help me with this patient please

[kelanor]

I'm hoping someone can help me out with this patient.

Habitual rx :
+.25 -2.75 x 15
-1.00 -1.75 X 163
add +2.25/+2.00
gt-2 progressive lens polycarb. 5.5 bc pd 29/29 seg at 20 marked slightly below center of pts pupil. silhoutte drill mt frame

1st rx we gave her:
+.50-2.25 x 15
-1.00 -1.25 x 165
add 2.25 ou

gt-2 polycarbonate progressive lens. 7.0 bc. pd 29/29 seg 18 marked at center of pupil. rayban semi rimless frame.

pt complained that right eye felt like it was pulling and that she had to tilt her head down to see distance.

2nd rx given:
+.25 -2.50 x 15
-1.00 -1.75 x 165
add +2.25 ou

gt-2 poly progressive lens matched base curve 5.5 to old pair. dropped seg 1mm.

now pt says they make her nauseous at the computer and her right eye is still pulling.

I really, really don't want to remake these glasses again...esp for no good reason. We have done multiple adjustments to the glasses and she says nothing makes any difference no matter what we do.

Any suggestions?

[optical24/7]

Majic shelf?

[Fezz]

Refund and tell her to beat it!

[obxeyeguy]

Sounds to me like trying to get minus (candy) back from a baby, it won't happen easily.

[Uncle Fester]

Are the wrap vertex and panto matched?

OOpps - noticing last line now.

Uhmm- Drop back 10 and punt.

[optical24/7]

Does she really like the new frame?

[obxeyeguy]

Does she really like the new frame?

You win!!:cheers:

[Uncle Fester]

Does she really like the new frame?

The right eye pulling tells me it's not buyers remorse. It's too specific. I've heard it before as a legitimate complaint. Usually because of a change somewhere along the line.

[Ginster]

She could still be catching some of the intermediate even if you dropped the sg 1 mm. check the face form and panto of the old glasses and match it. If you can, spread the nose pads a little. also re-measure the mono Pd. to the old ones. Yours may be correct but are the old ones that she has adapted to. if no luck refund. :) Just my take, I don't think its the rx or the axis. Good Luck.

[opticalpig]

Is that two different add powers in her original glasses?

[kcount]

Have you looked at how the pair is 'Plaining" across the face? By this I mean are the temples balanced so the glasses are running parallel to her face when viewed from the top. This one little adjustment will give that pulling sensation or just a non-discript complaint that would stump my old staff all the time.

I dont think changing the Rx is going to do much although upping her Sph and dropping the Cyl like that always gets my 'spidey senses' tingling. Which usually ends up with me pulling out the trial frame set.

[Uilleann]

Have the doc trial frame her in the new Rx - if it's still clear, it's gotta be a lens/measure somewhere as others have pointed out. Otherwise, yeah, I'd suggest a happy refund. Best of luck!

[Robert Martellaro]

I'm hoping someone can help me out with this patient.

Habitual rx :
+.25 -2.75 x 15
-1.00 -1.75 X 163
add +2.25/+2.00
gt-2 progressive lens polycarb. 5.5 bc pd 29/29 seg at 20 marked slightly below center of pts pupil. silhoutte drill mt frame

1st rx we gave her:
+.50-2.25 x 15
-1.00 -1.25 x 165
add 2.25 ou

gt-2 polycarbonate progressive lens. 7.0 bc. pd 29/29 seg 18 marked at center of pupil. rayban semi rimless frame.

pt complained that right eye felt like it was pulling and that she had to tilt her head down to see distance.

Checked for prism in the old glasses.

The old lenses are over-minused, so that a new Rx with more plus might blur the distance vision slightly, for some short period of time, until the accommodation relaxes. A slight pulling sensation or frontal headache might be noted, although that's much less common. Usually this is resolved by the next morning.

The +7 BC is incorrect for this Rx/lens. Did you ask for a non-standard BC? If not, I would question the quality of the labs work. I would search for other fabrication errors.

2nd rx given:
+.25 -2.50 x 15
-1.00 -1.75 x 165
add +2.25 ou

So she wasn't that over-minused at all. Or they're fudging the Rx with the hope that that's the problem.

gt-2 poly progressive lens matched base curve 5.5 to old pair. dropped seg 1mm.

I wouldn't be surprised if something closer to +4.50 is Zeiss's recommendation. I wouldn't fit lower than 1mm below pupil center. 17mm is too low for this lens and Add power IMO.

now pt says they make her nauseous at the computer and her right eye is still pulling.

I really, really don't want to remake these glasses again...esp for no good reason. We have done multiple adjustments to the glasses and she says nothing makes any difference no matter what we do.

Any suggestions?

The first Rx should have felt/performed better for intermediate use. Have her wear the old glasses to confirm that these also feel less than desirable at the monitor. Check for differences in the position of the optics between the old and new glasses. Be thorough.


Points to consider.

1. She's wearing glasses that are not well suited for a desktop monitor, especially for extended periods of use.

2. There may be undiscovered flaws in the lens grind along with positional errors.

3. She's lost some confidence in your work when the first pair arrived with the wrong BC. It may be difficult to win back that trust.

4. I would like a little more confidence that you have the best Rx for your client.

[MeMph|s]

try this:

decrease vertex distance gradually. see if this can solve the pulling in e right eye...

[drk]

A thought on the Silhouette frames: very, very often they come back from mounting with insufficient faceform. It's kind of tough, but you have to bend the bridge. It can make a big difference.

True "pulling" is really a binocular phenomenon (she has no accommodation or I'd include accommodative phenomena). Robert is right to ask about prism in the original pair. Even if there is none, I'd have the OD check her vertical and horizontal phoria with and without the new Rx.

Oh, that reminds me...what about incorrect prism thinning leading to vertical prism imbalance?

[braheem24]

Oh, that reminds me...what about incorrect prism thinning leading to vertical prism imbalance?

Too much prism thinning will leave a slight imbalance and induce chromatic abberation in the distance, however her complaint is mainly the intermediate.


let me **** Uilleann off for a minute...

2.75 cyl drill mount belongs in a 1.6 not poly.

[Barry Santini]

My money, as always in situations like this Rx change, is that the client is reacting to this change in their habitual binocular/accomodative balance.

Try adding -0.25 sph over the OD, or +0.25 sph over the OS, and ask if they feel "more relaxed".

Betcha!

B

[CCGREEN]

Take a road trip to another town, pick up some business cards of the first Neurologist office you come across and take them back to the office with you. When pt. returns, PLEASE refund and REFER.....

That or stop at the first liquor store you come across and pick up a bottle of rum for the both of you to share and have a, "come to jesus meeting."

[CCGREEN]

Oh by the way......get the Dr. to give you a Rx that makes the pt. 20/happy.....regardless of what the Dr. may refract....trial frame, make them 20/happy and you will be happy also.

[drk]

A careful review of the symptoms as described does not indicate that the pulling sensation is distance dependent.

[RKJ]

Kelanor, it would be helpful if we knew the patient's age, her chief complaint at the time of her exam, and her visual demands. What does she see great with her habitual prescription and what were her symptoms with her previous prescription? Did she have different lenses for different life activities?

Does it appear that such a small prescription change should solve the real chief complaint? Are you confident you have the best lens solution to her problem?

Thoughts Regarding Troubleshooting:

· It appears you are confident the lenses were made to prescription and small prescription changes will not guarantee success.

· How much cylinder does she really have? And did she wear her habitual prescription full time?

o This is one of those prescriptions where some patients will get by without glasses, during a significant percentage of their waking hours, because squinting improves vision. She should be coached during refraction to blink and then open her eyes wide during refraction behind the phoropter – so doctor can measure an accurate prescription. ( Do K readings indicate Rx is correct?)

· If she has had a lifestyle change, and needs clear vision all the time, she may need different lenses for different activities.

o Sometimes, we hit that age where the numbers of the prescription have not changed much, but our ability to accommodate did change – due to birthdays – and now we need better options.

· Are you confident there is no disease, like a beginning cataract, impacting perceived comfort and quality of vision?

Business Decision:
If you think you have lost the patient’s confidence, regardless of what you do, perhaps you should give a refund and cut your losses.

If you need to win this patient to keep her family and friends in your care, then you need the best possible solution to solve her chief complaint. If you lose her, she should leave your care knowing 1. You did your best. 2. How to be a smart consumer to avoid the same experience with another provider. 3. That you will follow up to see how she is doing after some reasonable period of time. You are concerned about her; plus if she finds a solution, you want to know about it, so you can help others in the future. She might keep her family in your care, and she might return to you for her next purchase.

Best Wishes,
Renee

[kelanor]

Sorry this took me such a long time to respond, your responses have all been helpful.

To answer a few questions:

-Pt is in her mid 40's

-She wanted a new style but felt that her vision was fine; in fact she has actually refused to finish the exam (we fit her refraction in), so she has not been dialated.

-She wears her glasses full time, however every time she comes in I have to straighten out the frame because they end up quite crooked.

-There is no prism thinning in either pair of glasses.

-I do not feel that we have this pt's confidence. I don't feel that we ever had it. She stated from the very beginning that she had very "sensitive eyes" and she usually had to have her glasses redone multiple times...sometimes going to multiple offices.

-I would love nothing better than to give her a refund and send her on her way but our office has a strict no refund policy. I'm thinking of begging the office manager anyway.

Thanks for all the help!!!

[idispense]

Sorry this took me such a long time to respond, your responses have all been helpful.

To answer a few questions:

-Pt is in her mid 40's

-She wanted a new style but felt that her vision was fine; in fact she has actually refused to finish the exam (we fit her refraction in), so she has not been dialated.

-She wears her glasses full time, however every time she comes in I have to straighten out the frame because they end up quite crooked.

-There is no prism thinning in either pair of glasses.

-I do not feel that we have this pt's confidence. I don't feel that we ever had it. She stated from the very beginning that she had very "sensitive eyes" and she usually had to have her glasses redone multiple times...sometimes going to multiple offices.

-I would love nothing better than to give her a refund and send her on her way but our office has a strict no refund policy. I'm thinking of begging the office manager anyway.

Thanks for all the help!!!

Call in the G2 lens rep for that company and let them see the patient. Give them a shot at it . That is exactly what they are there for . You have nothing to lose. The patient may react diferently with a company rep as well .

[drk]

Ok. Nutjob protocol #124.

[Uncle Fester]

She stated from the very beginning that she had very "sensitive eyes" and she usually had to have her glasses redone multiple times...sometimes going to multiple offices.

Wouldn't it be nice to have a data base of names of these patients.:shiner::idea: