patient cannot find comfort outside of a Comfort

Hi friends, I have a -750/-050 x 120 -900-075x135 with a +175 add in a frame with same measurements as (8 year) old frame a = 45, B=30, frame PD is aligned with pupils. getting woosy with his new free-form digitals in 1.74 versus his old Vari Comforts in poly which appear to have a 16 mm seg which is cutting off 60% of add OD and 15% OS. He has a history of remakes and wants his comfort back. the lab i used for his original pair and chemistrie clip will remake them, but only in a shamir for an upgrade fee. Or, i could just bail and remake them with another lab in the comfort. Is an old comfort that good? I can't see that it's a comfort 2 or short because so much of the lens is cut off.

Was this patient wearing the same lenses in that 8 year old frame? If they have been wearing a comfort for 8 years, than they have conditioned their eyes to that lens (and Rx) and will certainly take time to find anything else comfortable.

I would want to make sure the new Rx is clear in both distance and reading before determining that their discomfort is solely due to lens design.

I don't quite understand your note about cutting off the ADD 60% on OD and only 15% in OS... is the PD drastically uneven?

Quote:

---

Originally Posted by Quince

Was this patient wearing the same lenses in that 8 year old frame? If they have been wearing a comfort for 8 years, than they have conditioned their eyes to that lens (and Rx) and will certainly take time to find anything else comfortable.

Thanks Quince!The patient has used the same frame for 8 years, but charged the Rx 4 years ago. There is the issue of having had a remake per the patient, which was apparently resolved with a change back to the original pal design.

I would want to make sure the new Rx is clear in both distance and reading before determining that their discomfort is solely due to lens design.

Yes, I’ve now checked it several times, with some variation, but have a good idea of what should work.

I don't quite understand your note about cutting off the ADD 60% on OD and only 15% in OS... is the PD drastically uneven?

---

When I neutralize the rx, the dominant right eye reads a +0.75 add at the bottom of the lens, and the left eye add reads a +1.50, even though laser marks say +1.75. Patient is 47, young for that add, oddly, but complaining of near issues. Also has a wide bridge of nose, so the frame is limited even more in the available seg placement. But he likes the small ovals... One thing is he’s used to poly, not the 1.74 I “upgraded “ him to. May try to stretch the metal bridge as a next step, to bring down the frame and lengthen the corridor!?

You have a couple things going on here that I see could be causing the "woozy" feeling.

1. Changing poly to 1.74. Such an increase in the index of the material is going to cause drastic flattening of the base curve, which could cause peripheral distortion if the patient is not used to it. I get the same problem as a -10.00. I wear 1.67 index because I can't tolerate the flatness of 1.74.
2. Changing PAL design. Seriously, if you find a solution to this "changing Comfort to anything else causes problems" issue, please tell me. I usually don't change anyone who currently wears Comfort because there always seems to be an issue.
3. Compensated versus non-compensated PAL design. I've run into this issue a bunch too, especially with people who have had the same pair of glasses for a very long time (which seems to be the case here). If their old design is non-compensated, they start to have issue with the compensation and say that they feel like their eyes are fighting with each other. I've seen this a lot going from say like a HOYA Summit ECP to a Summit ECP IQ.

Honestly, I'd probably trial frame the Rx both distance and near, and if he's comfortable with it, I'd seriously consider remaking to Comfort, regardless of how his add power gets cut off. Maybe he was previously over-refracted at near to compensate for a small frame? Now, if we had a conversation about trying something else and if he got on board with being a guinea pig for another go around before going back to his Comforts, I may take the lab up on the remake. That's a financial decision you have to make between you, your office, and your patient, and anything I say on that front won't be worth a darn.

If you are considering switching back to the Comfort and thinking about the Comfort Short make sure the patient is unhappy with their near. It's quite possible that the previous Dr. upped the add assuming it was going to be cut of so that they would end up with the (approximately) +1.00 add. If the patient is happy with their intermediate and uses it a lot I wouldn't switch. If they are only complaining of their reading and you are thinking of switching to the Comfort Short definitely trial frame the reading, because they're probably going to be overplussed with the full add in a short corridor (because you're now looking at a 0.75D increase).

We see a small percentage of patients who we can't switch to a compensated digital lens even not changing materials. I can't explain it but it happens (mostly Comfort to Autograph 2/3), I can't remember if we had issues switching the patient to the Element or the Spectrum, if you have a remake you can try one of those but I agree with bretk that's a huge change from Poly to 1.74.