here's a doosey!

[gatorbait]

ideas, thoughts?

Lets start from the beginning

New Patient.
Old Rx read @ +3.00-1.50x70
+4.75-1.00x100
2.75 add
Dr's new Rx +2.50-1.00x74
+4.50-1.25x087
2.75 add
PD 29.0/32.0
Swaravski rimless Reveal FF 1.67
Pt complained reading and distance is blurry.
Dr change to +2.50-1.00x90
+4.25-1.25x087
2.75 add
Pt complaining of eyepull and blurred vision.
I then read the old Rx personally
+1.75-0.75x87 2.00BD
+3.75-1.00x097 3.50 BD(prism thinning?)
2.75 add
PD 31/31
Dr change
+2.25-0.75x087
+3.75-1.00x097
2.75 add
PD 31.5/30
Change to reveal 1.67 w/ 6.25 BC OU

Pt now complaining of double vision

Second opinion by a different dr.
new Rx(today)
+2.25-0.75x087
+4.25-1.00x088
250 add
PD 30.5/31.5
reveal 1.67 6.25 BC OU
Frame change to full metal

Any thoughts and why cant the Reveal FF(a customized lens not have a specific requested Base Curve?)

Thanks for the help.

Matthew

[optical24/7]

The prism that you read, was it at the prism reference point? Also, many FF lenses do not allow for BC selection (it's not in the software.) Contact I-Coat labs. You can specify BC on theirs (Inscribe). (Lee Prewitt here reps for them).

[fillindoc]

The first thing I see is there was prism in the OLD RX but not the new...is that right?

Was the patient complaining of his habitual Rx? if not, stick closer to that!

second thing, the cyl axes for both eyes is quite different from his habitual Rx. That can cause a sensation of "double" vision and pulling.

As the doctor, I would spend more time refracting in a trial frame, and performing binocular work up out of phoroptor (ct in tf and maddox rod).

I sense he may need prism in the new rx and adjust cyl closer to his habitual.

If all else fails, Rx what he is comfortable with, not what testing suggests...

[gatorbait]

The first thing I see is there was prism in the OLD RX but not the new...is that right?

The prism found is in question as possible prism thinning.
During the exams, Pt was not tolerant of any prism during refraction or in trial frame.

[fillindoc]

ok. Were they complaining of their habitual Rx?

[Judy Canty]

Any pathology present?

[gatorbait]

@fillindoc No complaints of the former Rx other than the distance was getting blurry.
@curiouscat No pathology present. Pt checks out great.

The pt did however wear the old Rx for 3 years. Is the 1.5D of BD prism something she may have gotten used too?

[Judy Canty]

That's possible as well. Did you check that with a trial lens over the most recent rx?

[gatorbait]

yes. Pt complained about feeling "off balance"....

Here is another... She would wear the new glasses and start to feel off balance so she would switch to her old glasses and still feel the same....?

[Judy Canty]

If you're confident that the newest rx is correct, can you convince her to leave the older pair with you for 24-48 hours while you give them a "tune-up"? She may accomodate because there is no other option.

[fillindoc]

I would start with having her wear her habitual Rx for a week to make sure she is not dizzy with them. Then begin a trial frame refraction with her old Rx (provided she is comfortable and not dizzy - she should be fine, since she wore them for 3 yrs with no dizziness), and then push toward the new Rx (if it gives her significantly better vision). I would let her walk around the optical after each "step" in the refraction and stop as soon as she is uncomf, then back off to where she is comf.

I would not introduce prism if she did not present with diplopia / binocular related complaints.

[gatorbait]

If you're confident that the newest rx is correct, can you convince her to leave the older pair with you for 24-48 hours while you give them a "tune-up"? She may accomodate because there is no other option.

A great idea. I thought about that. But I she has an antireflecive bubble on one of the lenses and not much "tuning-up" I could explain....

[gatorbait]

correction... sorry I read my notes wrong. She has been wearing the current pair of glasses for 10 years and the Dr who Rxed is no longer in business.

Any idea how long labs keep records of glasses made?

[Judy Canty]

By "tune-up", I mean taking the old pair apart, cleaning everything, replacing nose pads and temple tips, if possible. Then some "spa" time in the "magic drawer".

[gatorbait]

Would the lab give her 1.5 BD prism instead of using a slab off?

[AngeHamm]

By "tune-up", I mean taking the old pair apart, cleaning everything, replacing nose pads and temple tips, if possible. Then some "spa" time in the "magic drawer".

How I love the magic drawer.

[optical24/7]

Gator, where did you read the prism? In the distance area or at the PRP?

[FVCCHRIS]

From what I can see you have probably verified the Rx in the distance portion of the Rx and at that position it would be normal for you to see that much vertical imbalance due to the power difference between the lenses. All progressive lenses need to have their prism amounts measured at the lens PRP, or Prism Reference Point, which is directly ON the Datum line 2-4 mm below the lenses MRP(fit point). You will always get varying amounts of imbalance vertically, especially in plus powers, if you are comparing and measuring prism in the Rx verification circle. I suggest you take a break, then come back and carefully remark the patient's old progressive lenses(all the markings including the PRP this time). Once you have accurately remarked the lens you can then accurately neutralize(verify) the lenses and you will have your CORRECT starting point this time and then go from there. I suspect your patient DOES NOT have any prism in his old glasses and he DOES NOT like the Dr's new weaker Rx's.

[gatorbait]

The prism was read at the OC... Our if you will the meridian where the digital points of lens markings. That's why I am starting to think the 1.5 was used instead of a slab off. It makes a bit of sense. She is 64 so she can't seem to accommodate the difference.

[Speed]

Wow!....WoW!

[BMH]

I never had much luck with the Reveal. Not all, but quite a few of the Reveals I fit ended up in Individuals after Rx trouble shooting was done. What was her previous progressive lens type? If your dealing with a VSP lab not Zeiss you could also try the VSP Unity. Our office manager loves hers but I have not fit them on any patients.

Also, I agree with previous comments about the cyl. axis. It is different and with more than a diopter of cyl. its going to "feel" different. Axis shift with drop in plus power from habitual Rx. Pt complaining blurred dist. and reading with new and old Rx, hmmmm. How old is the patient? You sure she is not formed some amount of cataracts?

Sounds like a fun one. Good luck.

[OHPNTZ]

You need a little more specifics. Testing needs to be isolated to each eye...

Blurred VA...which eye? What are the acuities?

Diplopia? Monocular or Binocular? Vertical, Horizontal, or Diagonal?

[gatorbait]

The last complaint was monocular diplopia. VA OD 20/20, OS 20/25 in distance corrected with new Rx before this newest change. Trial lenses was 20/20.

No one has answered my question of the possible prism used instead of slab off for aesthetics....

I tried to contact the previous Dr however he retired 8 years ago and I have no idea what lab was used. I know it a Varilux Panamix Poly but 10 years ago, that was the lens to use(other than the comfort)... So it could be any lab and without having the Dr's practice name, I don't think the lab would be able to locate the patient info in the system.

[optical24/7]

Monocular diplopia is pretty rare. The exam should have found keratoconus or sub-luxation of her lens. (The most common causes of mono diplopia).

As far as a lab subbing the amount of prism you found for a slab-off, I think more than likely no. If the prism you read was at the PRP then it would indeed balance out at near (OD .30 DN/ OS .00 at 13.5mm below the PRP (aprox.) but in the DRP you would have increased the imbalance (at 4mm above the PRP OD 2.7DN/OS 5.0DN (aprox.) With her habitual I would expect diplopia in distance, not at near. (but no mono-diplopia unless there's path.)

[Aarlan]

DID THE OD TRIAL FRAME????
in the phoropter, there are some pts that will absolutely love an Rx in the chair (in a dark room with a V/A chart x feet away), but if the patient is still having probs, you need to trial frame the new Rx vs the old....Also, if the pt is slightly less than 20/20 (cataracts, etc.).

also, old rx w/ 29/32 vs new 31/31 and 2nd opinion 30.5/31.5....make sure you dot the OC w/ a marker to see how frame fits....pupilometers are great, but have limitations, especially when the bridge of nose is assymetric....I like to see where the OCs are on the pt...if the Pupilometer (which sits on the very top of the bridge) is slightly off, the glasses may sit differently depending on anatomic differences.

ALso, any chance she hates the specs...I have many cases sat the pt down, and said if you want, we can also change the frame while we're at it....they jump at the chance, new frame...pt fine and sometimes they confide afterward that it was the frame that they didn't like in the first place.

AA