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Thread: Feedback....I need feedback...Gimme Feedback!

  1. #1
    Master OptiBoarder Alan W's Avatar
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    Feedback....I need feedback...Gimme Feedback!

    Our robot friend Short Circuit (aka: Movie Title) said it better than all of us. For a clinician (Thats us!) to really know if the progressive lenses are fitted and positioned optimally, it is necessary for us to get some form of information, one that can be evaluated, measured, and used to base further adjustments on, etc. Refractionists have come a long way since the "Which is better, A or B" days. But, for those of us who have to fit the lenses, there isn't a whole lot out there that gives us that information, immediately and interactively. We get tons of statements from manufacturers touting their front, back, up, down and sideways designs. Personally, I don't think most of that stuff is worth a hoot unless and until the patient says: "Oh, yes . . . that's better. I don't see the _____ like I used to. Or....... "I'm seeing thus and such with these new lenses.....what can you do to get rid of that?" In fact, using a graphic feedback method, we can actually "see" what the patient sees....and can change things in whatever necessary way, to alter the response to the benefit of the wearer.

    What we do know is that the patient sees "stuff" we don't see, and if that "stuff" isn't right . . . we have little language we can give them that will describe it.

    In other words . . . we have a limited "language of feedback" that we can "teach" a patient that will tell us what we need to know. I was taught a method of diagnosing progressive fit that was excellent and worked well. It gave the patient an opportunity to tell me what he/she sees in such a way that not only could I correct the fit, but also get a defineable and measurable indication of what he/she is experiencing that I could use to base my decision on to make adjustments/fit, etc. We nick-named it a "TFA" or tangential field analysis. And, it actually gave both me and the patient something to look at that told us both what needed to be done. If anyone wants it, I'll do a write up or something and upload it. The technique goes back 35 years and I learned it from a Swiss optician friend. We didn't have computers and video stuff to work with in those days. But, it's your turn to teach us your techique. Maybe you can teach others things like . . . .

    How does the patient describe what's happening if, while looking through the glasses, one progressive seg is higher in front of the eyes than the other?
    How does the patient describe his visual experience, when the sagital distance of the respective lenses is not "right"? How does the patient tell you, while wearing the glasses, that the height of the segs is "right"?
    What if the PD is not "right"? What are the indicators?

    And, notice that I use the word "right." Often in terms of measurements, you can stand on your head til your ears turn red . . . . measuring and signing your life away based on the pupillometer, dots, etc. But, when it's "right" the patient knows it . . . because he knows it when they are NOT RIGHT. What's WRONG with that? But, how does he tell you in a defineable and measurable way through his feedback? And, are you "tuned in" to the nuances, grunts, ahhhs, and oooohs and other body language that makes measurements less reliable than an errent head thrust?

    Those of us "old dudes" have learned that no matter what the rep tells us and the so-called lens designers lead us to believe . . . the proof of the pudding is through the patients eyes. Not ours . . .not the manufacturers.

    Technique is a wonderfull thing. It is the positive proof that somebody is on the ball with his way of doing things. And, that needs to be shared. The bottom line of it all is to fit lenses and eyewear in order to provide Clear, Comfortable, Single, Simultaneous, Binocular vision. And, with respect to progressives . . . how do YOU do that?

  2. #2
    Master OptiBoarder optigrrl's Avatar
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    How does the patient describe what's happening if, while looking through the glasses, one progressive seg is higher in front of the eyes than the other?
    How does the patient describe his visual experience, when the sagital distance of the respective lenses is not "right"? How does the patient tell you, while wearing the glasses, that the height of the segs is "right"?
    What if the PD is not "right"? What are the indicators?
    Not being formally trained in the physics of optics, I have had to learn things the hard way. Basically, I have learned the art of communication - aka: Infomation Extraction.

    It goes kinda like this:

    Pt: "Something's not quite..right."
    Me: (looking puzzled) "Hmm. Can you be a little more specific?"
    Pt: "I dunno. Just ... not right."

    This is where I go into the "20 questions" discovery mode.
    - Is it in the reading?
    - Is it in the distance?
    - Is it better in the left or right eye?
    - Look at this reading card - move your head around until you can read line 4. Hold that position. (note head position)
    - If you pull the card closer/farther do the words come into focus?
    - How many letters can you see clearly at a time without moving your head?
    -Stand up and read that sign outside. If you move your head down, does it get clearer? How about if you move your head up?
    - Do you feel a "pulling" sensation in your eyes?
    - Do you have any physiological conditions with your eyes that may affect your vision? (AMD, cataracts, retinal probs, diabetes, dry eye, etc.....)
    - May I see your old glasses (check segs, pd's, bc's material, so on...)
    - If I (place uncut spherical lens + or - .25, .50 or even .75) over eyes is this better/worse?

    I was told rule-of-thumb is:
    Verify rx, segs and pd's ordered on new lenses before dispensing.
    Check pd in old lenses. Check measurements in old lenses. Check adjustment in old frame.
    Lay out measurements on new lenses - check them on pt.
    If pt. feels swim in periphery, try face-form
    If pt. feels reading area too small, try panto
    (After checking measurements):
    If pt. gets clarity in dv only if they put their head down then: try putting more minus over their lenses to see if that helps
    if pt. gets clarity in di only if they put their head up: then try putting more plus over their lenses to see if that helps

    Learn as much as you can about progressives' designs. Which ones are the cleanest above the 180, which designs have the least induced prism, who has the wider intermediate and reading corridors. Which designs are aspheric or spherical. How many base curve options (which ones best fit your pt.'s rx)?

    Some adjectives I use as prompters are:

    swim, tunnel-like vision or small area of vision, blur, pull, fatigue, eye-closing and periphery.

    Contour plots have been a girl's best friend. Collect all you can. I have compiled my own "special" list of PAL designs and by trial and error and constant questioning I now have a fair idea of which conventional designs work well with certain rx parameters and lifestyles.

    And although I hate to admit it because it is stereotyping, I can also sense personality traits that lean towards success or failure in a PAL.

    I now have an almost (ALMOST) zero non-adapt ratio that I have to attribute to communication and product knowledge. I still embrace the challenge of converting engineers from lined multifocals, though! Just kidding, no really - I understand the advantages and limitations of progressives (finally), and I try to make a point to take into consideration the rx changes since their last lenses were made (and how that affects pal designs) and combine that with their needs/wants/desires and eyewear uses to try and come up with a solution as best as I can.


    ...Ouch my fingers! I think I have typers' cramp!

  3. #3
    Master OptiBoarder
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    OPTIGRRL-great reply!

    I really think that we have to become detectives. Watch body language, head motions, blinking etc.. I am careful with questioning. I do not want to "lead" the patient in a certain direction. Experience is really helpful. Sometimes you can just tell whats wrong.

    Fezz
    :cheers:

  4. #4
    Bad address email on file Grubendol's Avatar
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    opti, that's exactly how I approach it too.

    We're Optical PI's. The Sam Spades of Optical.

  5. #5
    Optician Extraordinaire
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    Optigrrl, great reply. This is basicly what I do, too. I also double check that the prescription was written down correctly.

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