Solve this problem!!

[soumya]

I'm a fresher in this industry and got the first practical problem in the field of dispensing. So, I thought of starting a new thread for the people like us. My problem is,

I've dispensed a patient, aged 52, female, with CR-D BIFOCAL with ARC. Patient has returned with the complain of "getting head-ache within 5 minutes after wearing the new glasses". Her data was as follows:

OLDER Rx: OU: +1.00 ADD: +2.25
OLDER LENS: CR-D without ARC fitted in frame with 18mm 'B'
SEGMENT WIDTH: 31mm
NEAR PD: 61MM

NEWER Rx: OD: +1.00/+0.50 X180 OS: +1.25 ADD: +2.50
NEWER LENS: CR-D with ARC fitted in frame with 30mm 'B'
SEGMENT WIDTH: 28mm
NEAR PD: 58MM
Patient's DISTANCE PD: 62mm

Patient has a mild Exophoria in near and distance.

I request seniors to kindly provide your valuable suggestions to solve this problem. Thanking you in anticipation,

Regards,
Soumya

[mike.elmes]

Sounds to me like she is over plussed....lose the +.50 cyl. Go back to the +1.00 OU distance and use the +2.50 add.

[chip anderson]

Gittin too much light due to ARC. Feels was over charged due to add on for ARC, trying to find a way for refund after he feels he was overcharged for useless Add-on.

Chip

[nickrock]

This could be so multifaceted, or it could be a simple adjustment. I would guess by the information provided that it is neither the extra quarter of plus or the ARC but rather the discrepency in PD measurments. Now since we don't have the dist. PD from old glasses we could assume that it is 64 or 65 based on near. If the pt.'s actual PD is 62 this would cause induced BO (base out not body odor). I would say this is probably unlikely, since an exophoric pt. would probably not tolerate BO very well. OR, it could be that pt.'s PD is actually 64-65 and new lenses are 62 and inducing BI. If anything an exotropic pt. might prefer this but not as likely an exophoric. I would recheck all measurments. Sorry, after all that I don't actually know what the problem is, but again I think it is the measurements. AR, refraction, and exotropia are most likely not contributing factors.

[gemstone]

Gittin too much light due to ARC. Feels was over charged due to add on for ARC, trying to find a way for refund after he feels he was overcharged for useless Add-on.

Chip

Right on Chip!

[Snitgirl]

How long has she had the old RX?

What was the exam date on the new rx prescription?

How were the PD's taken?

[DocInChina]

I've dispensed a patient, aged 52, female, with CR-D BIFOCAL with ARC. Patient has returned with the complain of "getting head-ache within 5 minutes after wearing the new glasses". Her data was as follows:

OLDER Rx: OU: +1.00 ADD: +2.25
OLDER LENS: CR-D without ARC fitted in frame with 18mm 'B'
SEGMENT WIDTH: 31mm
NEAR PD: 61MM

NEWER Rx: OD: +1.00/+0.50 X180 OS: +1.25 ADD: +2.50
NEWER LENS: CR-D with ARC fitted in frame with 30mm 'B'
SEGMENT WIDTH: 28mm
NEAR PD: 58MM
Patient's DISTANCE PD: 62mm

Regards,
Soumya

Before you start re-making glasses test the patient with trail lenses held over the new glasses as well as the old glasses. This is how I would start your investigation:

New glasses: (assuming the patient is getting headaches when viewing both distance and reading). Have the patient wear the new Rx and look into the distance only until they start to feel the "pulling" sensation or beginnings of a headache. Once this occurs hold the following over the new Rx and see if these symptoms lessen

Trial Lens #1 when distance viewing: OD +0.50 cyl X 90
OS -0.25

If the symptoms lessen then the new DV Rx is one of the culprits. If the symptoms do not lessen, then the DV Rx is likely not the culprit. Could likely be attributed to wearing PD and/or AR.

Next test the near symptoms with the new Rx:

Trial Lens #2 when near viewing: OD +0.50 cyl X 90
OS -0.25

Again see if the symptoms lessen and if the clarity/comfort level for reading improves.

If so, try one more set to see if this is an improvement over the #2 trial lenses when the patient is reading:

Trial Lens #3 when near viewing: OD -0.25 Sphere +0.50 cyl X 90
OS -0.50 Sphere

and see which trial lenses (#2 or #3) were most comfortable over the new Rx.

Once you have this answer you are in a better position to re-make the glasses to match the old wearing PD. You should also try to match the base curves when you re-do and likely eliminate the AR.

If you would like to go the extra mile you could the do the following:

With the old Rx when the patient is viewing distance:

Trial Lens #4 when distance viewing: OD +0.50 cyl X 180
OS +0.25

If this starts to illicit headaches then this confirms the new DV Rx was the culprit.

Trial Lens #5 when near viewing: OD +0.25
OS +0.25

The last set of trial lenses will determine if their is any appreciable improvement (in vision or comfort) from the old Rx. Test to see if there is a loss or working distance as well. Some people habitual reading/ working distance is further than 16" and adding a small amount of plus could create discomfort.

Good luck,
Doc

[chip anderson]

As far as add power I have seen prescribers who went to elaborate lenghts to determine this, even those that wrote +cylinder for one eye and - cylinder for the fellow. Those who wrote differing add powers.
Then there were the older more experienced ones that detemined add powers by age and patient's height (translation arm lenght) alone, always (except for unilateral aphakes) with the same add power for both eyes.
Some exceptions for those with low vision problems, but for the run of the mill healthy patients this was the standard.
The latter group had more happy patients with many less complaints and re-makes.
Seems we don't take the patient's arm length into conciderations into concideration at all. Short people hold the reading material closer, tall people hold it further away. The myope that has been presbyoptic but reading by removing their glasses, is used to reading closer(usually) and will have trouble to adjusting to new distances.

Just observations by an old man ignorant of the newest gourd shaking theories. You can ignore this if you like.

Chip

[HarryChiling]

I would start with an ocluded PD, measure th frames DPD and NPD measure the OC height most FT's are ground with the OC splitting the B which means that if the B size is larger in the new frame, the eye will need to rotate further than in the old pair which could be a culprit. To correct this just match the OC to the old pair. Just from experience I always question scripts that are written in (+) cyl, with the axis in 5 and 10 degree steps. To me I often read between the lines this could mean an ophthalmologists Rx and they commonly employ technicians to do the refracting, the 5 to 10 degree steps can sometime mean that the tech didn't refine the Rx to the correct axis. I usually in a case such as this offer the patient to see our in house dr. for a refraction. In this case matching base curves wouldn't hurt since the Rx is so similar to the old rx that it would probably fit on the same or similar base any way, but usually I find that matching base curves is often a fools errand. (Most often uswed by doctors as a bandage to a problem they don't feel like bothering with). If the Rx changes and you match the base curve you are introduceing oblique errors in both the tangential and saggital meridians which make things worst by coupleing you original problem with another. Start with verifying the Rx, then verify the measures, then use corrected curve lense. I think once you cover the bases it shoulg all work itself out.

(My first guess is OC to seg OC mismatched, my second would be a bogus script)

]Ood luck let us know how it turns out.

[bt5050]

wanted to know - your feelings on matching BC's in general -
I understand in this case - we are dealing with a FT - but - when we are dealing with a PAL - do u also try to acheive matching the old BC / ?

I have one OD - that alwasy has the remarks - MAtch BC - I know this is intended usually to say - DO WHATEVER you have to so this PT does not come back - and take up more chair time -

BUt what are your feeligns when workign with PALS ? - I was alwasy under the assumption form the vendors that it is MORE important to use the recomended BC - for the specific lens - and not take the OLD wearing BC into consideration - since we would be doing more "Damage" by adjusting the BC - since they are lets say "optimized " for specifc powers -

and as you know - it appears they are running Flatter and flatter as the years go by - ( at least that is what i ahve seen )-

so in general when dealing with PAL's - do u go for the rec... manufacturers BC - or try to get the BC close to their own - and disregard the lens designers ?

[AngryFish]

We are all freshers in this industry so welcome aboard. I have also dispensed a few 52 year old women, but to much older men, even so they seemed to work out fine.

[DragonLensmanWV]

As far as add power I have seen prescribers who went to elaborate lenghts to determine this, even those that wrote +cylinder for one eye and - cylinder for the fellow. Those who wrote differing add powers.
Then there were the older more experienced ones that detemined add powers by age and patient's height (translation arm lenght) alone, always (except for unilateral aphakes) with the same add power for both eyes.
Some exceptions for those with low vision problems, but for the run of the mill healthy patients this was the standard.
The latter group had more happy patients with many less complaints and re-makes.
Seems we don't take the patient's arm length into conciderations into concideration at all. Short people hold the reading material closer, tall people hold it further away. The myope that has been presbyoptic but reading by removing their glasses, is used to reading closer(usually) and will have trouble to adjusting to new distances.

Just observations by an old man ignorant of the newest gourd shaking theories. You can ignore this if you like.

Chip

<shakes gourd in Chip's direction>:D
Weirdest one I had was the guy who came in and was absolutely incensed that his bifocals were set for him to read at the usual 16" or so. He was angry because he couldn't read the newspaper when it was spread out on the floor with him standing up. We asked -"You stand up to read the paper you spread on the floor?" Who could believe that. huh? "Of course," he replied, "Doesn't everyone?":hammer::hammer::hammer::hammer:

Gave him a +.75 add instead of his +2.75 and he was happy as a clam. Could not see squat at normal reading distances, but hey, he was happy.:hammer::finger::hammer:

[HarryChiling]

wanted to know - your feelings on matching BC's in general -
I understand in this case - we are dealing with a FT - but - when we are dealing with a PAL - do u also try to acheive matching the old BC / ?

I have one OD - that alwasy has the remarks - MAtch BC - I know this is intended usually to say - DO WHATEVER you have to so this PT does not come back - and take up more chair time -

BUt what are your feeligns when workign with PALS ? - I was alwasy under the assumption form the vendors that it is MORE important to use the recomended BC - for the specific lens - and not take the OLD wearing BC into consideration - since we would be doing more "Damage" by adjusting the BC - since they are lets say "optimized " for specifc powers -

and as you know - it appears they are running Flatter and flatter as the years go by - ( at least that is what i ahve seen )-

so in general when dealing with PAL's - do u go for the rec... manufacturers BC - or try to get the BC close to their own - and disregard the lens designers ?

Manufacturers suggested BC is ideal especially in PALs as the design is dependent upon the correct curve being used to give it the performance needed. The only case I use a different curve is with a wrap and even then I explain to the patient that the lenses optics will be comprimised to work in the frame. I usually ignore Match BC directions, because if the power changes then by matching the base curve instead of picking corrected curve I will be introduceing more unwanted oblique astigmatism and comprimising off axis performance. I coudl see if the Rx says match magnification or match off axis powers, but in essence match bc says the power changed so please make the center of the lenses clearer and the periphery more blurry.

[soumya]

Before you start re-making glasses test the patient with trail lenses held over the new glasses as well as the old glasses. This is how I would start your investigation:

New glasses: (assuming the patient is getting headaches when viewing both distance and reading). Have the patient wear the new Rx and look into the distance only until they start to feel the "pulling" sensation or beginnings of a headache. Once this occurs hold the following over the new Rx and see if these symptoms lessen

Trial Lens #1 when distance viewing: OD +0.50 cyl X 90
OS -0.25

If the symptoms lessen then the new DV Rx is one of the culprits. If the symptoms do not lessen, then the DV Rx is likely not the culprit. Could likely be attributed to wearing PD and/or AR.

Next test the near symptoms with the new Rx:

Trial Lens #2 when near viewing: OD +0.50 cyl X 90
OS -0.25

Again see if the symptoms lessen and if the clarity/comfort level for reading improves.

If so, try one more set to see if this is an improvement over the #2 trial lenses when the patient is reading:

Trial Lens #3 when near viewing: OD -0.25 Sphere +0.50 cyl X 90
OS -0.50 Sphere

and see which trial lenses (#2 or #3) were most comfortable over the new Rx.

Once you have this answer you are in a better position to re-make the glasses to match the old wearing PD. You should also try to match the base curves when you re-do and likely eliminate the AR.

If you would like to go the extra mile you could the do the following:

With the old Rx when the patient is viewing distance:

Trial Lens #4 when distance viewing: OD +0.50 cyl X 180
OS +0.25

If this starts to illicit headaches then this confirms the new DV Rx was the culprit.

Trial Lens #5 when near viewing: OD +0.25
OS +0.25

The last set of trial lenses will determine if their is any appreciable improvement (in vision or comfort) from the old Rx. Test to see if there is a loss or working distance as well. Some people habitual reading/ working distance is further than 16" and adding a small amount of plus could create discomfort.

Good luck,
Doc

Will u plz explain what u wanted to mean by these trial lenses? Do u want me to use, e.g. the +0.50D x90 and -0.25 D over the distance correction in case of trial lens#1 and then see what's happening? Plz clarify.
Regards
Soumya

[DocInChina]

Will u plz explain what u wanted to mean by these trial lenses? Do u want me to use, e.g. the +0.50D x90 and -0.25 D over the distance correction in case of trial lens#1 and then see what's happening? Plz clarify.
Regards
Soumya

Hold the trial lenses physically in front of the glasses that were made and alsoover the old eyeglasses.

[chip anderson]

God! Hold trials over glasses, they haven't had an O.D. or M.D. that concientious in 25 years. Hell I cann't find many that will take the effort to refract over a contact lens today even if the patient is wearing a cone or aphakic lens. What in the Hell they think I am gonna do with a spectacle Rx (especially post removal of a contact) on these patient's, I haven't a clue.

Chip

[Fezz]

The trial lenses and trial frame set is your friend!

I am looking to buy my own set, because the Docs here get sick of me "borrowing" theirs!!!

Fondly,

Lowly Trial Frame and Lens Using Optician

[f2chow]

Will u plz explain what u wanted to mean by these trial lenses? Do u want me to use, e.g. the +0.50D x90 and -0.25 D over the distance correction in case of trial lens#1 and then see what's happening? Plz clarify.
Regards
Soumya

Let's not get too crazy here. It seems like a fairly straight forward problem.

But before anything, I don't see some important info:

#1. VA's with old specs
#2. VA's with new specs.

[Bill West]

SHE DON'T LIKE HER NEW FRAME. :hammer:

[DocInChina]

God! Hold trials over glasses, they haven't had an O.D. or M.D. that concientious in 25 years. Hell I cann't find many that will take the effort to refract over a contact lens today even if the patient is wearing a cone or aphakic lens. What in the Hell they think I am gonna do with a spectacle Rx (especially post removal of a contact) on these patient's, I haven't a clue.
Chip

I was one of those OD's that did that. If a doctor doesn't do that how the heck can they correct the problem without trial and error redo's?!?!

Let's not get too crazy here. It seems like a fairly straight forward problem.

But before anything, I don't see some important info:

#1. VA's with old specs
#2. VA's with new specs.

The complaint is comfort not visual acutiy. Comfort is a better indicator of a patient accepting a prescription then clarity. (unless you have a job requiring exceptional visual acuity).

[f2chow]

DocInChina

It amazes me with your response. Would you say that a prescription and asthenopic symptoms don't correlate to eachother?

So to explain my thinking, since it obviously escapes you:

If entering acuties with +1.00 DSare 6/6, and this doc in India changed it to +0.50 -0.50 x090 ... what do you think the cause of the discomfort when wearing the new specs?? ATR astigmatism ...? You think DocInChina?? Then if entering acuties with sepcs are 6/6, and this doc increased the plus by +0.25 OS, don't you think that might affect things also? This is basic first year clinical optics man.

But again, acuties are needed to know.

[DocInChina]

DocInChina

It amazes me with your response. Would you say that a prescription and asthenopic symptoms don't correlate to eachother?

I was pressed for time and did not have more time to elaborate before. I am always happy to amaze though.

Based upon the prescriptions that were given for this patient I would attribute other factors. Do you believe there will be a one line difference in VA based upon the change from old to new RX? Based upon your reaction I assume you prescribe based upon best VA and not best comfort. This is a philosophical difference we have in practicing.

So to explain my thinking, since it obviously escapes you:

If entering acuties with +1.00 DSare 6/6, and this doc in India changed it to +0.50 -0.50 x090 ... what do you think the cause of the discomfort when wearing the new specs?? ATR astigmatism ...? You think DocInChina?? Then if entering acuties with sepcs are 6/6, and this doc increased the plus by +0.25 OS, don't you think that might affect things also? This is basic first year clinical optics man.
But again, acuties are needed to know.

Actually, I nothing you said escaped me I just disagree with your approach for this particular patient. Yes, I would check the VA's but I would not be overly focused on them in this case. When I was a practioner I examined people and prescribed based upon their needs. This included listening to their complaints and understanding the person sitting before me. When the patient is sitting there in an unreal environment we find static numbers that work in that particular environment. When the patient stands up and starts walking, turning their head and interacting with their environment the numbers change. IMHO , the answer for this patient is not in the visual acuity. I still stand by my advice on how to manage this patient. There were numerous changes made in these new glasses (prescription, wearing PD, base curves, etc) that are likely creating the complaints.

DocInChina (formerly DocInNYC)

[f2chow]

Are you truly reading what I wrote ... because essentially I am agreeing with your last post. No I don't prescribe on VAs. This is the whole point, if VAs were equaly 6/6, entering and manifest, than why on earth would you give the new Rx with ATR cyl in one eye and more plus in the other eye? But again, both our arguments are moot if the OP doesn't give us VAs. and yes, VAs are important. I would hope regardless of what year you graduated in that they taught you to always take VAs or else risk losing your licence come time for your board to review your charts.

Maybe you've never heard of asthenopia with ATR cyl ... ? I don't know .. but I know if VAs are fine with the current Rx that I'm not going to be adding anying wonky to their new spec Rx.

[HarryChiling]

Hold the trial lenses physically in front of the glasses that were made and alsoover the old eyeglasses.

In the US that's illegal in most states as it would be considered refracting. If as an optician you trial frame and the patient doesn't like what they see your only recourse is to send them back to the doc.

[DocInChina]

In the US that's illegal in most states as it would be considered refracting. If as an optician you trial frame and the patient doesn't like what they see your only recourse is to send them back to the doc.

This I did not know. I think many opticians are more than qualified to trouble shoot this kind of problem. On a side note, soumya lists his occupation as an optometrist.