better progressive for high astig patients?

[optilady1]

I've got a patient who has new glasses, you know the story, small changes, can't see. Specific complaint is increased distortion in periphery.

OLD RX:

-2.75 +2.25 x105
-3.25 +3.75 x60 /+2.75 add

NEW RX:

-2.75 +2.50 x100
-3.25 +4.00 x60 /+3.00 add

RE-REFRACTION:

-2.75 +2.50 x105
-3.00 +4.00 x60 /+3.00 add

Old AND new lenses:

Trivex, Definity Short, Transistions, A/R. Pd's 35/33.5 seg old pair- 16, seg new pair 18. Very similar frame. Same base curves.
My question is, is there something better for a patient with high astig/oblique astig?

Thanks in advance!

[Uilleann]

If they insist on a short corridor, then they also insist with increased distortion. Personally I wouldn't fill that scrip in anything compressed...no doubt others here will likely disagree...but that would be suspect number 1. Second, I'd ditch the Definity design.

[SoopaTroopa]

I've had good luck with freeforms on patients like that. Shamir Autograph II is a great lens for things like that imo.

[becc971]

Every time i fit a patient in the definity they don't really enjoy it ... switch them to the physio enhanced and theyre happy as a lark, which is what i use for most of my higher weird rx people ... i think i've only had 2 or 3 people dreally like the definity and stick with it

[mdeimler]

If they insist on a short corridor, then they also insist with increased distortion. Personally I wouldn't fill that scrip in anything compressed...no doubt others here will likely disagree...but that would be suspect number 1.

Agreed. 18 is too high for the Short.

[Fezz]

Seiko Surmount!

[Kane]

Either the autograph ii, Hoya id, or the new s design physio

[Judy Canty]

Seiko Surmount!

+1

[n711]

I've had good luck with freeforms on patients like that. Shamir Autograph II is a great lens for things like that imo.

YES! With the seg of 18 I would do the Shamir Autograph II Fixed 15 (and yes she can stick with Trivex , Trans!) then step back for the "wow" factor!

[Uilleann]

One advantage the S series allows is a 100% guarantee. If the pt washes out, you get a full refund of your lab fees and can try a different design. I would also suggest it as a viable contender for a good working design in this scrip. Along with a deeper frame. I'd try and get at least a couple more mm in that B if there is any possible way...

[Yeap]

anything freeform i think should be a better option.
secondly adaptation is important and for patient like this manage their expectation is more important than the lens design prescribed.

[sharpstick777]

The Definity is a hybrid lens, its not entirely free-form. You will do better with that Cyl in a pure Free-form lens. The second question is "what are her lifestyle needs?"

If she likes the wide corridor of the Definity, but wants more and better distance, the Surmount (as mentioned) will triple her peripheral vision but keep the wide corriodor. If she doesn't need that width for the computer, the Auto II handles mid to high cyls very well, but will require some adaptation. But the corridor is fairly narrow.

Although her RX change was small, the increase in cyl, the increas ien add, and the short corrider combined, increases distortion at a geometric rate. Some lenses (less adaptative designs) "break" at a certain RX points, and it could be you simply stepped over the edge of what the Definity does well.

The Definity is a great lens, I dispensed probably a thousand or more, but it has limitations... and downsides... as do most lenses made. Its just that we have to "drive by feel" to find those limititations unfortunately. I did have problems in a few high cyl patients with the Definity. The Surmount would be my first choice for her, the Auto II the second, or you could wait for the Auto III (or whatever Shamir will call it, they are in meetings this week).

[optilady1]

Thanks everyone for the advice. I'm still thinking and working with the lab as to what to do, because I definitely don't want to have to make them again.

[Robert Martellaro]

Prescribers, when their older clients complain of unsatisfactorily near vision, frequently bump the add power. This is effective with SV and segmented multifofocals, although there can be problems with having to hold the near object too close, sometimes resulting in physical discomfort. What they don't know is that PALs with add powers over +2.50/2.75 should be avoided due to high levels of unwanted astigmatism, narrow view zones, and unpleasantly strong blur boundaries, possible degradation of the distance vision, resulting in a significant (for most folks) reduction in visual and general sense of refinement.

Optilady,

My recommendation is to change the add power back to +2.75. Recommend separate SVNO or segmented if they need better near performance.

[optilady1]

Prescribers, when their older clients complain of unsatisfactorily near vision, frequently bump the add power. This is effective with SV and segmented multifofocals, although there can be problems with having to hold the near object too close, sometimes resulting in physical discomfort. What they don't know is that PALs with add powers over +2.50/2.75 should be avoided due to high levels of unwanted astigmatism, narrow view zones, and unpleasantly strong blur boundaries, possible degradation of the distance vision, resulting in a significant (for most folks) reduction in visual and general sense of refinement.

Optilady,

My recommendation is to change the add power back to +2.75. Recommend separate SVNO or segmented if they need better near performance.

Lets not even go there with the high add powers. I've got some doctors who push a 3 add on EVERYBODY. There are times when I just want to bang my head on the wall. I can only work with what I'm given.

[mdeimler]

Yea, no need to "bump the add" anymore. We don't need to fit a comfort at 16 anymore.

[Judy Canty]

Hmmmm...been wearing a +2.50 add for several years in a number of different PALs with no problems, save for the last pair which I simply cannot wear. My Surmounts are awesome!

[Robert Martellaro]

Lets not even go there with the high add powers. I've got some doctors who push a 3 add on EVERYBODY. There are times when I just want to bang my head on the wall. I can only work with what I'm given.

Rock and a hard place. Give them a taste of their own medicine- try a +3.00 PAL on one of the older doctors.

If separates and/or Rx changes aren't feasible, the only workaround I can think of is to improve the PAL optics. The high cylinder power and oblique axis of the O.S. calls for a more optimized PAL. Zeiss's Individual is not just aspheric/atoric with an optimized inset like the Definity, it is also optimized for position of wear, and for the Rx, the latter allowing the progressive optics to stay closer to the intended design across a wide range of Rxs, especially important for high cylinder, oblique axes.

In the end, all your doing is polishing the turd; a high add PAL has inherently very bad optics, and is difficult to adapt to, with for most folks, degraded distance and near vision. Avoidance is the best recommendation.

[Robert_S]

There are very few people who really need a 3 add. If they truly do then it's manageable... but when you factor in the high astigmatism and short corridor, you really are asking a lot. However, not that much has changed to significantly reduce the peripheral distance zone further than it already was, so my guess is that he/she probably needs more time to adapt to the different astigmatic error he/she is interacting with. If not, then obviously there are better lens designs you can try. Zeiss Individual is your best bet as it has the widest distance zone of any progressive, regardless of the prescription. I think the ID is great but it isn't exactly great at distance vision. Auto II should work if the budget is lower.

[Robert_S]

Why not revert to the 2.75 or even 2.50 and fit sv readers for concentrated reading?

[sharpstick777]

There are very few people who really need a 3 add.

You are right.... but when you take add power away it will be one difficult patient.

[Robert_S]

true.