -0.75 x 084
OS -8.00 -0.75 x 112

VISUAL ACUITY
Dist VA Near VA Dist PH Underlying condition
OD 20/20
OS 20/20

[Paul Smith LDO]

It sounds like an issue with the Rx. Define, "slightly raised the seg"

[drk]

Need trial frame.
If good, look for decentration issue. I've seen it even when the markings look good. I don't understand it, but it happens.

[fjpod]

did she say...she sees blurry through the right eye even when sitting in the exam chair? Sounds like a physiological issue.

Also, I wouldn't overlook a lens defect. Look carefully in the center of the lens where the block was mounted. In such a high Rx with a thin center, you can induce cracking and crazing in the center.

[Uncle Fester]

My first thiought is the creeping add in the re do along with slightly higher fit. I would've gone lower if anything.

From Opticampus "Optics of Progressives".

I like too much chuck pressure as well!

[harry a saake]

Slim, while your at it, cut out the chain store crapt, you probably don,t even know what the lens was

[braheem24]

Exam room is too short, she's under minused.

All that from a message board.

Thank you Holiday inn express.

[Wes]

Exam room is too short, she's under minused.

All that from a message board.

Thank you Holiday inn express.

Funny you point this out; I was just talking to an OD that said the same thing about a similar situation today.

[Wes]

Braheem, at what point do we start charging for expertise?

[braheem24]

Like I said Wes, it's the Holiday Inn but thank you for the compliment.

Sometimes with patients like this I prefer working backwards by looking at the near.

Initial Rx was a +2.50 add, Assuming typical OD doing a typical non PITA exam on the first Rx I can assume patient is over 55.

First new Rx by new OD got her to J1 @ 1.75 add, patient being a -8.00 of course rejected +1.75, the doctor seeing no reason to remake for +0.25 gave her a +0.50 to bring her up to +2.25 which is still a low add for someone over 55 considering the minification caused by the -8.00 so I have to assume she's most likely under misused since she can read J1 with a +2.00 on a -8.00 minification Rx.

A second issue could be an axis issue which could also give you a narrow distance feeling but that's usually much more prominent in amblyopic patient who notice every slight change in the dominant eye, this one would have to be way off. I'm assuming the doctor confirmed cyl and axis considering the PITA nature of the issue.

If the phoroptor faces the exam door, The doctor could put up a tumbling E chart across the office and have the doctor use that for a final distance tweak along.

[drk]

Braheem, either you're a genius, or you're crazy.

[Robert Martellaro]

Ok I have a PT that came to me on my suggestion. Her complaint from going to a chain store, that her progressive had a VERY VERY narrow distance.

I put her in a Surmount and at dispense it was night and day for the better, but ended up with a recent rx change.
Now she tells me after the remake that its back to very narrow in the distance.
If I have her focus on the clock across the room, straight on, its great. But if she looks about 8 foot left of right its blurry. Even with her head tipped down.

That's due to a combination of aberrations: unwanted astigmatism from this particular PAL design, chroma, power error, and oblique astigmatism, pretty much in that order.

Here is a quote from the email she sent as well.

"The left eye seems ok but the right lens is still blurry and it appears to be off center. When I am looking at something to read, I close my right eye and I can see it but when I try to look at it with my right eye, I actually have to move my head over to the left to see it. And everything seems out of focus just like it does when I am in the Drs chair and looking at the letters on the wall. When I am looking at those letters, they never get clear enough during the exam. So, I was wondering if the Varilux 4ds lens would be my only option. I would like to actually see clearly and see more in my peripheral. I can tell my eyes are straining. I am feeling frustrated and hoping this is not how I am going to have to see things. Do you have any ideas? "

Lay folks don't know how to self test- they turn and tilt their heads, hold the object too low or too high, sometimes off-center, and at the wrong distance. Do your own testing.

Who initiated the PAL brand discussion?

I did tweak the PD's a lil (wider 30mm to like 31ou) than the orig pair as we picked up a digital measuring system and slightly raised the seg. from 20 to 21

Surmount 14
hi-index 1.67
trans grey

Came in with

OD -7.00 -0.75 095 +2.50
OS -8.00 -0.75 115 +2.50


Our RX First round...

-6.75/-0.75/090 add 1.75
-7.75/-0.75/115 add 1.75

I can see why she was miserable with the habitual pair; the add was .75 D too strong! This is common (overplussing the add) when the client complains of poor near vision, when the problem is improper PAL design (primarily too long of a corridor), positioning, trying to squeeze multiple functionalities into a single pair of eyeglasses, and unrealistic expectations.

RX for 2nd round...after recheck

-6.75/-0.75/090 add 2.25
-8.00/-0.75/115 add 2.25

That makes no sense, that is, a half diopter swing in the add. That needs justification. What was the reason for the "recheck"? Include time frames, and client's age.

Refraction was
OD -6.75 -0.75 x 084
OS -8.00 -0.75 x 112

VISUAL ACUITY
Dist VA Near VA Dist PH Underlying condition
OD 20/20
OS 20/20

Pulmonary hypertension can cause blurred vision, but is probably not a contributor because her on-axis distance vision sounds good.

http://seikoeyewear.com/lenses/progr...nses/free-form

Note that their are two versions of this lens. Also note that the default work distance is 35cm, and seems to be the only POW optimization (inset and work distance) available, and that the long and wide corridor of the regular Surmount might be advantageous for hyperopes, but certainly not for myopes, unless there are infrequent near tasks, and the distance periphery PAL design is clean and generously sized.

[Uncle Fester]

Love the schooling! Thanks guys!!!

My bet when all is said and (re) done is still over expectation. Three "zones" pick two to maximize at the expense of the third.

[Slim]

Wow all great stuff my friends!

Ok so right before her 1st exam she went and laid in a tanning bed with eyes open... yeah.. these are notes from 1st visit...(5th of Feb)

This is a 46 year old female who comes in for a chief complaint of blurred vision
involving the left eye. The blurred vision is central and associated with wearing
glasses. The blurred vision is mild in severity, left eye worse than right eye. The
blurred vision has been present for 1 week and 1 day. The blurred vision is relieved by
closing one eye. The patient is being treated with artificial tears. The patient has a
history of opened eyes in tanning bed.

Plan: Counseling - Cystoid macular edema.
I counseled the patient regarding the following:
Eye care: Cystoid macular edema may improve with topical steroid and nonsteroidal anti-inflammatory
drops. Often a posterior subtenons injection of steroid will supplement the effect of the drops. Ultimately,
intravitreal injections of anti-VEGF medication may be needed.
Expectations: Cystoid macular edema is swelling or thickening of the retina that causes loss of vision. It
commonly occurs following cataract surgery, other types of intraocular surgery, ocular trauma, or chronic
inflammation of the eye (uveitis).
Contact Office if: Cystoid macular edema does not improve or worsens despite treatment. This will
manifest itself by persistence or worsening of the vision, or visual distortion.
Plan: F/U for Next Visit Retina.
The patient should be scheduled in: 1 month
with: Gandhi
Instructions: Consult with Mac OCT


This is from recheck Apr 7th

This is a 47 year old female who is following up for Myopia. She was seen on February 5, 2015, at which time
the following items were planned:
The patient should be scheduled for the following in 1 year:
- CEX. The patient is now here for Re-check Rx. Interval History: Worse at near.

[drk]

Ok, she's a mess. What can you do about that?

[newguyaroundhere]

Ok, she's a mess. What can you do about that?

Dark Sunglasses, a white cane and a seeing eye dog named Lucky?

[Robert Martellaro]

This is from recheck Apr 7th

This is a 47 year old female who is following up for Myopia. She was seen on February 5, 2015, at which time
the following items were planned:
The patient should be scheduled for the following in 1 year:
- CEX. The patient is now here for Re-check Rx. Interval History: Worse at near.

So the edema resolved? Back to 20/20? If true, you still need to justify the unusually high add power, typically +1.50, to at the most +2.00 for an age 47 subject. I'll be age 63 next month and I'm cruising comfortably with a +2.25 add (40cm J1 -4.75 D in the strongest meridian).

The incorrect add will force the subject to read through the narrow corridor (about 3mm wide depending on the PAL design), a corridor that is already too long for most high myopes, decreasing the visual acuity due to insufficient power, and an incorrect inset that brings the blur boundary really close to if not in the line of sight at near.

[braheem24]

If Holiday Inn Express fixed stupid it would have been bought out by the Hiltons.

This lady along with every engineer you meet needs to be taught physics does not fix biology.

[Slim]

ok so she came in as her hubby had an appt.. got a chance to talk for a good while. Here is what I found.

I cut the lenses and centration is off for some reason... I marked up the lenses and vs what I'd get with the marker and the digital measuring system (marker and digi were the same) and found out they were 2mm OU to wide. so something went wrong during blocking. My fault somehow. So that would solve some of this...

Now I also trial lensed her. I put some + on top of her lenses... she liked +0.75 on top of what shes wearing. hmmmmmmm.

she has been wearing PG and BF since mid 20's and shes 47 now.

I dont think a +3.00 add is the answer here...
Any lens change suggestions? Zeiss individual 2I? or keep the surmount? (seg ht is 23mm.)

[braheem24]

You never over refract a progressive to test near vision, it's always better with more plus. You need to trial the lenses, not over-refract on a 4mm too wide a progressive.

It's not the lens design, look elsewhere. If her vision is worse some days more then others, it's pathology.

[drk]

Centration strikes again.

Stop listening to Braheem. :)

No, he's really right...forget design. Forget over-refracting.
She's one of those who's worn a progressive since pre-presbyopia, apparently, so all of Robert's reasonableness is kaput.

Just remake them on center and use the old, trusty +2.00 catch-all add and you're golden. Don't fit them too high.

[Robert Martellaro]

ok so she came in as her hubby had an appt.. got a chance to talk for a good while. Here is what I found.

That conversation needs to take place at the very start of the process, before decisions are made WRT ophthalmic lens solutions.

I cut the lenses and centration is off for some reason... I marked up the lenses and vs what I'd get with the marker and the digital measuring system (marker and digi were the same) and found out they were 2mm OU to wide. so something went wrong during blocking. My fault somehow. So that would solve some of this...

1mm wide in each eye is very good work. If you mean 2mm wide in each eye, then the induced BI prism alone is enough to reject.

Now I also trial lensed her. I put some + on top of her lenses... she liked +0.75 on top of what shes wearing. hmmmmmmm.

Distance or near? Can't read your mind my friend.

she has been wearing PG and BF since mid 20's and shes 47 now.

Probably the most important piece of data in this troubleshoot, and you hold it back until the end. If you want any more future help from me, I'll need to see some goodies in my inbox. Crown Royal is my first choice, but VO might be acceptable.

I dont think a +3.00 add is the answer here...
Any lens change suggestions? Zeiss individual 2I? or keep the surmount? (seg ht is 23mm.)

As drk says, she's a (manageable) mess. Give her the moderate add as suggested, and put segmented multifocal, PAL, or SVNO task eyeglasses on the table.

[Slim]

Haha sorry Robert, I had no idea till last night.

The +.75 was on top of her read.

I did discuss with her at length about a work pair, she works at a bank so lots of desk and pc work.

She is open to that as a second pair. Im going to remake these last pair and go from there.

I do appreciate all the help everyone!

[Robert Martellaro]

Haha sorry Robert, I had no idea till last night.

The habitual +2.50 add at age mid 40's was a neon sign flashing accommodative or convergence disorder, or that the lenses had been replaced (pseudophakia).

The +.75 was on top of her read.

That's pretty much expected- a lower add power combined with a too long of a corridor (for most myopes) underperforms at near point.

I did discuss with her at length about a work pair, she works at a bank so lots of desk and pc work.

She is open to that as a second pair. Im going to remake these last pair and go from there.

I do appreciate all the help everyone!

It depends if they are a teller or an officer. Sounds like the latter if she's at a desk. Push segmented multifocals for the task eyeglasses (don't forget to mention they're less expensive than PALs for some extra motivation).

Hint: If task eyeglasses are provided, that might free up some PAL design distance/near bias more towards the distance vision with the general purpose glasses, placing more weight with the quality of vision on the primary gaze on and off-axis.