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Thread: What does your mental flowsheet for progressive selection look like?

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    What does your mental flowsheet for progressive selection look like?

    Hi,

    I've not got a whole lot of experience fitting progressives - and am trying to learn more about the different designs, and what might compel an optician to choose one design over another.

    I am also curious, how do you get reliable information about products? I've seen so much sales information that touts EVERY lens as the best, and am working at a method to sort through it. Does a GT2 really have as much width in the distance as a GT1? what about the former GT3d (and is the zeiss pure precision actually the same lens with fixed fitting heights? like my lab rep told me.)

    How did you begin learning all of this in the first place?

    What are compelling reasons to switch a patient to a new progressive geometry?


    Specifically - what is the first lens you go to when fitting a new progressive patient (And what particular hobbies/interests/complaints/prescriptions might compel you to fit them with a different lens)
    How do you learn about new lenses?
    How do you learn about other existing lenses you just haven't had experience with yet?
    Any good advice in general?

    Thanks.

  2. #2
    Ghost in the OptiMachine Quince's Avatar
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    Trial and error, reviews, and research.

    Most business models are going to include 2 or 3 levels of progressive lenses. Good-better-best.

    This could be multiple designs within a brand or you could use multiple manufacturers. This will most likely be dependent on pricing, package deals, and availability.

    You should look at your clientele and their needs to appropriately accommodate.
    When choosing for a specific patient, you should be looking at what they are currently wearing first. It is good to have an 'opinion' of brands you don't even carry so that you can make sure you are always offering something comparable, if not better.
    Think about whether you are surfacing in house or only ordering from outside labs. Depending on what labs you use- this may effect what lenses you have access to.

    For example-
    *My office offers a conventional design processed in house as the basic option. I do not sell this to people currently wearing any digital designs unless this is a back-up or emergency pair.

    *The next option is an entry level digital for patients looking to upgrade from conventional or who are first time progressive wearers.

    *The 'best' option is a high end digital. This is for difficult Rx and people looking for an upgrade from lower-end digitals.


    My best advice to you- if you yourself or someone who you trust who knows optics has a multifocal script- try some free pairs from different labs. Everyone wants you to sell their product; therefore they want you to try it so that you can talk to your patients about how awesome it is.


    I hope this helps!
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  3. #3
    Ghost in the OptiMachine Quince's Avatar
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    Some extra food for thought- because it is becoming more and more relevant- think about how 'independent' your business cares to be. Could be a moot point or a deal breaker for certain lines.
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    This is a tough one. Ask 10 opticians and you will get 10 different answers. As Quince stated....trial and error and research.

    Pals vary from distance-centric to near-centric, with everything in between. And this is just molded PALs. FF is a whole other ballgame.

    Also, what works for one patient may not always work for another. Call your labs and lens reps and get as much information from them as possible.

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    Quote Originally Posted by Quince View Post
    Some extra food for thought- because it is becoming more and more relevant- think about how 'independent' your business cares to be. Could be a moot point or a deal breaker for certain lines.
    the office I work in values independence highly - but also wants to be able to provide the best product to patients (I.E. if big E has the best progressive for a patient, they are getting it, if there is an equal lens from another vendor I am going to go with the other vendor, not to spit in E's eye, but instead to try to keep things level where I can, while still providing the highest standard of care that I can for my patients)

    so - tightrope act.

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    Quote Originally Posted by lensmanmd View Post
    This is a tough one. Ask 10 opticians and you will get 10 different answers. As Quince stated....trial and error and research.

    Pals vary from distance-centric to near-centric, with everything in between. And this is just molded PALs. FF is a whole other ballgame.

    Also, what works for one patient may not always work for another. Call your labs and lens reps and get as much information from them as possible.
    I'm trying to figure out which of my lens/lab reps to fully trust (Of course my Hoya rep is going to speak to the advantages of hoya lenses over competitors, but how much of that is sales, and how much of that is hard data, can I get hard data?)

    I believe I have very good reps, but I also know that I've seen as many different opinions on a given lens as I've seen opticians - some people think the comfort 2 is garbage, and others think it's a fantastic entry level progressive, and figuring out why they believe each of those things is challenging.

    I am experimenting, but there is a certain point where I start to feel ethically gross, and don't have enough guinea pigs for certain things.

    Like - if I know ABSOLUTELY nothing about a lens, and only have a few anecdotes - how do I figure out what cases it might be good in a given case, and single subject design is good for fitting, but worries me as far as developing overall philosophies (requires more attention and rigor than I necessarily have)

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    Master OptiBoarder OptiBoard Silver Supporter lensmanmd's Avatar
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    Many labs use the IOT designs, including us, with tremendous success. Perhaps giving FEA a call might help.

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    Quote Originally Posted by lensmanmd View Post
    Many labs use the IOT designs, including us, with tremendous success. Perhaps giving FEA a call might help.

    Lets say I had a long tuesday and cannot for the life of me figure out what those acronyms are atm.

    ?

  9. #9
    Ghost in the OptiMachine Quince's Avatar
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    http://www.feaind.com/ -lab

    http://www.iot.es/ -manufacturer/ designer


    Both are independent, knowledgeable, and have high quality.

    Many other companies will buy rights to IOT designs and rename them as their own house brand lens.
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    Heck of a question, Dave! The perfect decision-tree is probably a moving target...by the time you could print a flowchart it'll have changed. I think it's important to mention that when you're serving presbyopes, your flowchart should already have started when line multifocals are still on the table (and not uncommonly the best option.)

    With PALs: A good rule of thumb is that the higher-quality (and pricier) lenses of the major manufacturers will enjoy broader customer satisfaction--and the differences between the brands generally becomes less noticeable and consequential in adaptation, at least statistically speaking.

    It's also important to remember the biggest cause of PAL dissatisfaction is poor dispensing. No amount of money spent on a PAL can make up for sloppy measurements--and in fact the fancy free-forms may be more sensitive to it.

    If you've read everything you can by Darryl Meister at this point, you're doing well.

    Lens manufacturers won't make it easy to get comparative data...although most will be happy to supply a zingy sound bite and technobabble in hopes you'll mistake it for logic. Their internal studies on customer satisfaction can be useful, but you really have to have a head for math and science to glean what's actually 'real' versus spinning numbers. (For brand loyalists, you'll first be able to have cogent discussion with patients about why the brand upgrade might be better.)

    Then let the lens reps have their way with you---it is information you'll need. Just take it all with a grain (--well, bags and bags--) of salt and don't regurgitate it to the patient just because the lens rep said so. By the time you've listen to them all subtly (or not so subtly) trash each other, then you'll really be breathtakingly confused and ready for real learning! All the shredded terms will be laying on the floor ready for you to put them back together, not a salesman.

    From there, as feedback from your own patients keeping you learning, you're well on your way to building your own experience base which will inform your own decision-tree.

    Existing PAL wearers happy in their old PAL really ought to stay put. When they're not happy, was it really the lens, or just bad opticianry? Then it's time to flip through your mental rolodex of PAL designs, focusing on what problem needs to be solved without creating new ones.

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    Follow Qunice's links. Hayde is very correct about PAL workflows being a moving target in today's ever-changing optical landscape.

    Listen to your reps and ask for their printed PAL design guides. They should be able to provide you with soundbites on which PAL does what. Listen to the needs of your patients. Do they want an 'all inclusive' lens? Distance and reading lens? Distance and intermediate lens? Your design guides can help you determine the best designs for their needs.

    In my years as a dispensing optician and as a production manager, I have trialed a multitude of PALs. I have been unable to wear only a handful. I have my favorites, and have my true go-tos. If you are a PAL wearer, I would strongly recommend requesting trial samples from your reps to get first hand experience with the varying designs.

    We sell Zeiss and IOT designs as a general rule, but also include the Amplitude, Image and GT2 molded designs. I have found that a majority of our wearers can switch from one design to another with minimal effort. Heck, many wear different designs from their sun to dress without issue. Again, as Hayde referenced, the optician's skills are more important than the actual design. An improperly fit premium design will be worse than a properly fit generic design.

    There are many here on Optiboard that swear by Shamir and Essilor (yes, they are both Essilor now). Unfortunately, I am not one of them. I prefer the Precision Plus by Zeiss and the Alpha45 by IOT. I did also like the ID3 by HOYA, but the TAT and limited lens choices was not worth it. The Alpha 45 will go by many names, as they are licensed as OEMs. Both are compensated designs and both are balanced designs. The Alpha45 has a slightly wider intermediate and the Precision Plus has a wider reading area. The distance is comparable in both.

    The Alpha45 does have a one huge advantage over the Precision Plus. The Alpha45 design can be made on any lens brand, giving you a wide variety of choices, from gradient polarized, to HEV, DriveWear to Coppertone. Precision Plus is only available in Zeiss formulary, though good, they are still a little limited. IOT does have a new set of designs coming out, and can be combined with the Camber puck.

  12. #12
    Ghost in the OptiMachine Quince's Avatar
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    Quote Originally Posted by Hayde View Post
    If you've read everything you can by Darryl Meister at this point, you're doing well.
    +1
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    Ghost in the OptiMachine Quince's Avatar
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    Quote Originally Posted by lensmanmd View Post
    IOT does have a new set of designs coming out, and can be combined with the Camber puck.
    Exciting news! I look forward to hearing more about this.
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    Quote Originally Posted by lensmanmd View Post
    There are many here on Optiboard that swear by Shamir and Essilor (yes, they are both Essilor now).
    Unless something's changed since I last checked, Shamir is still independent. Essilor does own a chunk, but it's not a controlling chunk. Shamir's development infrastructure and design philosophy doesn't share much in common with the big V. A 2% stock transaction could tip them into true subordination...but today they still steer their own ship while still motivating the big E to give them market access through their labs.

    Great run down on the rest! Zeiss makes top notch products, but it's important to keep in mind that unlike most every PAL on the market any more, they work around a 6mm drop instead of 4. (I'm not versed enough on Zeiss portfolio to know if there are any exceptions?)

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    Quote Originally Posted by Hayde View Post
    Unless something's changed since I last checked, Shamir is still independent. Essilor does own a chunk, but it's not a controlling chunk.
    It was a "merger". Essilor owns 50% of Shamir. Which was delisted form the stock exchange and is now a joint-owned privately held company.

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    Quote Originally Posted by Kwill212 View Post
    It was a "merger". Essilor owns 50% of Shamir. Which was delisted form the stock exchange and is now a joint-owned privately held company.
    I thought they only bought % 49 so shamir would retain control??

  17. #17
    Ghost in the OptiMachine Quince's Avatar
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    Either way- Essilor has a full hand in that pot. Doesn't mean its not good product; its not independent though.
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    Semantics...if I own 51% of my company, then I'll call it independent control. I can't be outvoted or replaced for any decision. If E owns 49% of it, they just have to live with whatever I decide, but we both have an incentive to maximize my profits in a friendly distribution arrangement. So E only loses a stamping fee when I sell a Shamir when their lab surfaces it for me---that won't prevent me from prescribing it when it's the right choice.

    That's very different from what Definity did. Definity sold out, and unsurprisingly faded off the menu. That's a disappointing result for the patient.

    I wish the lab industry wasn't organized around "Cola Wars" and it would make sense for me to sell Zeiss, too. But it is what it is, and what it is doesn't turn Dr Pepper into Coke. Coke is smart to bottle Dr Pepper by contractual arrangement. (So is Pepsi...I mean Hoya...in doing the same thing.) Dr Pepper can get itself on the menu darn near everywhere, even across Cola War borders---and that's a benefit to the patient. So that makes me happy.

    Shamir is an awesome company, y'all. "We Have A Lens For That" task specialization is a mighty fine toolbelt to bring with you to the job. Superlative quality for very affordable prices. Outstanding patient satisfaction rates (when I do my job right. When you have that much customization at your fingertips, better not get caught snoozing.) They deserve more credit than being accused of what Definity did. They easily could have...and they wouldn't be around for us to talk about now.

    I guess my point is that industry political opinions have no place in patient prescription--coming back to the point of the thread. I have to factor in that Hoya labs have a sketchier QC reputation even though their designs are upper tier--but that's a patient satisfaction consideration, not politics. If Hoya turns it around, I'm open-minded. Not that I'd move a happy Varilux wearer to Hoya if they did unless I had good reason to think it was going to work better for the patient.

    Can't knock Zeiss or lensmanMD's preference for it. He didn't post that his prescriptive preference was political--and I'm not accusing him of it. I'm glad Zeiss remains in the market, for everyone's sake.
    Last edited by Hayde; 05-25-2017 at 11:38 AM.

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    Quote Originally Posted by UtilityDave View Post
    what is the first lens you go to when fitting a new progressive patient (And what particular hobbies/interests/complaints/prescriptions might compel you to fit them with a different lens)
    I always default to something free-form. Autograph III usually works pretty good, so do Hoya's ID Lifestyle lenses. It also depends on how much the patient is willing to spend. If they don't want to spend a lot, or they are very apprehensive about PALs, I like to spin Shamir Duo as a "beginner's progressive" and that tends to work pretty well. As long as you make it clear the limitations of the lenses along with the positives, it's usually a good experience.

    Typically, I emphasize position-of-wear measurements and why they are so effective at creating a unique lens for each unique set of visual needs. This gives the patient a pretty good idea of the level of control and precision the lab has over lens designs.

    Simply put, free-form lenses are always going to be more comfortable for new wearers to adapt to. As for changing designs in existing wearers, I tend NOT to do this if I don't have to. Generally speaking, if someone is comfortable with what they are wearing, I'll keep them in it. I would upgrade to new technology though (i.e. a Physio Enhanced wearer would move to Physio W3+, etc.). That's always one of the first questions I ask - "How do you like your current lenses? Is there anything you don't like about them?" If there is a change that needs to be made, I try to put them in something that is set up similarly.

    Quote Originally Posted by UtilityDave View Post
    How do you learn about new lenses?
    How do you learn about other existing lenses you just haven't had experience with yet?
    As has been stated here, it's generally pretty time-consuming to sift through all the nonsense that your sales reps give you. If your sales rep just so happens to have been an optician previously, they typically give out better information. I tend to find that my independent lab reps are excellent sources of unbiased information. If you have to do the research on your own, look for common themes between lenses. As also stated before, if you've read information from Darryl Meister, you're in a pretty good starting spot. Check out some ABO accredited CE articles on the web too. Not completely unbiased, but the writers of the articles generally do a pretty good job of giving you facts in addition to branded spin.

    Quote Originally Posted by UtilityDave View Post
    Any good advice in general?
    No matter how much you know or communicate with the patient, there will always be some people that you just simply can't make a PAL work for. This is the human element at play. There will always be those people who think that "bifocals mean I'm old", and won't adapt to them simply because of their own personal bias. And there's nothing you can do or say that will change their mind.

    Trial and error is also the king of your own unbiased knowledge. As long as you're upfront with your patients, they'll generally be pretty receptive to a lot. If you are excited about a new progressive lens, and you think that they would be a good candidate for it because of x, y, and z, then they'll get excited about it and try it. You know your clients, and specifically those who would be receptive to these changes.

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    What is the best way to practice position of wear measurements? Is there a good way to get good at them without risking patients quality of vision experience? Without looking silly - or making the patient look silly?

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    Utilize your co-workers! Role playing exercises are such a bore, but they work.

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    Ghost in the OptiMachine Quince's Avatar
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    We also have multiple opticians sometimes double and triple check measurements. Different sets of eyes or techniques for measuring can be good for ironing out the discrepancies.

    For example: we have some opticians use a pupilometer while others take a manual PD with their seg hts. Or that some people measure a seg from the bottom of the pupil while others measure from the center and then subtract 1 or 2mm.
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    Quince, I know this totally deviates from the OP, but I'm curious - When you have opticians that take measurements on the same patient in different ways, how do those measurements usually compare with one another? In your experience, is there a noticeable difference in patient experience using one set of measurements over another? (i.e. manual vs. automatic POW, PD stick vs pupilometer, etc.)

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