Need help troubleshooting my Mom's progressives

**Happylady** · 08-08-2006, 12:58 PM

My mother has always been nearsighted but had cataract surgery last fall and now has only a little astigmatism correct in the distance. She had the Restor lens but needs correction for near if the light is not good.

I had make her some new lenses in the Hoya Wide(which she had been wearing) with a +2.50 add in her own frame and she was doing fine with them but still had some trouble with very fine print.

Well, she lost her glasses. She got another exam and the distance is similar but we increased her add to a +3.50. She liked it in the trial frame. I changed her from cr-39 to Trivex but used an identical frame and same PD, fitting height(18), and progressive.

She can't read with her new lenses. They are a +3.50 but when I read the power I have trouble reading the full add power thru the reading circle especially on the right lens. But even if the reading is weak she could read better through her +2.50's she lost.

I am wondering if the reading area is just too small with a +3.50 add However, even through the very bottom of the lenses she said it was blurry. She had a +3.25 add before her catarat surgery but since she was nearsighted the actual reading area was still a minus, now it is a plus.

We are rechecking the rx in a couple of days. When I trial framed her again she says her distance in her right eye is not as clear as her distance in her left eye.

Any ideas? Should I go back to cr-39? She had 1.7 in her glasses before her surgery.

She is getting by with some readers with a +2.50 but she doesn't like how they blur the distance.

**Ory** · 08-08-2006, 01:40 PM

Is she actually bringing her reading material in 10 cm closer? By upping the add you must decrease the reading distance. Include that she's got a Restor lens and she may be dealing with an even larger add. I'm not sure giving her that much add power would be necessary. Keep in mind if there is other pathology present then what I just wrote may be of no use anyway.

**chip anderson** · 08-08-2006, 02:04 PM

Put a -1.00 flipper over glasses and ask her if she can read better, if so problem solved. You might also experiment similarly with -0.50 flipper.

**Robert Martellaro** · 08-08-2006, 02:35 PM

The focal length of a +3.50 add is about 11", a +2.50 add is about 16", and might be slightly less due to the multifocal implant. The first thing I would do is to make sure she's holding the object about 5" closer than she did with her previous pair.

The PAL your using is probably not achieving its full add until about 18mm, and if your fitting height is 18mm then the field of vision is essentially zero. That's probably not the problem here, but I'd like to see a +3.50 add PAL at 22mm.

Consider half glasses or ST28s for extended close tasks, and magnifiers for the smallest objects. Experiment with different types of reading lamps for increased contrast.

Regards,

**Happylady** · 08-08-2006, 03:14 PM

Thanks for your imput.

I did have her bring the material in closer and that didn't seem to help. She has been wearing the Hoya Wide at 18 high for several years, I realize deeper would be better but it was fine before.

She really likes progressives and wants to stay with one. A second pair is an option, though.

Does anyone think that a +3.50 is just making the reading area too small? Since I had trouble getting the full power in the reading circle(though the lenses were marked with a 350), could there be a defect in the lenses perhaps?

I get one free dr's change and I don't want to blow it!

**chip anderson** · 08-08-2006, 03:27 PM

One never sees an aphakic patient that needs over a 2.50 add unless they have macular degeneration or some other retinal disturbance. Almost always when I get Rx's on an aphake (or pseudophake) with an add over 2.75 the patient ends up seeing the doctor again for a "re-evalluation and comes back with a revised add of 2.50.

Chip

**Happylady** · 08-08-2006, 03:54 PM

Originally Posted by chip anderson

One never sees an aphakic patient that needs over a 2.50 add unless they have macular degeneration or some other retinal disturbance. Almost always when I get Rx's on an aphake (or pseudophake) with an add over 2.75 the patient ends up seeing the doctor again for a "re-evalluation and comes back with a revised add of 2.50.

Chip

Thanks Chip, that is very interesting. I wonder. The eye surgeon mentioned "cell changes" in the back of the eye and was only able to correct her to 20/40. I was surprised that the OD I work for was able to correct her to 20/25 and said she didn't see any problems in the back of the eye. However, my mom declined to be dialated.

She can read fine in very good light, but in dimmer light she has a problem. I trialed framed her with a +2.50, +3.00,+3.25, and +3.50. This was in very good light and she liked the +3.50.

The doctor orginally came up with a +2.50 add but said my mom might perfer stronger in dimmer light. She okayed the +3.50 add.

**Robert Martellaro** · 08-08-2006, 05:07 PM

Originally Posted by Happylady

Does anyone think that a +3.50 is just making the reading area too small?

No doubt, especially at 18 high.

I get one free dr's change and I don't want to blow it!

Then I would follow Chip's advice and keep the add at +2.75, and make a separate pair with the bumped add in a pair of half readers or STs.

I hope your mom's retinas stay healthy.

**Happylady** · 08-08-2006, 05:09 PM

Originally Posted by Robert Martellaro

No doubt, especially at 18 high.

Then I would follow Chip's advice and keep the add at +2.75, and make a separate pair with the bumped add in a pair of half readers or STs.

I hope your mom's retinas stay healthy.

This sounds like good advice. I'll let you all know what the doctor says on Thursday.

Do you think I should switch her back to cr39? I went with Trivex for the lightness and good optics but of course nothing beats cr39(except glass).

**chip anderson** · 08-08-2006, 05:10 PM

No I don't think +3.25 is making the reading area too small, I think it's making it too close and causing over convergence. Would do the same in a straight top..
Go back to 2.50 or 2.75 and buy her a good reading lamp if the flipper-over-glasses test works out.

Chip

**hotsauce** · 08-08-2006, 07:51 PM

Originally Posted by chip anderson

Put a -1.00 flipper over glasses and ask her if she can read better, if so problem solved. You might also experiment similarly with -0.50 flipper.

Seconded. I'm still often surprised at what a +/- 0.25 will do for patients.

**Ory** · 08-08-2006, 08:03 PM

Without dilating you really can't get a great assessment of the RPE. Refracting someone to a shaky 20/25 or a firm 20/40 can sometimes be one and the same. Sounds like there is some limiting factor for her vision and that is why a higher add is helpful.

Regardless, if you're having the rx rechecked just wait for those results. Then decide what to do.

And not to be too big of a pain, but I really don't see how this post is much different than a consumer post asking for advice. Sure, happylady is better educated than the average consumer but it is still asking for specific advice for a specific patient.

**Happylady** · 08-08-2006, 08:34 PM

Originally Posted by chip anderson

No I don't think +3.25 is making the reading area too small, I think it's making it too close and causing over convergence. Would do the same in a straight top..
Go back to 2.50 or 2.75 and buy her a good reading lamp if the flipper-over-glasses test works out.

Chip

Except she liked it in the trial frame.

**chip anderson** · 08-08-2006, 09:04 PM

Happy:
I don't know how long you have been in this business but when you are old and tired you will find a lot of people that find thier "likings" and the doctor's "findings" to be somewhat different when they leave the exam room. While I recognise the value of dilation during the exam and optometrists concider this to be the holy grail now that they have gained this tool, many people don't see the same in an undilated condition in a well lighted room. What was great in the dark while dilated may not be what they "like" in real world conditions.

Chip

**Happylady** · 08-08-2006, 10:32 PM

Originally Posted by chip anderson

Happy:
I don't know how long you have been in this business but when you are old and tired you will find a lot of people that find thier "likings" and the doctor's "findings" to be somewhat different when they leave the exam room. While I recognise the value of dilation during the exam and optometrists concider this to be the holy grail now that they have gained this tool, many people don't see the same in an undilated condition in a well lighted room. What was great in the dark while dilated may not be what they "like" in real world conditions.

Chip

Chip, I have been in this business for over 25 years but hopefully I am not old and tired yet. :) I agree completely with the above statement, but I am confused by it. I don't understand how it relates to my mom.

**chip anderson** · 08-09-2006, 07:40 AM

Happy: Because you said: "But, she likes +3.25 in a trial frame." See what she likes over her finished glasses as they are ready anyway.

**Happylady** · 08-09-2006, 10:39 AM

Originally Posted by chip anderson

Happy: Because you said: "But, she likes +3.25 in a trial frame." See what she likes over her finished glasses as they are ready anyway.

I will.

**Robert Martellaro** · 08-10-2006, 12:32 PM

Originally Posted by Happylady

Do you think I should switch her back to cr39? I went with Trivex for the lightness and good optics but of course nothing beats cr39(except glass).

Trivex will be fine.

I just noticed that the Hoyalux ID is available in a +3.50 add. It might be worth considering if your mom is strongly resisting multiple pairs of eyeglasses. I would also investigate the feasability of reducing the add power.

Regards,

**Happylady** · 08-10-2006, 08:50 PM

She came in today for a recheck. The distance was increased +.50 on the OD and the left was unchanged. We lowered the add to +2.75. I also changed her back to plastic. Trivex might be fine, but with her RX the plastic works well.

I hope this takes care of it. Thank you everyone for your imput. It is very much appreciated!

**FVCCHRIS** · 08-11-2006, 02:02 PM

Sounds like a good plan. As much as I like Trivex myself, I think when a patient has a problem adjusting to something new you have to take into account all the "changes" that were made. Trivex was one of those and even though I think it's great stuff your mom may not. Good luck!

**Happylady** · 08-11-2006, 02:35 PM

Originally Posted by FVCCHRIS

Sounds like a good plan. As much as I like Trivex myself, I think when a patient has a problem adjusting to something new you have to take into account all the "changes" that were made. Trivex was one of those and even though I think it's great stuff your mom may not. Good luck!

That was what I was thinking. She was fine before with regular plastic, they weren't heavy, so I decided to go back to it. Probably it wouldn't make a difference but you never know.

**k12311997** · 08-12-2006, 08:22 AM

I don't have any new or different advice to offer and it seems as you have decided on a plan of action but I am intrested to know the outcome please post when your mom gets the remade glasses. Thank You

**Happylady** · 08-27-2006, 06:52 PM

I just wanted to add an update on my Mom's glasses. The distance correction was tweaked and the add was lowered to +2.75. I changed her back to standard plastic. She is happy with the glasses and can read well with them.

Thank you everyone for all your advice and help. It was very much apreciated!