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Thread: Patient complaint of reduced acuity in right eye.

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    Patient complaint of reduced acuity in right eye.

    Have 63 yr. old male who had cataract surgery 6 mos. ago. He has worn verticle prism of 9dn od and 9 up os. We have made plano rx lenses with the prism in frames for polycarbonate polarized sunglasses with a 5 base curve. He complains of less clarity in the right lens as worn. The lenses have been checked for waves, abberation, etc. with no findings. His IOLs are the bifocal type where the right has an add of 4 and the left an add of 3. I suspect the IOLs to be responsible for the variance in accuity but wonder if the prism applied may also create issues with polarization. Are there other factors that may play a part in his problem?

    Any input would be helpful. Thanks, Bob Wheeler, ABO-AC

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    Rochester Optical WFruit's Avatar
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    There may still be medical issues at play in the right lens.

    My next question would be, is he still actually Plano in the right eye or does he need a slight correction? Is his complaint distance, near, or overall? Does he have less clarity ONLY with the sunglasses, or all the time?

    I don't think the prism in the polarized should be an issue, although they can't be a pretty pair of glasses.

    On a completely unrelated research note, does anyone know what the effect would be (and would there be any real benefit) to putting a light (say 20% grey) polarizing filter in an IOL?
    There are rules. Knowing those are easy. There are exceptions to the rules. Knowing those are easy. Knowing when to use them is slightly less easy. There are exceptions to the exceptions. Knowing those is a little more tricky, and know when to use those is even more so. Our industry is FULL of all of the above.

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    If the IOL has peripheral add, the higher add may become more apparent when the pupil enlarges behind the sunglass? Find out more about the configuration of the IOL, as that might be helpful in determining things like pupil influence.

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    How's the vision with a plano polarized readymade sun with OS occluded?

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    Master OptiBoarder rbaker's Avatar
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    Quote Originally Posted by WFruit View Post
    On a completely unrelated research note, does anyone know what the effect would be (and would there be any real benefit) to putting a light (say 20% grey) polarizing filter in an IOL?
    For one thing, he possibility of complications caused by the delamination of the IOL would far exceed any benifit to the patients vision.

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    ABOM Wes's Avatar
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    9D of prism is a lot of prism to be using poly; personally I won't use poly for any prism job over 3D. The chromatic aberration becomes terrible. We tend to look straight ahead and down much more than up, so the aberration in the OD may be more obvious to the pt, especially when reading. I'd suggest trivex or cr-39...
    My two cents. This is rather interesting; I'd love to hear how it turns out.
    Wesley S. Scott, MBA, MIS, ABOM, NCLE-AC, LDO - SC & GA

    “As our circle of knowledge expands, so does the circumference of darkness surrounding it.” -Albert Einstein

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    OptiWizard Yeap's Avatar
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    agree tat 9D of prism is lots and it get worse with the poly material. lots of the issue has been mentioned above, but i think the dominant eye is a important point to look at.. if happen that it falls on right eye then your patient complaint make sense if not then have to do some further assessment to rule out the blur vision.. hope it helps..
    Yeap


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    Thanks for your interest in this patient. He did have a recent refraction to verify the prescription. I had him compare his vision with a clear pair and he noticed the same problem but with lesser degree. Adding a fit over with plano polarized lenses confirmed this. I am reasonably sure that he is sensative to the different vision the IOLs present, and it becomes more apparent when the pupil dialates in sunglasses. I agree that polycarbonate is not the best optical performer in this instance and will remake them in trivex. Thanks again to all who participated.

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    Glad this is being solved rwheeler! A suggestion, if I may. Can you choose a slightly lighter tint and/or in Brown? This may cut down on the pupil reaction.

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    I will review that option with the patient. And thanks for the suggestion.

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    Doh! braheem24's Avatar
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    If BVAs are not equal you could also decrease the prism in the dominant and increase in recessive to further lower CA in the good eye.

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    Eyes eastward... Uilleann's Avatar
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    Question # 1 should have been - what are his doctor recorded best VA's?

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    Bro Bri, Bri Bro, He's plano.

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    Eyes eastward... Uilleann's Avatar
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    Quote Originally Posted by braheem24 View Post
    Bro Bri, Bri Bro, He's plano.
    ...yes, but he could still have reduced VA's. Do we know what they are OU from the chair?

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    What's up? drk's Avatar
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    This case is baffling, somewhat.

    Let's assume this guy can binocularly fuse with all that prism. If so, he'd be wearing it full time. Does he need full time prism? If not, is the prism really helpful? Is he binocular at all?

    Does his vertical imbalance increase on downgaze, and that's why the aggressive IOL approach was taken? I sure hope so, because it's pretty stupid if not.

    Certainly he'll have worse distance acuity in the higher add implant. It may be as simple as that. Pupil dilation may be a factor, indeed, even if it's slight.

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    One eye sees, the other feels OptiBoard Silver Supporter
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    Quote Originally Posted by drk View Post
    This case is baffling, somewhat.

    Let's assume this guy can binocularly fuse with all that prism. If so, he'd be wearing it full time. Does he need full time prism? If not, is the prism really helpful? Is he binocular at all?
    I sure hope so! I'm assuming the subject wears a prism Rx (poly clear?) full-time, and is symptomatic without, and is more comfortable with this solution compared to a Fresnel prism.

    Does his vertical imbalance increase on downgaze, and that's why the aggressive IOL approach was taken? I sure hope so, because it's pretty stupid if not.
    I suspect that VI did not exist before the surgery.

    Certainly he'll have worse distance acuity in the higher add implant. It may be as simple as that. Pupil dilation may be a factor, indeed, even if it's slight.
    Slight for sure. I would think our pupils would be smaller behind sun lenses when outdoors (full sun) compared to clear lenses indoors in normal light.

    Assuming all else being equal between the clears and the suns (lens material, design, etc.), the only thing left is the tint density and hue. Uncut's recommendation of a brown tint is worth a look, especially when dealing with the poor optics and reduced light transmission of multifocal IOLs, and the high degree of chromatism from the combination of very strong prism and low Abbe material.
    Science is a way of trying not to fool yourself. - Richard P. Feynman

    Experience is the hardest teacher. She gives the test before the lesson.



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