Progressive lens issue

[jpways]

I have a patient who is stumping me. They had a small change in both eyes, but is having trouble with their right eye, the left eye is fine.

Old Glasses (2007):
+0.75 -1.50 X 95 / 2.25
-1.25 -1.00 X 90 / 2.25
Lens: Comfort in Poly w/SH=22

We're on our second set of lenses:

New set of lenses 1:
+1.00 -1.00 X 95 / 2.50
-1.25 -1.00 X 90 /2.50
Lens: Comfort in Poly w/SH=21

Patient couldn't use the left lens distance of the right was good (since it's the same), but reading was a little week, so we went to:

New set of lenses 2:
+1.00 -1.00 X 95 / 2.50
-1.25 -1.00 X 90 /3.00
Lens: Comfort in Poly w/SH=21

Patient wears a Silhouette 3 piece with frame size and lens shape unchanged between the new and old glasses.
Reviewing my invoices base curve is constant (5.50), but between the old glasses and both pairs of new lenses, 1.25D of prism thinning was added (old lenses have none).

The patient has been re-refracted by our doctor twice (once between pair 1 and pair 2, once after pair 2), both times the patient had subjective improvement of VA between old prescription vs. new prescription, both monocularly and binocularly.

So I have 3 questions:
1. What is the likelihood that this issue is related to the prism thinning?
2. What is the likelihood the issue due to the increased difference between the left and right eyes?
3. What is the likelihood that I'm better off giving the patient their old distance prescription in his right eye (compensating the add to give him the same reading) and hope next year is a better year?

[For-Life]

Ok, I am a little confused. What was the problem with New Lens 1 and what was the problem with New Lens 2?

[jpways]

Same problem patient can't see out of the right lens.

[For-Life]

Now, here are a few questions

- Did you take monocular PD's?
- Did the VA improve in the exam room with the new RX? Have you over-refracted the patient?

[jpways]

Now, here are a few questions

- Did you take monocular PD's?

Yes, Monocular PDs were taken for the patient and did not change between the old and new glasses.

- Did the VA improve in the exam room with the new RX? Have you over-refracted the patient?

Yes the VA, using a phoropter, went from 20/25 (old distance) to 20/25+ (new distance) in the right which was confirmed in the 2 subsequent re-exams. While this is not a huge improvment, it is an improvment, so I am hesitant to say that the patient was over-refracted in the exam room. There is the question of whether the change of prescription is being tolorated in hte real world, but in the controlled enviroment of the exam room, the change seems to be necessary.

[MarcE]

Does she happen to have a Grade 1+ or 2 cataract in the OD?

I have seen this too. It's always a 52-57 yo female. I can't explain it. We have approx one of these per year.

[jpways]

Yes the has cataracts in both eyes grade 1 in the left, 2 in the right. But it's a 64 y/o male.

[flexonman]

The prism thinning negates the process I would believe. I think it is strongly related to the patient preferring the power of the old cylinder. It is +.50 stronger than before. She did not gain a significant change with her VA. I would redo the Rx to the same cyl.

[wbvci]

The old spherical equivalent is Plano versus the new one being +0.50. She's getting a half point more at distance and for that matter, at near too now, and when you're at a +2.25 or +2.50 add, I have seen a number of patients who report seeing worse when you try to bump up their near power further. That's why patients like their refraction at the optometrist more than at the ophthalmologist. I see way too many over-plused unhappy people coming from the opthalmologist to get a new RX at my office. If the distance VA is only improving by one or 2 letters on the same line, that half point may be over-kill. You may also want to decrease the OD Rx by a quarter on the Sphere and increase the cylinder a quarter if the doctor is convinced the cylinder is definitely not the same as it was last time, kind of like an "in-between" Rx.

[jpways]

First off I'll repeat that HE is having problems with his glasses (I know I didn't say it in my original post so that's probably why I had to repeat the gender now). He did prefer his reading with the higher OS add (even though it was making the adds uneven which is possibly complicating the issue with the distance even further). But I sent back the glasses on 10/30 after talking with the lab manager (which didn't give my much help) and we're trying it without the prism thinning, which I just got back in today, so I know in the next few days whether that was the problem (which I'm praying it is , but I won't be shocked if it's not the complete problem at which point I'll start looking at the prescription again, and probably start screaming about how much of a pain in the butt this whole job has been :finger:.)

[wbvci]

Haha. Sorry about the "she" part :) So the prism is new, never been used before on him? Maybe it's a simple matter of not including the prism. I guess if his symptoms warrant prescribing it, then he's gotta have it. Have you tried just having him hold a -0.25 or -0.50 trial lens over the Right lens of the new glasses and have him walk around like that for a minute? Just throwing a few ideas out there.

[flexonman]

Are the visual acuities 20/30 or better ou? od vs os?

the original rx would be just before the cusp of a slab off; the third rx, however, is just over.

seems to be a combination of a multitude of "issues"

and poly? uugh. trivex or 1.60 for better optics add an a/r if there is not one

[Mr. Finney]

Looks like a good candidate for contact lenses to me :bbg:. Those anisometropes are always fun .

and poly? uugh. trivex or 1.60 for better optics add an a/r if there is not one

I know I'll take some heat for this *dons flame-retardant suit* but seriously, I've only seen half a handful of people who claimed their poly lenses weren't as crisp as their old CR/Trivex/Glass lenses, and they were either latent hyperopes or engineers, lol! I'm jus say'n :)

[jpways]

The patient has been wearing a comfort poly for 4 years and a Comfort for 8 year (the patient wore CR-39 for the other 4 year), since the complaint seems to be on vision in the channel (though after 8 years of wearing the same lens design and only this lens design, if it was most likely a progressive design issue, I wouldn't be worrying about the correction in the lenses) so I'm hesitant to change the lens design (to switch to trivex) and possibly complicate the matter with that. Furthermore if this was a material issue, I would have expected him to reject the material switch 4 year ago, at which point we would have tried 1.60 or 1.67, if we didn't just decide to keep him in CR-39. And he does have an A/R (for those who care Alize w/Clearguard 2 years ago, Avance this time).

As for the VA question, just to review

Yes the VA, using a phoropter, went from 20/25 (old distance) to 20/25+ (new distance) in the right which was confirmed in the 2 subsequent re-exams.

The left is 20/25 -> 20/25⁺ but the patient isn't having a problem with the vision in that eye, so I haven't mentioned it before.

Contacts are not an option for this patient, due to tear pattern.

We have tried trial lensing twice, the first time gave us the addition +0.50 Add OS. Both times trial lensing back to the old Distance Rx did not help, though it wasn't until this last time that I thought to check the old invoice to see if prism thinning was done (which it wasn't), since prism thinning is so common on progressive lenses that I sort of just skim over it on the invoices.

[AWTECH]

The challenge is to determine if the new refraction is correct for the right eye or not.

If it is correct, the patient is probably just having trouble adjusting to a major change in one eye only.

Prism thinning if done correctly would not likely have any bearing on this.

You might use a trial lens over the new Rx that takes it back to the original power and see if he is more comfortable with the increased reading.

Due to the right eye power change he also have a difference in reading powers.

My guess would be it is adaptation to change. The cataract issue causes a need for change slowly. Now you asking him to instantly adjust to a major power change in one eye. The brain gets confussed. It maybe optically correct but it just does not feel right.

[MIOPE]

I am spanish speaking so excuse my english.
This is not a easy one. If i understood right, this patient is 64 years old and has catarat on both eyes and has a small change on the prescription on R.E.with a small increase in vision. Old glasses has no prism new ones has 1.25 base down if it is a thinning prism.
The problem is that patient can't see out of the right lens.
I suppose that what this means is that the patient can not see thru right eye binocularly with new glasses. I have a few questions,
First i would examine the old glasses. Take the glasses to a lensometer and check prescription and prism. Just in case they where not made as you think.
When the patient sees at far distance does he sees thru where the should (far distance prescription)? Are them correctly adjusted? Is the frame properly leveled? I would check monocular and binocular vision with old glasses. Also, What happens if you put a 1.25 prism base down in front of each lens at the same time?
New galsses:
Does he has the same visial acuity monocularly with the new glasses as he had with the phoropter?.
Recheck new glasses on the lensometer.
Put the new prescription on the trial frame and see if he complains as not seeing thru right eye. If so, the prescription is the problem. If has no problem binocularly then the prism could be the problem.
On this prescription
+1.00 -1.00 X 95 / 2.50
-1.25 -1.00 X 90 /2.50
At far distance the power of the right lens is almost +1.00 vertically and -1.25 on the left eye. Which make a difference of almost 2.25. If i where to make single vision lenses to someone having this prescription i would measure pupil hight to descenter the lenses vertically if needed.
On multifocals the place to meassure the prism (the dot) is 4 mm below of the mark that should be in front of the pupil.
So i would place the new far prescription on the trial frame including the 1.25 prism base down and adjust the trail frame so that the patient sees 4 or 5 mm over the center of the trial frame. What happens? What if i remove the prism now.

This may take some time and i would do it if i would be curious of what could be happening but to be sincere, i would repeat the presciption of old glasses (without the prism) and maybe if needed, increase the add.

The vision of a patient with catarat may change in different scenarios due to amount of light, etc. so i do not use to change prescription on this cases unless the new prescription produce an important increase in visual acuity.

[jpways]

I just heard back from the patient today, he's glasses are now fine, so it was just the prism thinning. I'd like everyone for your help.