This should be fun!

Oi.

Bring on the weekend! But until then, I've got a treat that's fallen in my lap. Pt presented today: 38 yo male, Videographer by trade. Hx of retinal detachments OU. Scleral buckles performed OU. PC IOL OD only. Vertical imbalance corrected with prism OS only. Inferior coloboma in OD iris. Pt states none of the prior damage was trauma related. Was wearing a 2 year old Proof frame (wood) that looked like it was 10 years old. Held together with tape and super glue - because Proof.

OD was a Zeiss PAL 1.67, OS was SV of unknown indice. History of some awesome aniso. CLs were tried in the past (prior office), but pt rejected due to poor vision and comfort.

Today's spec refraction came back as follows:

OD -1.75 -2.50 x 023 +2.00 ADD 20/25
OS -7.50 -4.75 x 179 4.00 BU (OS Only) 20/30, 20/20- OU, Near J2+ OU

He's looking at a new frame today. PD 34.0 / 31.0 He was looking at 48/18-ish frames, which places his seg/OC nice and close to GC. He likes wood, but is also looking at some nicer zyles. Full frame styles. We were going to look at using his EyeMed for lenses, but it actually ends up cheaper doing the lenses privately - which opens up our options.

I've got a good general idea of where I'm wanting to go with this, but wanted to run it past the collective here. So, where would you all start in designing this masterpiece? :)

I have no words of wisdom, but I'm dying to see how it all ends up. Keep us posted. :)

Quote:

---

Originally Posted by Uilleann

Oi.

Bring on the weekend! But until then, I've got a treat that's fallen in my lap. Pt presented today: 38 yo male, Videographer by trade. Hx of retinal detachments OU. Scleral buckles performed OU. PC IOL OD only. Vertical imbalance corrected with prism OS only. Inferior coloboma in OD iris. Pt states none of the prior damage was trauma related. Was wearing a 2 year old Proof frame (wood) that looked like it was 10 years old. Held together with tape and super glue - because Proof.

OD was a Zeiss PAL 1.67, OS was SV of unknown indice. History of some awesome aniso. CLs were tried in the past (prior office), but pt rejected due to poor vision and comfort.

Today's spec refraction came back as follows:

OD -1.75 -2.50 x 023 +2.00 ADD 20/25
OS -7.50 -4.75 x 179 4.00 BP (OS Only) 20/30, 20/20- OU, Near J2+ OU

He's looking at a new frame today. PD 34.0 / 31.0 He was looking at 48/18-ish frames, which places his seg/OC nice and close to GC. He likes wood, but is also looking at some nicer zyles. Full frame styles. We were going to look at using his EyeMed for lenses, but it actually ends up cheaper doing the lenses privately - which opens up our options.

I've got a good general idea of where I'm wanting to go with this, but wanted to run it past the collective here. So, where would you all start in designing this masterpiece? :)

---

I would keep him in lenses that match what he was wearing as closely as possible. 1.67 zeiss PAL in the OD ;1.67 sv in the os. I would be curious what base curves were used on the old pair; try to match back curve more than base curve.

EDIT: wait maybe i read your post wrong. Was the sv lens in the OS just a temporary fix until he gets an IOL in that eye?

Whoa. As a photographer, I feel for this patient. Ability to focus properly is critical. 20/25 is doable looking through the viewfinder, as it is adjustable.

Not sure which direction you are going, but I would consider FF OU. The oblique OD would definitely benefit from FF, and the OS is w/i range for most SV FF. I'm thinking average POW would suffice here based on what you wrote. I really don't think personalized POW is worth the time and effort.

Definitely interested in what you come up with and how it turns out.

Segmented multifocals for work (confirm the add power in general, but especially for the camera monitor), and a separate pair for editing at the desk monitor. Many questions about what to do for the left eye but I'm sure you'll sort that out before you write it in stone.

Hope this helps,

Robert Martellaro

FF / OU was certainly a direction my thoughts were headed. He has had dis-similar materials OD to OS in his last pair, though he is unsure about specifics. Interestingly, his fusion is quite good historically. No plans or need for IOL in the OS as yet that I know of. The Doc mentioned all looks good there so far medically. As for POW measurements - they're not hard or time consuming to properly measure at all. And he isn't concerned about cost per se. He's already wanting digital / FF lenses, and many allow for POW measurements without any added cost (they're already pricey enough!)

Still thinking 1.60 for the OD and 1.71/1.74 OS, pulling the OD in as much as possible, and pushing the OS forward as much as possible. Though, depending on frame dimensions and fit, we may be able to drop down to either 1.60 or Trivex for the OD, and a 1.67 OS. He's doing some homework on a few different frame manufacturers we carry, and looking through their catalogs online. Then we may special order, and go from there.

Super nice fella. Hoping we can hit it out of the park for him. Thanks for all the advice so far!

Quote:

---

Interestingly, his fusion is quite good historically.

---

What is his history- is he wearing a similar Rx presently and is mostly binocular? He got lucky image size-wise with the detach and buckle, but there's still going to be vertical prism imbalance in the high single digits at near. You'll need to see if he can suppress, or is suppressing presently. Trial framing will provide most of the answers.

What does the 4.00 PD represent?

Quote:

---

No plans or need for IOL in the OS as yet that I know of.

---

Calculating the power for binocular vision should be challenging. Co-management with a very experienced optometrist would be prudent.

Best regards,

Robert Martellaro

So, is the thought process of going with a high index lens OD strictly for trying to balance the magnification or am I missing something else here? With the magnification difference being as high as it is I can't imagine the .1% or so reduction in difference from material alone is going to make a bit of difference. Regardless of currently VAs, with a history of retinal detachments and impending cataracts OS I would treat this pt as monocular and use trivex.

I also have a very hard time believing pt has good fusion historically. I could believe that they alternate/suppress vision and don't see double, but fusing with that unbalance just seems very unlikely to me. If they do somehow fuse, great. But, if they are currently alternating or suppressing vision and you do manage make the magnification difference close enough that their brain does try to fuse and can't, they may end up with double vision that they didn't have before.

When we're referring to vertical imbalance, is there an actual CI or is it a preemptive BU by the doc in order head off a slab-off? (Is that BP supposed to be a BU?)

Zeiss enjoys a superior reputation in my book, but with a six drop I'm not sure they're the right choice for this guy--if any PAL is.

Quote:

---

Originally Posted by Robert Martellaro

What is his history- is he wearing a similar Rx presently and is mostly binocular? He got lucky image size-wise with the detach and buckle, but there's still going to be vertical prism imbalance in the high single digits at near. You'll need to see if he can suppress, or is suppressing presently. Trial framing will provide most of the answers.

What does the 4.00 PD represent?

---

Sorry - that was a typo on my part. That's 4 base up, OS. Our doc spent a good deal of time with him to make sure he was solid on his numbers. Thankfully, the patient was very helpful with his prior Hx and came armed with a good deal of useful information. Fusion hasn't been a large issue for him in the past to hear him tell it - even with the dissimilar lens styles, ansio, and prism. In short this boy's brain is chewing on a lot, and coping very well to date. Thank goodness!

Quote:

---

Calculating the power for binocular vision should be challenging. Co-management with a very experienced optometrist would be prudent.

Best regards,

Robert Martellaro

---

Thankfully, our OD who did his exam is our binocular/prism guru. I'm just trying to think, re-think, and think again about how to best design, order, and dispense the next chapter in his optical saga.

May the force be with us! :wink:

Make sure to have some very good, COLD beer to crack open after you make him happy. That is the best advice I can give you.

Quote:

---

Originally Posted by Kwill212

So, is the thought process of going with a high index lens OD strictly for trying to balance the magnification or am I missing something else here? With the magnification difference being as high as it is I can't imagine the .1% or so reduction in difference from material alone is going to make a bit of difference. Regardless of currently VAs, with a history of retinal detachments and impending cataracts OS I would treat this pt as monocular and use trivex.

---

He's had a 1.67 OD previously, and an unknown 'high indice' OS. Not trying to reinvent the wheel per se, but just wanting to make sure I'm crossing t's and dotting 1's as I go. Anything I can do in the design phase to minimize imbalance and not increase it in his scenario is my general goal.

Quote:

---

I also have a very hard time believing pt has good fusion historically. I could believe that they alternate/suppress vision and don't see double, but fusing with that unbalance just seems very unlikely to me. If they do somehow fuse, great. But, if they are currently alternating or suppressing vision and you do manage make the magnification difference close enough that their brain does try to fuse and can't, they may end up with double vision that they didn't have before.

---

As for his fusion, I can only reiterate his statements. Apart from some difficulties with transient and nondescript 'lack of sharpness' in lower light scenarios, he continually stated no perceptual trouble with diplopia, and a good sense of depth perception. *shrug* If he is indeed fusing (which I agree is far less likely than just suppressing...but I can't say one way or the other myself), he's a master at it. I doubt very much I can affect much change in potential fusion, but that isn't a reason for failing to try.

Quote:

---

Originally Posted by Hayde

When we're referring to vertical imbalance, is there an actual CI or is it a preemptive BU by the doc in order head off a slab-off? (Is that BP supposed to be a BU?)

Zeiss enjoys a superior reputation in my book, but with a six drop I'm not sure they're the right choice for this guy--if any PAL is.

---

He presented with prism in his previous specs (3.5 diopters if memory serves...don't have the chart notes in front of me to review presently), so I imagine Doc wanted to keep thinks fairly similar to his current. I also agree that Zeiss wouldn't be my 1st choice. Or 2nd, 3rd or 4th really. And they were set crazy low in the frame. I didn't have a chance to see them marked up and hanging on his nose to confirm his prior lens placement and his pupil centers. But just glancing at the layout marks during his intake work-up, they struck me as subjectively quite low. An Eagle Camber lens from FEA was my initial thought...but I'm still waiting to see what his thoughts are on a new frame before trying to lock the design down with any certainty.

Thanks all for the thoughts so far! Really appreciating the feedback.

Quote:

---

Originally Posted by Tallboy

Make sure to have some very good, COLD beer to crack open after you make him happy. That is the best advice I can give you.

---

YAAAAAASSSSSS!!! :biggrin::biggrin::biggrin:

Quote:

---

Originally Posted by Uilleann

He presented with prism in his previous specs (3.5 diopters if memory serves...don't have the chart notes in front of me to review presently), so I imagine Doc wanted to keep thinks fairly similar to his current. I also agree that Zeiss wouldn't be my 1st choice. Or 2nd, 3rd or 4th really. And they were set crazy low in the frame. I didn't have a chance to see them marked up and hanging on his nose to confirm his prior lens placement and his pupil centers. But just glancing at the layout marks during his intake work-up, they struck me as subjectively quite low. An Eagle Camber lens from FEA was my initial thought...but I'm still waiting to see what his thoughts are on a new frame before trying to lock the design down with any certainty.

Thanks all for the thoughts so far! Really appreciating the feedback.

---

I hear you about rolling with what works. Can't fault the doc for doing just that. If he's blessed with fusing that much aneiso, man, let's hope it lasts. I love the idea of Camber blanks, but for a high myope I'm not sure this is the guy who's gonna notice its advantages as much. You could switch to a short channel PAL or the Shamir Autograph 3...at the risk of flagrantly upsetting the apple cart, he might really be 'wow'ed by the higher ADD acceleration and your superior frame fitting.

The risk is that his Hx Zeiss ADD has been pushed down so low in the past maybe he's never even effectively seen 'reading' through the PAL at all---and forcing him into it may be a bumpy adaptation. Have you observed his reading through his Zeiss's? How is he with the reading card? Still binocular?

Quote:

---

Originally Posted by Hayde

The risk is that his Hx Zeiss ADD has been pushed down so low in the past maybe he's never even effectively seen 'reading' through the PAL at all

---

Bingo! Certainly not with 8+ prism diopters of vertical imbalance at near. He has to be reading through the single vision OS lens. That's what my visual cortex would do. Just make SV OU and then go for drinks. You can start sweating when he becomes presbyopic in the OS.

Best regards,

Robert Martellaro

Quote:

---

Originally Posted by Robert Martellaro

Bingo! Certainly not with 8+ prism diopters of vertical imbalance at near. He has to be reading through the single vision OS lens. That's what my visual cortex would do. Just make SV OU and then go for drinks. You can start sweating when he becomes presbyopic in the OS.

Best regards,

Robert Martellaro

---

I just couldn't figure out yet if that BU prism OS was really a convergence insufficiency or one of those "One Weird Trick" OD things that miraculously pulled it together for this guy in the reading zone if he otherwise tolerated 4D VI top and bottom.

If it's a legit CI, yeah--save him some money and skip the PALs altogether. Then straight to FT slab-off when the day comes.

Quote:

---

Originally Posted by Hayde

I hear you about rolling with what works. Can't fault the doc for doing just that. If he's blessed with fusing that much aneiso, man, let's hope it lasts. I love the idea of Camber blanks, but for a high myope I'm not sure this is the guy who's gonna notice its advantages as much. You could switch to a short channel PAL or the Shamir Autograph 3...at the risk of flagrantly upsetting the apple cart, he might really be 'wow'ed by the higher ADD acceleration and your superior frame fitting.

The risk is that his Hx Zeiss ADD has been pushed down so low in the past maybe he's never even effectively seen 'reading' through the PAL at all---and forcing him into it may be a bumpy adaptation. Have you observed his reading through his Zeiss's? How is he with the reading card? Still binocular?

---

This is more or less my thought process too. His old add was a +2.25, and we've rolled him back a quarter. Chart notes show he's J2+ OD & OS (Our EHR doesn't have a space for OU near VAs) But I can only hope he is either getting proper, usable fusion of some form (super iffy of course...but I've seen stranger things!), or he's got some cool alternating suppression going on. His better VA is in the OD after all, so I don't think I want to mess with that add anymore than I have to.

Given that he's spending a good deal of time at a screen while he edits his video stuff, ideally, I think a task specific SV set might be his best bet there. But he sounds like he really has liked the prior set up, and I'm not inclined to muck with it over much. Just trying to infuse a few of my own little tweaks to help sharpen it where I can.

Cheers!

OOF! Just realized I had flipped my material choice OD/OS in my initial reply. Fixed!

Quote:

---

Originally Posted by Robert Martellaro

Bingo! Certainly not with 8+ prism diopters of vertical imbalance at near. He has to be reading through the single vision OS lens. That's what my visual cortex would do. Just make SV OU and then go for drinks. You can start sweating when he becomes presbyopic in the OS.

Best regards,

Robert Martellaro

---

I think that this is the right way to think.

Firstly, there's no way in hell that the patient is going to be binocular even a few millimeters off the optical center, let alone 8-10 mm below. So any "vertical imbalance on downgaze" stuff isn't an issue.

Therefore, you probably don't even need a multifocal in the pseudophakic right eye. (Unless, somehow, he prefers the OD. The acuity is a little better on the right. I don't know why he's 20/30 in the left, but there are a multitude of possibilities. I would see if there's any dominance or preference for the right eye. If so, maybe an add is a good idea, but I'd still rather let him accommodate and use the phakic left eye at near. )

It's riskier to take lenses out of eyes when there are retinal detachment histories, but it sure would be nice to get that guy to a cataract surgeon in his mid-40's when the accommodation is waning to "de-bulk" the refractive error OS. Life would be a lot easier.

So if all the above is true, you may be able to do well with FFSV.

It would be nice to know why there is a vertical imbalance in primary gaze, as was stated upthread. It could be from the surgeries. But if it's some heroic compensation for prismatic imbalance on downgaze, well, I'd forget that, too.

It would be well within the purview of opticianry to trial frame the distance powers and see how he does with just that, alone. Maybe the prescriber did all that, maybe not.

"Occam's" sounds like a good name for a beer!

Great case, and great analysis by you all.