after cataract surgery progressive problem

**tolpuppy** · 01-23-2009, 10:08 AM

Hi guys,

I need some input on an rx problem. I have a patient in his sixties who has completed cataract surgery in both eyes. Long term progressive wearer. New rx as follows:

-.25 -.25 x 088
+.25 -.50 x 025
+2.50 add

I fit him in Varilux Comfort 21 high. After wearing a few days, Patient complained of near vision not being clear and having to raise his head to read the paper. Fitting cross is mid pupil. After consulting with Doc, we remade and bumped the add to +2.75. At dispense I went over progressive lens design and told patient that near vision at eye leve (ie the newspaper) does require some upward head movement. He does not recall having to do this in his old pair before surgery. Patient said near vision is better but he still has to raise his head and the glasses make him dizzy when he tries to read.

Old rx:
+2.50 -1.25 x105
+2.25 - 1.00 x 090
+2.50
vision ease illumina

He is coming in for a recheck today before I remake these again. The only thing I would change on my end would be to switch to a short corridor progressive. Any ideas would be appreciated. I have not worked with the Illumina. Is it a short corridor along the lines of a Definity short? I use the Definity short a lot and like it but if it would be best to use the Illumina I would.

Thanks for any Feedback!

**chip anderson** · 01-23-2009, 10:42 AM

How tall is the patient? Where does he like to hold his reading material?
These can be important factors. If he holds reading material too high perhaps a trifocal or even a bifocal might be a better choice. Is he an eye turner or a head turner when he reads wide material (such as the newspaper)?
Lots of stuff can be going on here. Are the pupils well centered an round?
Do his glasses stay in the fitting position when worn or do they slip down his nose?
Do his head and neck move normally or his he restricted or even slump shouldered?
Check everything.

Chip

**tolpuppy** · 01-23-2009, 10:51 AM

Patient is about 5'8" and I believe he holds reading material about 18" however we will recheck that today. He also holds the newspaper close and up.
I guess when I have someone who has been in a progressive for 20 years, I don't automatically think about switching to bifocals or trifocals. It's difficult to make a patient understand why what worked for them before is no longer optimum.

To your other inquiries. he has not complained of frame slipping. I will check pupil size and shape as well.

Any info on the Illumina if we elect to remake in a progressive?

**obxeyeguy** · 01-23-2009, 10:58 AM

It's difficult to make a patient understand why what worked for them before is no longer optimum.

Its no longer optimum because of his/her new Rx. Patient was previously a moderate hyperope (+2.50 ) with a +2.50 add. Interpret magnification. Most hyperopes like at least a +3.00 add after cataract surgery if new Rx is close to the plano area.

I would max the plus in the distance, and take the add to a 2.75 or +3.00.

My opinion is that the Doc's should shoot for leaving these people still a little farsighted, about a +.75 to a +1.00. I hate it when they take them to the minus side, and so do the patients.JMHO

**tolpuppy** · 01-23-2009, 11:04 AM

I am very appreciative of the input!

Would you remake in a bifocal/trifocal or keep him in a progressive/short corridor?

**fvc2020** · 01-23-2009, 11:47 AM

Just a quick FYI, illumina is not considered a short progressive:) Why the switch to comfort?? just curious

Christina

**tolpuppy** · 01-23-2009, 12:39 PM

When I initially fit this patient, he did not bring his old glasses as he was no longer using them after the surgery. Not knowing what kind of progressive he had been in, I chose comfort having found few that had a problem switching to it.

As to the Illumina, I had heard it referred to as a shorter corridor lens on this forum because of it's 17mm minimum (though perhaps not optimum) fitting height.

**KStraker** · 01-23-2009, 04:14 PM

Did you try raising the ht or putting some retro tilt on it?

**DragonLensmanWV** · 01-23-2009, 06:46 PM

I also agree an add bump will be in order. I just had cataract surgery and went from a minus 15 to a minus .50. Yay! Now that I wear a more normal correction, with a 2.75 add I'm thinking is a bit weak. Next pair goes to 3.00 add. Remember, no accommodation at all now. I'm finding my short corridor Autograph II progressives are working really well at reducing peripheral distortion around the add.
I had only tried the Illumina once years ago but didn't care for it. Not much other experience with it.

**tolpuppy** · 01-27-2009, 08:24 AM

Thanks to all the replies to my post! The doc did a recheck and we are changing the rx to

pl
pl -.75 x015
+2.75

Apparently the +3.00 add was rejected as being too close. Patient will not switch to a straight top. I have decided to try a definity short. I'll let you know the result! We'll see...

**chip anderson** · 01-27-2009, 08:49 AM

I'm not the expert Darryl and Chilie Harry are, but I am pretty sure using a "short" with a high add will only make things a whole bunch worse.

Chip

**DragonLensmanWV** · 01-27-2009, 09:24 AM

Originally Posted by chip anderson

I'm not the expert Darryl and Chilie Harry are, but I am pretty sure using a "short" with a high add will only make things a whole bunch worse.

Chip

Not necessarily. Until I got my Autograph II, I wore some Kodak Precise Short lenses as my temporary glasses with a 3.00 add. They didn't have much intermediate width, but the reading was good and the distortion bearable.
Actually there are some people who prefer a "hard" design because to them it outlines the boundaries of the progressive pretty handily so they know when to re-center their head.
We even had good luck ages ago with the Super-No-Line, and I don't know if there was ever a "harder" design.

**obxeyeguy** · 01-27-2009, 09:41 AM

Originally Posted by chip anderson

I'm not the expert Darryl and Chilie Harry are, but I am pretty sure using a "short" with a high add will only make things a whole bunch worse.

Chip

I'm with Chip on this one. The origional lens was a comfort fit at 21mm. Why not just a regular Definity fit at 21?? You will in fact help to eliminate the patients NV complaint, but you sure will cause an intermediate one to replace it.

**Newyorkoptician** · 01-27-2009, 03:11 PM

Originally Posted by tolpuppy

Hi guys,

I need some input on an rx problem. I have a patient in his sixties who has completed cataract surgery in both eyes. Long term progressive wearer. New rx as follows:

-.25 -.25 x 088
+.25 -.50 x 025
+2.50 add

I fit him in Varilux Comfort 21 high. After wearing a few days, Patient complained of near vision not being clear and having to raise his head to read the paper. Fitting cross is mid pupil. After consulting with Doc, we remade and bumped the add to +2.75. At dispense I went over progressive lens design and told patient that near vision at eye leve (ie the newspaper) does require some upward head movement. He does not recall having to do this in his old pair before surgery. Patient said near vision is better but he still has to raise his head and the glasses make him dizzy when he tries to read.

Old rx:
+2.50 -1.25 x105
+2.25 - 1.00 x 090
+2.50
vision ease illumina

He is coming in for a recheck today before I remake these again. The only thing I would change on my end would be to switch to a short corridor progressive. Any ideas would be appreciated. I have not worked with the Illumina. Is it a short corridor along the lines of a Definity short? I use the Definity short a lot and like it but if it would be best to use the Illumina I would.

Thanks for any Feedback!

Someone else said hyperopes like more plus and I would agree especially with his old rx being total reading OD +5.00 -1.25 x 105 and OS +4.75 -1.00 x 90 i believe he liked the added mag. I would offer a pair in st.tops with maxed out plus in a st.top 35 mostly for reading but if he wants he can still look through the top for dist. like tv. Also would offer him to re-make progressive and still max out the plus but also tell him anytime you increase the add your reading area does diminish.

**Fezz** · 01-27-2009, 04:38 PM

Are you chasing Dragons?
They don't exist.

If all of the above great suggestions do not help.

Give this patient a refund, tell them to beat it, and cut your loses.

**tolpuppy** · 01-28-2009, 08:26 AM

I appreciate all the responses and will let you know the result after dispensing. My true feeling is that this is a user issue due to visual changes after cataract surgery.

Fezz, I may be chasing dragons as I tend ( even after 17 years ) to obsess when I have an Rx problem. My nature I guess. :hammer: I will cut my losses if it comes to that. If this were an antagonistic patient that would be easier but he is a very kind, apologetic, retired pastor.

Thanks again

**Chris Ryser** · 01-29-2009, 06:47 AM

First hand experience from a guy who had cataracts done in both eyes (November 2008)..................

Before the right eye was done (last one) vision was 20/35 in that eye with the best correction possible. So there is no way of judging how well the old glasses were doing. I just used to forget reading the newspaper, as it was just a pain to do it.

I am now back to 20/20 with a plano-0.50 cyl and an add of 2.50. I just do find the progressive reading too small for comfortable reading and working on desk and computer.

So I went back to my comfortable ST35s of which i made a few pairs for different occupations and can openly say that it is a very positive feeling to see a clear desk and reading material without the lateral distortions, versus the progressive lenses.

**sharpstick777** · 01-30-2009, 08:44 PM

I have had this problem many times with Post-Op Cataract patients. I believe in some of these cases that its due to the change in effective prism. He has been looking through an effective power of about +4.50 for reading except the reading in the Progressive is about 14mm below the center of the lens, creating approx 5-6 D of effective BU Prism. It can be even higher if they didn't do prism thinning in his old pair of eyewear.

I would trial lens him 1D-2D of BU prism OU to see if his reading improves. If it does most people can tolerate a bit of prism in their distance (since Progressives always create prism anyway) its usually not an issue. If it does help even a little ... you are on the right track and you can work with the Dr. an RX that will work.

I believe peoples muscles get used to working through the prism that was once there, and once its gone they don't know what to do.

Sharpstick