anisometropia pal

[tolpuppy]

I have a patient (amblyope ) 60's presented with new rx currently using contacts and using progressives when not in contacts.

rx is +2.00 -1.25 x 090
+6.00 -2.50 x040

va 20/25
20/30-2

complained of swim in progressives/nausea

described slab off and reccomended st 28

at dispense patient complained with intermediate distance

remade in 7x28 slab

now patient complains that they hate the lines and can't see upclose!

I've decided that slab probably wasn't the best idea since he is had never had it and is probably supressing at near. I will remake these one more time but wanted advice on progressive to choose.

I am considering definity short. fitting height is 19.

any other suggestions on pal for this very challenging situation would be appreciated!

Thanks!

[braheem24]

You've got 3 diopters of Anisekonia to overcome (spherical equivalant) as well as a prism imbalance in ALL maridians not just vertical.

First, can the patient tolerate the Anisekonia in the distance?

Using an 8 base for the OD while using a 6 base for the OS to further reduce the image size.

If the image size issue is resolved I would use the smallest "B" and "A" measurements possible to fit a progressive to ensure the least amount of vertical imbalance at the distance as well as near horizontal imbalance from the peripheries.

Another trick would be to place the OC in the optical center of the "B" measurement to reduce vertical imbalance. Ideally you would want that to match the patient OC also if possible.


Good Luck :cheers:






You'll need it :p

[Robert Martellaro]

I have a patient (amblyope ) 60's presented with new rx currently using contacts and using progressives when not in contacts.

rx is +2.00 -1.25 x 090
+6.00 -2.50 x040

va 20/25
20/30-2

How many hours per day are the glasses worn. Are near and/or intermediate tasks frequent and extended.

complained of swim in progressives/nausea

How many days has he used them. What was his previous PAL design, if any. Note any changes in Rx, especially the Add power.

described slab off and reccomended st 28

Were the previous multifocals segmented. Was there discomfort when the old multifocals were used for near tasks.

at dispense patient complained with intermediate distance

Are the intermediate tasks infrequent (speedometer) or frequent (computer). How has the intemediate vision been corrected (contacts or glasses) heretofore. Note changes in Rx, especially the distance.

remade in 7x28 slab

now patient complains that they hate the lines

A real possibility when segmented multifocals are introduced for thr first time.

and can't see upclose!

Subject is reading through the trifocal (seg height low). Add is to strong. Prism is incorrect.

I've decided that slab probably wasn't the best idea since he is had never had it

What has he had before?

and is probably supressing at near.

You can check, but with this VA he's probably binocular.

I will remake these one more time but wanted advice on progressive to choose.

I am considering definity short. fitting height is 19.

any other suggestions on pal for this very challenging situation would be appreciated!

It depends on your answers to the above. If he's a reader, then you might have to go short, but then there's more swim, but the VI is reduced, but if he uses a computer and won't wear separates then the short will reduce posturing, but the distance vision (mostly the periphery) will suffer, but if the CLs are for social and sports and he's not an avid reader then go long, with the option of separate readers if necessary- and so on.

This is one of the most challenging RXs to fill, not because so much can go wrong, but that so much can be right and still go wrong.

[Happylady]

deleted

[tolpuppy]

How many hours per day are the glasses worn. Are near and/or intermediate tasks frequent and extended.

complained of swim in progressives/nausea

How many days has he used them. What was his previous PAL design, if any. Note any changes in Rx, especially the Add power.

described slab off and reccomended st 28

Were the previous multifocals segmented. Was there discomfort when the old multifocals were used for near tasks.

at dispense patient complained with intermediate distance

Are the intermediate tasks infrequent (speedometer) or frequent (computer). How has the intemediate vision been corrected (contacts or glasses) heretofore. Note changes in Rx, especially the distance.

remade in 7x28 slab

now patient complains that they hate the lines

A real possibility when segmented multifocals are introduced for thr first time.

and can't see upclose!

Subject is reading through the trifocal (seg height low). Add is to strong. Prism is incorrect.

I've decided that slab probably wasn't the best idea since he is had never had it

What has he had before?

and is probably supressing at near.

You can check, but with this VA he's probably binocular.

I will remake these one more time but wanted advice on progressive to choose.

I am considering definity short. fitting height is 19.

any other suggestions on pal for this very challenging situation would be appreciated!

It depends on your answers to the above. If he's a reader, then you might have to go short, but then there's more swim, but the VI is reduced, but if he uses a computer and won't wear separates then the short will reduce posturing, but the distance vision (mostly the periphery) will suffer, but if the CLs are for social and sports and he's not an avid reader then go long, with the option of separate readers if necessary- and so on.

This is one of the most challenging RXs to fill, not because so much can go wrong, but that so much can be right and still go wrong.

Great Questions!
Patient had previous progressives three years and said that they made him nauseated to walk or drive in them and that he did not want progressives again. Rx change was truly minimal. He wanted lined bifocals and had never had slab off before. When I explained what the slab off was used for he said that letters did tend to run together after he read for a while. When he picked up glasses he immediately noticed the intermediate vision loss. Hence the remake into trifocals fit at base of pupil. I have since learned, (not from patient) that he has had trifocals before. (previous to progressives- they were not slabbed)

Patient wears contacts most of the time. wears glasses in the evening at home.

Patient picked up glasses wearing his contacts and would not take them out to try glasses. Patient Called several days later said distance was clear but reading was not. The glasses checked correctly. I felt that some minor adjustments would probably have taken care of near vision but patient said he "hated the lines" and new glasses were heavier etc. There seemed no point to trying to make these glasses work as buyer's remorse was clear.

I could not see the progressive identifying marks clearly. previous optical provider said they used Nikon progressive but did not know which one.

Thanks for your input!

[Happylady]

He sounds like nothing is going to make him happy. He wants vision in his glasses like he has with his contacts. It isn't going to happen. :(

[john-atlanta]

Don't overlook monocular near PD measures. We have a pt who had a similar differential and we discovered that she had less convergence in one eye.

The lab optician then worked with the variable inset to account for that and patient was much happier.

With that kind of Rx, I would be cautious of a short corridor, due to it's compromise of the distance, unless they never wear them out of the house.

J

[optiboarder]

You've got 3 diopters of Anisekonia to overcome (spherical equivalant) as well as a prism imbalance in ALL maridians not just vertical.

First, can the patient tolerate the Anisekonia in the distance?

If his Rx is the result of axial lenths-pt. will not experience aniseikonia. Usually aniseikonia happens if difference in Rx is the result of post-trauma or cataract Sx in one eye.

[tolpuppy]

Update,

I fit patient with physio, poly,ar in a very small (46 eye) round frame. No slab.

Patient loved them! It's been two weeks since dispense so I almost feel safe now. :)

Go figure!

[Uncle Fester]

Update,

I fit patient with physio, poly,ar in a very small (46 eye) round frame. No slab.

Patient loved them! It's been two weeks since dispense so I almost feel safe now. :)

Go figure!

Third times a charm! Just curious. How high were they fit and did you notice how much prism was in the near?

[kk636]

just a question...will the current free form lens will be more benefit for the pt such as Rodenstock impression which it will cauculate the Pt prescription to optimize the vision?

[brucek]

I would adjust base curve------use a as worn in PD if he is eso or exo when you take a mono PD his eye will straighten out also use a free form lense with the shortest corridor ie: seiko succeed WS 11 also keep prism thining to a min or check old progressive to srr how much thinning and match

If he wears contacts does he not complain about inter missing I would think he is used to not seeing inter