What do I do with this customer? ODs please help!

OK I am going to compress a really long story that spans months into a tiny post, so here it is.

Patient's old Rx had BO prism, but never really comfortable with it. She goes to a doctor, doctor writes new Rx and doesn't really attempt the prisms and writes, "duplicate prisms in old glasses." The doctor tells me that the patient has intermittent exophoria. Unhappy with this, the patient goes to another doctor who says she has intermittent exotropia and prescribes the following:

OD -4.50 -1.00 x105 1.5 BI prism
OS -3.75 -0.50 x136 1.5 BI prism
Add +2.50 ou

I filled the Rx in 1.67 Varilux Physios with Alize. Within a week the patient came back complaining about the right eye, I called to confirm the Rx and it turned out that the doctor wrote the axis wrong. I re-did the lenses, a week later the patient comes back and says she has a lot of peripheral distortion and overall it just seems wrong. I compared her old Rx, the new Rx, and the Rx the original doctor had written and refracted her myself at the following:

OD -5.00 -1.00 x105
OS -4.25 -0.50 x136
Add +2.50 ou.
Without any prisms

I put her in 1.6 Definity with Alize, she seemed much happier without the prisms, but finds that she really has only a tiny spot for reading in the left eye. I checked two old glasses (progressives) that she brought me and both had about 1.5D of prism base out, AND both were made at a PD of 61 instead of that patient's actual PD of 56. She said neither of these ever seemed right.

So, feeling really bad for this lady who's never had a proper pair of glasses made for her, I'm determined to solve the problem. She does not want to go back to the doctor again because she wrote the Rx wrong and billed her for a followup appointment the following week just to check the Rx (which ended up to be wrong anyway). She seems happy with my refraction, but I am thinking I am missing something. Maybe she does need some type of prism? Maybe it's just a wave in the left lens? Maybe it's the type of progressive? I told her I'd remake the lens in a different progressive (I am thinking the SolaONE - I like this one for a larger reading area), but before I do I wanted to check with some of you experts out there who may have an opinion, or if you could recommend a doctor that really knows how to do prisms in New York City.

Thanks for your help!!!

Why dont you trial frame her with near correction only and confirm it is indeed the lens design before remaking it?

EDIT: I noticed you bumped the rx up -0.50 OU, were you able to Red/Green? considering her possible condition she may read much more comfortably with the extra plus in the near to accommodate for her lack of convergence.

Good luck,

Ibrahim

Yes, already trial framed the near. The Rx seems good. Also, I'm just an optician, I don't have an exam chair. Her old Rx was a little higher, I think a -6.00 sph OD.

keep in mind the original BO prisms were negated by the 5mm too wide PD. It seems whomever made her original glasses may have been try to keep the reading area wide for her lack of convergence at the near without inducing prism in the distace.

Good luck with your search :cheers:

Seems that she has NEVER been happy with PAL -'s and i have had many pt with prism - that i have found - some have expectaions that are not realistic - in any pr of glasses - never mind in a pr of PAL's

Maybe you should try to just make her a pr of SV - with the prism - and see if she is even happy with that ?
my guess is that it will be a 50-50 shot - when she will return and have no probelms -

I have also found that when i have tried to trouble shoot - issues - and have not explained to the pt - but dup'ed the old rx - and had the pt try it - they are even so - so with that -

I have also had od-mds - state " dup prism" = and they give me a new rx - and they seem to forget that as the power changes - so does the amnt of prism - so therefore they should not take the easy way out - and say dup' it -
I have learned to contact the doctor - and expalin to him - what is going on - and ask that they actually DO A COMPLETE EXAM - ( which the pt has usually Paid for anyways ) - and fine tune the prism - and actually perscribe it -

I also have been wearing prim - for the last 10 yrs - and although it has changed after each of the 3 strabismus surg.- every time - they trial framed me - they had me spin the side dials - on the trail frame - to tune in the prism - at the axis - i felt most comfortable - and let me tell you - 10 degrees - one way or the other made a huge amount of differance - and there where many times - they had to back off the power or increase the prism diopters - to get it to work well- with out a pulling cencation -

BTW - i had 1 prism - pt that was havign issues with her pals - in her reading - and I WAS able to SPIN THE PAL - OFF AXIS - ( can't remember if i blocked it rotated up or down in the nasal - BUT IT DID THE TRICK - so know on - i always make her Varilux COMFORT's with the pal ( seg placemnt ) - off axis -

Dear Original poster,

1. Overall prism on a PAL is risky business.
2. The prism may have been prescribed with the near PD in mind and by design
3. If she has 3 BI overall ground originally and she has a IPD< PD , then she is probably getting an additional 2.5-3.0 BI for a total of 5-6 BI OVerall. If the 5-6 is too much for her she will actually try to converge and may not be able to do so.

Quote:

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Originally Posted by braheem24

keep in mind the original BO prisms were negated by the 5mm too wide PD. It seems whomever made her original glasses may have been try to keep the reading area wide for her lack of convergence at the near without inducing prism in the distace.

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Bingo. I'm not an OD, but I stayed at a Holiday Inn Express once.

Without the benefit of knowing her old Rx, how many years she was wearing it, what her occupation and hobbies are it would be difficult to answer your posting. I will tell you that changing the wearing PD more than 1 or 2 mm from the last spects, dropping out all the past prism and increasing the DV RX without compensating the DV increase for the NV Rx (assuming they were asymptomatic) have all the signs of multiple re-do's and an unhappy patient.

This is a total mess. Where to start to disentangle all this?

You don't! Send her to Jeffrey Cooper, O.D. at SUNY. The guy's among the best. He'll get it straightened out, and then send back to you.

Seriously, you diagnosticians out there:
1.) Refraction cannot be done without regard to accommodation
2.) Accommodation cannot be determined without regard to EOM status.

You're wasting time and money trying to put patches on things. Stop it.

Rx with BO prisms came from a doctor at Dr. Cooper's practice. Not only did the doctor bill her a second time a week later because just because the doctor wanted to double check the Rx, after all that the doctor wrote the axis wrong and I didn't catch it until after the customer had been wearing them a week! As an optician in New York City without an optometrist in our store, I find myself correcting a lot of prescriptions from MDs so I feel pretty comfortable doing it. We even have one MD who does the entire refraction from a trial frame! But I work in an area where my customers would rather see an MD because they "want the glaucoma test," and think optometrists aren't real doctors, meanwhile I end up fixing the prescriptions...

Anyway, I digress. As for the customer, I sent her to SUNY to see Dr. Wren. Her appointment is in 2 weeks. I'll keep you posted.

This is treated w/BI, not BO. There is no "intermittant" exophoria. That turn is used to differentiate an differentiate intermittant from constant tropia. Offsetting the horizontal optical center in a minus lens (i.e. setting it greater than the pt's PD) creates BI prismatic effect, which may have been the RXg OD's intention. Also, some PALs may create enough induced prism to cause asthenopia. Is her problem near/far? Is it strain vs. blur.

But I agree, she needs to be evaluated by, perhaps another OD. Her BV/accommodative status needs to be evaluated thoroughly for convergence insufficience. Ususally high myopes can be relieved of this just by using their minus powered lenses. This stimulates accommodation and causes the eyes to converge. However, in a presbyope, this can cause significant near blur if over minused. This really needs to be evaluated by an OD. Get a second opinion even if she must pay for it.