New PAL wearer having issues with swim; suggestions?

Hi folks,
I was paid a visit this morning by a fellow who picked up his glasses a couple of weeks ago. This is what he received:

OD -0.75 +1.00 x005
OS -1.50 +1.75 x163
+1.50 add OU
Varilux Comfort W2+, 23 seg height on 35 B measurement.

This guy prefers to wear his glasses a little bit further down his nose; his comment was "if I wear my glasses up at the top of my nose, I feel claustrophobic." When he first picked up his glasses, I encouraged him to try wearing them closer to his eyes, and explained that wearing them further away narrows the window of clear vision through his glasses (especially for anything arm's length away and closer), and doesn't provide the level of correction that he needs. Nonetheless, he has continued wearing his glasses further down on his nose.
Today, his complaint was that the waviness of the peripheral blur area in his lenses was bothersome when at his desk at work. He noticed that if he placed the glasses even further down his nose, it wasn't as problematic. I marked the lenses up and asked him to position them at that spot, and the fitting cross was 6 mm below his pupils--lower than his eyelid. I told him that because all progressive lenses have at least some element of that peripheral blur, it would be difficult to avoid that issue with any lens we tried, so he needed to turn his head a little more to avoid that distorted area. Not satisfied, he asked if I could remake the lenses "with the bifocal area lowered," and I said that I could, but if we lowered the fitting height enough to where he preferred it, that he would have trouble seeing at arm's length. He didn't seem bothered by that.

I am reluctant to do what this patient is asking me to do, mostly because I think he still won't be happy with the results. The arm's length focal area will be totally useless, and the area of full reading power will shrink. His insurance lab will only remake lenses once for an issue like this, so I need to feel sure that I'm doing the right thing. I've thought about switching him to another progressive lens in the category, but not all of the lenses offered by the insurance are in my price book or billing software. Ideally, I would've fit him in the Lifestyle 2 Clarity to begin with, but he was not a fan of the $100 difference in price. He's also not interested in two pairs, or he'd be wearing iD screen lenses, too.
The other lenses in the category that I can offer:
Definity
Comfort Enhanced
Physio Enhanced
Summit iQ

Others on the list:
Accolade Freedom
Ideal/Short/Advanced
Supercede
Autograph II
element
Kodak Unique
Compact Ultra HD
Sola HDV
SolaOne HD
Precision Pure
Synchrony

I would prefer not to fit this patient in a lens that we can't price out for him in the future, but I could be convinced to if y'all can assure me that the results will be noticeably different. I've thought about switching him to the Shamir Duo, because of how much more peripheral clarity it has. In comparing the end product, I have a feeling that the Duo will likely have the same amount of useful intermediate area as a Comfort W2+ with the seg dropped 6mm. (Read: none.) For most patients with a low add like this, they often don't miss (or even use) that focal distance anyway, and I often fit them in short corridor lenses to ease their access to the full add. I really do not want to fit a PAL incorrectly for this patient, because he'll only run into bigger problems as his add power increases if he becomes accustomed to wearing them this way.

Now that I've written a novel, does anyone have any suggestions for me, given the patient's non-compliance with my recommendations?

Thanks!

If he only has the problem at work, and is otherwise fine, I'd recommend a computer PAL. Perhaps a second set, either SVD, bifocal, or, if he's fine with it, a PAL, for all his other daily use. As far as I could tell, this would be the most complaint free way of doing it.

Manage. Their. Expectations.

1. Your patient is wearing his glasses in a way for which they are not designed. He will never be happy with the results.

2. Your patient is using his glasses for a function for which they are not designed. He will never be happy with the results.

I don't have any useful advice. The Comfort W2+ is the easiest PAL to adapt to that I've every worked with, but your patient's insistence on doubling the vertex distance makes these lenses essentially useless. Moving his lenses out is multiplying his peripheral distortion and moving it closer to his center vision. All lenses will cause identical problems if he can't be convinced to wear them the way they're designed to be worn.

Quote:

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Originally Posted by AngeHamm

Manage. Their. Expectations.

1. Your patient is wearing his glasses in a way for which they are not designed. He will never be happy with the results.

2. Your patient is using his glasses for a function for which they are not designed. He will never be happy with the results.

I don't have any useful advice. The Comfort W2+ is the easiest PAL to adapt to that I've every worked with, but your patient's insistence on doubling the vertex distance makes these lenses essentially useless. Moving his lenses out is multiplying his peripheral distortion and moving it closer to his center vision. All lenses will cause identical problems if he can't be convinced to wear them the way they're designed to be worn.

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I 100% understand what you're saying, and I did the best I can already at making your same points abundantly clear to him--not only when he first ordered, but during his visit today as well. I can only give that advice in so many different ways, and while it is his choice to not comply with my recommendations, I need to figure out a way to meet his needs.

Quote:

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Originally Posted by andshewas

I 100% understand what you're saying, and I did the best I can already at making your same points abundantly clear to him--not only when he first ordered, but during his visit today as well. I can only give that advice in so many different ways, and while it is his choice to not comply with my recommendations, I need to figure out a way to meet his needs.

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It doesn't matter, that is on him. You can give him the options. That is all. If his need to wear his glasses in this way outweighs the need for them to work correctly then he is not wearing the right lens, period. Its like wearing mesh running shoes in the snow and complaining that the shoes are broken because your feet get wet and cold.

After speaking with him I might try one more time, with a vertex compensated back side free form in his ACTUAL position of wear, change the seg to line up with his pupil. I have in this situation achieved something that works. Otherwise he can have computer pair and DVO pair. In my experience office lenses don't work well if they wear them so low, unless they are just the designs that only shift in add from 60% to 100%.

On of the greatest skills I have cultivated is being able to calmly and gently explain to someone their options as well as the inflexible rules of physics, and then guide them to making the decision for themselves.

I dare say that with a 150 add it is his first progressive? Second? If so then he is still in the learning curve of how to properly use progressives. If he has used progressives before do you have the option to use the same one for him with his new power?
The only way he is going to take to hart and believe what you have been telling him and trying to do for him would be when he goes somewhere else and someone tells him the same thing.
If he cant get past the claustrophobic feeling of wearing the glasses properly then his only option to see in the manner that he wants to is using 2 pair of SV.
Other then that I assume the Varilux X is not a option for you because you did not list it. We have had great success with it because of it being designed with a wider intermediate and wider near then most progressives have.
Best of luck with that one, sounds like hes going to be a tough cookie.

I hate to say this but.... maybe he needs to go back to single vision near??
Multiple pairs seems to be a good solution as well.

Agree with all of the optiboarders. Multiple pairs.

Quote:

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Originally Posted by andshewas

I 100% understand what you're saying, and I did the best I can already at making your same points abundantly clear to him--not only when he first ordered, but during his visit today as well. I can only give that advice in so many different ways, and while it is his choice to not comply with my recommendations, I need to figure out a way to meet his needs.

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I dig it. Been there. Sounds like multiple pairs are the answer for him.

Quote:

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Originally Posted by andshewas

Hi folks,
I was paid a visit this morning by a fellow who picked up his glasses a couple of weeks ago. This is what he received:

OD -0.75 +1.00 x005
OS -1.50 +1.75 x163
+1.50 add OU
Varilux Comfort W2+, 23 seg height on 35 B measurement.

This guy prefers to wear his glasses a little bit further down his nose; his comment was "if I wear my glasses up at the top of my nose, I feel claustrophobic." When he first picked up his glasses, I encouraged him to try wearing them closer to his eyes, and explained that wearing them further away narrows the window of clear vision through his glasses (especially for anything arm's length away and closer), and doesn't provide the level of correction that he needs. Nonetheless, he has continued wearing his glasses further down on his nose.
Today, his complaint was that the waviness of the peripheral blur area in his lenses was bothersome when at his desk at work. He noticed that if he placed the glasses even further down his nose, it wasn't as problematic. I marked the lenses up and asked him to position them at that spot, and the fitting cross was 6 mm below his pupils--lower than his eyelid. I told him that because all progressive lenses have at least some element of that peripheral blur, it would be difficult to avoid that issue with any lens we tried, so he needed to turn his head a little more to avoid that distorted area. Not satisfied, he asked if I could remake the lenses "with the bifocal area lowered," and I said that I could, but if we lowered the fitting height enough to where he preferred it, that he would have trouble seeing at arm's length. He didn't seem bothered by that.

I am reluctant to do what this patient is asking me to do, mostly because I think he still won't be happy with the results. The arm's length focal area will be totally useless, and the area of full reading power will shrink. His insurance lab will only remake lenses once for an issue like this, so I need to feel sure that I'm doing the right thing. I've thought about switching him to another progressive lens in the category, but not all of the lenses offered by the insurance are in my price book or billing software. Ideally, I would've fit him in the Lifestyle 2 Clarity to begin with, but he was not a fan of the $100 difference in price. He's also not interested in two pairs, or he'd be wearing iD screen lenses, too.
The other lenses in the category that I can offer:
Definity
Comfort Enhanced
Physio Enhanced
Summit iQ

Others on the list:
Accolade Freedom
Ideal/Short/Advanced
Supercede
Autograph II
element
Kodak Unique
Compact Ultra HD
Sola HDV
SolaOne HD
Precision Pure
Synchrony

I would prefer not to fit this patient in a lens that we can't price out for him in the future, but I could be convinced to if y'all can assure me that the results will be noticeably different. I've thought about switching him to the Shamir Duo, because of how much more peripheral clarity it has. In comparing the end product, I have a feeling that the Duo will likely have the same amount of useful intermediate area as a Comfort W2+ with the seg dropped 6mm. (Read: none.) For most patients with a low add like this, they often don't miss (or even use) that focal distance anyway, and I often fit them in short corridor lenses to ease their access to the full add. I really do not want to fit a PAL incorrectly for this patient, because he'll only run into bigger problems as his add power increases if he becomes accustomed to wearing them this way.

Now that I've written a novel, does anyone have any suggestions for me, given the patient's non-compliance with my recommendations?

Thanks!

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Of those choices, Auto II or Definity.

Quote:

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Originally Posted by andshewas

I 100% understand what you're saying, and I did the best I can already at making your same points abundantly clear to him--not only when he first ordered, but during his visit today as well. I can only give that advice in so many different ways, and while it is his choice to not comply with my recommendations, I need to figure out a way to meet his needs.

---

To the bolded, nope! You don't.

This is a heart patient complaining to his doctor that the pills won't work, even though they're stuffing the pills up their nose instead of swallowing them. That's too bad for them that they don't want to listen, and you should firmly refuse the opportunity to disappoint them.

Like everyone else said, it's SV or bust at this point, after that let him walk until he's ready to be compliant. He needs to learn that we can't just make magical lenses that break the rules of physics, no matter how badly he wants it to be true.

Your. head. will. explode. trying. to. make. him. happy. Cut. your. losses. Pass. on. your. opportunity. to. disappoint. him. again. Period.

Quote:

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Originally Posted by ak47

Your. head. will. explode. trying. to. make. him. happy. Cut. your. losses. Pass. on. your. opportunity. to. disappoint. him. again. Period.

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......................Amen

Hello again andshewas.

I have a client who also wears her PAL eyeglasses pretty far down her nose- she just sent her friend to me for new eyeglasses, triggering my memory of her and your clients shared idiosyncrasy.

The vertex distance was 19mm, OD -.50 +.50 x 15 and OS -1.00+.50 x20 add +2.50. The last lens used was a Zeiss Individual 2I. Lens size was 55 x 38, pupil heights 27/28. She also has SVNO for frequent close tasks, also worn low on the bridge. The Definity probably comes closest to the 2I (mostly soft, wide, long corridor with low unwanted astigmatism). As mentioned by others, PAL adaptation is probably the biggest hurdle to overcome, especially when worn in a non-optimal position.

Best regards,

Robert Martellaro

Quote:

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Originally Posted by ak47

Your. head. will. explode. trying. to. make. him. happy. Cut. your. losses. Pass. on. your. opportunity. to. disappoint. him. again. Period.

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Between this guy and another who is sensitive to 0.01 diopter difference in prescription (only slightly exaggerated), I'm already walking around with half of my skull gone. Vacation can't come soon enough!

Quote:

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Originally Posted by Robert Martellaro

Hello again andshewas.

I have a client who also wears her PAL eyeglasses pretty far down her nose- she just sent her friend to me for new eyeglasses, triggering my memory of her and your clients shared idiosyncrasy.

The vertex distance was 19mm, OD -.50 +.50 x 15 and OS -1.00+.50 x20 add +2.50. The last lens used was a Zeiss Individual 2I. Lens size was 55 x 38, pupil heights 27/28. She also has SVNO for frequent close tasks, also worn low on the bridge. The Definity probably comes closest to the 2I (mostly soft, wide, long corridor with low unwanted astigmatism). As mentioned by others, PAL adaptation is probably the biggest hurdle to overcome, especially when worn in a non-optimal position.

Best regards,

Robert Martellaro

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Hi Robert!
Thanks for your feedback. I have a feeling your patient does pretty well with how you've fitted her given A) that she saw you, and B) that the power error caused by how those lenses are worn isn't so noticeable due her low cyl and how it's oriented.
I ended up reordering the W2+ dropped 6mm after all because his insurance lab said we'd have another shot at a remake if these didn't work out. He's coming in Tuesday...we'll see what happens.

Regardless of the outcome next week, I'll be coaching this guy on either modifying his expectations for multifocal wear, or encouraging him to keep multiple pairs of SV/computer/free-form blended bifocal glasses for whatever he needs in the future. I can only imagine his reaction when he finally gets another pair of PALs with (likely) +2.00 add and even more off-axis astigmatism. :rolleyes:

Thanks to everyone who took the time to share their $0.02.

Quote:

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Originally Posted by gaspoweredrobot

This is a heart patient complaining to his doctor that the pills won't work, even though they're stuffing the pills up their nose instead of swallowing them. That's too bad for them that they don't want to listen, and you should firmly refuse the opportunity to disappoint them.

Like everyone else said, it's SV or bust at this point, after that let him walk until he's ready to be compliant. He needs to learn that we can't just make magical lenses that break the rules of physics, no matter how badly he wants it to be true.

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So much yes.