New Pt's DV good, but blurry at 12ft

[Caroline]

Pt picked up his glasses today and right away said, "Oh no, something's wrong". Great. He is new to our office, and he had said he was sensitive to poly and base curve changes. No problem, I kept him in plastic and +4 BC to match what he was currently wearing. His DV is fine when he looks outside, but in the office at around 12-15 feet, things are not very clear.

Old Rx: OD -2.00-0.75x069 OS -2.00-0.50x102 with a 68pd

New Rx: OD -2.25-1.00x070 OS -2.00-0.75x100 pd 65

New glasses have AR, and he thinks thats what could be causing the problem. Could it?? Also, I'd hate to remake them with the wrong pd at 68 when I measured 65, but will if that could be the issue.

What do you think?

[Robert Martellaro]

Pt picked up his glasses today and right away said, "Oh no, something's wrong". Great. He is new to our office, and he had said he was sensitive to poly and base curve changes.

He said the words "base curve"?

No problem, I kept him in plastic and +4 BC to match what he was currently wearing. His DV is fine when he looks outside, but in the office at around 12-15 feet, things are not very clear.

Old Rx: OD -2.00-0.75x069 OS -2.00-0.50x102 with a 68pd

New Rx: OD -2.25-1.00x070 OS -2.00-0.75x100 pd 65

New glasses have AR, and he thinks thats what could be causing the problem. Could it??

Preposterous.

Also, I'd hate to remake them with the wrong pd at 68 when I measured 65, but will if that could be the issue.

Nope.

What do you think?

I think the client's age is important, and if 35 to 45, I'd tell them that their accommodation is less compliant or snappy compared to when they were younger (note the increase in minus), and that they need to, as much as possible, suck it up until adaptation occurs. You may want to phrase that somewhat differently.

I also know that this is one of the worst full moons in recent memory. It seems like the gargoyles have flown off the cathedral, and they all need eyeglasses.

[SeaU2020]

Yeah, when a minus rx gets a new pair of glasses, it is common for the pre-20ft distance to feel strange until they adapt fully to the rx. My daughter is a -3.00 and every pair she ever got with a newer rx, she will say the floor looks funny. After a couple days she is good again.

[Judy Canty]

Caroline, I think you need to know more about his previous lenses, i.e. design, material, treatments, OC placement, vertex distance. There are so many variables in currently available lenses, simply duplicating base curves and material often isn't enough.

[Barry Santini]

I'll bet my license that this RX change is upsetting hios accomodative/binocular balance.

Mark my words. It's not BC, PD or AR or even poly. It's the Rx change.

It may be better Acuity monocularly, but the delta for comfort is out the window.

B

[Michael I. Davis]

Check the face form, and pantoscopic tilt

[King of the Lab]

Whats his age? And what exactly is he trying to read from afar inside/outside?

[Robert Martellaro]

I'll bet my license that this RX change is upsetting hios accomodative/binocular balance.

Mark my words. It's not BC, PD or AR or even poly. It's the Rx change.

It may be better Acuity monocularly, but the delta for comfort is out the window.

B

Barry,

The way I read it, the goal of binocular balance testing is to balance the state of accommodation, not the visual acuity, and if the corrected VA is the same for both eyes, the balancing procedure is simply a comparison of VA for the two eyes. I assume that's how it's typically done, but I have very little knowledge in this area. If this was my client, and they reported improved VA at infinity with the new Rx, I would let them go home with the glasses, even if the vision at 12' on in was slightly less clear than the old Rx, and ask them to call me in ten days to report success or failure with adaptation. With few exceptions, this is resolved in 5 to 30 minutes, or by the next morning.

[fjpod]

It's a very small Rx change. The first thing that pops into my mind is the patient's age. If they are 50 or so, that extra .25 minus could be doing it. If they are younger, then I would look more at PD, face form, etc.

[braheem24]

I would bet pt is OD dominant, make OD see better then OS and you'll probably fix it. But not before holding trial lenses over his old rx to prove the vision is better and sending or home for a few days with the option "if you don't like the better vision in the distance we can take some away to make it comfortable"

[uncut]

Pt picked up his glasses today and right away said, "Oh no, something's wrong". Great. He is new to our office, and he had said he was sensitive to poly and base curve changes. No problem, I kept him in plastic and +4 BC to match what he was currently wearing. His DV is fine when he looks outside, but in the office at around 12-15 feet, things are not very clear.

Old Rx: OD -2.00-0.75x069 OS -2.00-0.50x102 with a 68pd

New Rx: OD -2.25-1.00x070 OS -2.00-0.75x100 pd 65

New glasses have AR, and he thinks thats what could be causing the problem. Could it?? Also, I'd hate to remake them with the wrong pd at 68 when I measured 65, but will if that could be the issue.

What do you think?

Top Ten reason's why I said I am sensitive to poly and base curve changes............
1) I am a mensa 7 year old........
2) I am a nerdy 12 year old and a change in base curve.........magnifies my zits.
3) I am a anal retentive 17 year old, and I read it on Fbook, that poly is bad, big time!
4) I am 27 and I think I am way cooler in CR39. OOOOOkley says so, with Iridium.
5) I am 40 ish and in presbyopic denial.................and in the midst of a divorce settlement, therefore everything in the room is unclear.
6) I really like you............I'm sure that if I say: "Uh Oh" ... you will invite me back for followup.
7) I really meant to say: "You look great today, but something's wrong.......you don't have a ring on that pretty finger!" But, I see you have one already.
8) I am a 35 year old, and I am sensitive to paint drying, and grass growing as well.
9) I really liked being under-corrected, 'cause I stare at my i-phone all day long, even when I'm driving..............

And the Number Ten Reason why I said I am sensitive to poly and base curve changes, and said something's wrong with my new Rx...............

10) "I memorized the wrong chart, online, therefore I think I flunked my eye test"

[optilady1]

Top Ten reason's why I said I am sensitive to poly and base curve changes............
1) I am a mensa 7 year old........
2) I am a nerdy 12 year old and a change in base curve.........magnifies my zits.
3) I am a anal retentive 17 year old, and I read it on Fbook, that poly is bad, big time!
4) I am 27 and I think I am way cooler in CR39. OOOOOkley says so, with Iridium.
5) I am 40 ish and in presbyopic denial.................and in the midst of a divorce settlement, therefore everything in the room is unclear.
6) I really like you............I'm sure that if I say: "Uh Oh" ... you will invite me back for followup.
7) I really meant to say: "You look great today, but something's wrong.......you don't have a ring on that pretty finger!" But, I see you have one already.
8) I am a 35 year old, and I am sensitive to paint drying, and grass growing as well.
9) I really liked being under-corrected, 'cause I stare at my i-phone all day long, even when I'm driving..............

And the Number Ten Reason why I said I am sensitive to poly and base curve changes, and said something's wrong with my new Rx...............

10) "I memorized the wrong chart, online, therefore I think I flunked my eye test"

i heart this.

[ERHALT1]

One word: ADJUSTABLITY!

[Barry Santini]

Barry,

The way I read it, the goal of binocular balance testing is to balance the state of accommodation, not the visual acuity, and if the corrected VA is the same for both eyes, the balancing procedure is simply a comparison of VA for the two eyes. I assume that's how it's typically done, but I have very little knowledge in this area. If this was my client, and they reported improved VA at infinity with the new Rx, I would let them go home with the glasses, even if the vision at 12' on in was slightly less clear than the old Rx, and ask them to call me in ten days to report success or failure with adaptation. With few exceptions, this is resolved in 5 to 30 minutes, or by the next morning.

Good points as always, Robert. But the typical red/green balance test is predicated upon discovering beforehand the best, unaccomodatively-biased acuity *monocularly*, and therefore the only adjustment is to reduce actuity in one eye to achieve balance. Even if the new Rx can be shown to balance accommodation, if the changes presents a delta that upsets the patient's habitual state, which in this case may just be semi-mono vision yielding comfortable indoor acuity, their reaction is classically expressed as such. The reason I don't think it is base curve is that I fool with base curve changes all the time in FF SV, and these don't elicit the above responses. Or at least when they say the new eyewear feels strange, it is usually accompanied by the comment that it is sharp.

b

[NCspecs]

Top Ten reason's why I said I am sensitive to poly and base curve changes............
1) I am a mensa 7 year old........
2) I am a nerdy 12 year old and a change in base curve.........magnifies my zits.
3) I am a anal retentive 17 year old, and I read it on Fbook, that poly is bad, big time!
4) I am 27 and I think I am way cooler in CR39. OOOOOkley says so, with Iridium.
5) I am 40 ish and in presbyopic denial.................and in the midst of a divorce settlement, therefore everything in the room is unclear.
6) I really like you............I'm sure that if I say: "Uh Oh" ... you will invite me back for followup.
7) I really meant to say: "You look great today, but something's wrong.......you don't have a ring on that pretty finger!" But, I see you have one already.
8) I am a 35 year old, and I am sensitive to paint drying, and grass growing as well.
9) I really liked being under-corrected, 'cause I stare at my i-phone all day long, even when I'm driving..............

And the Number Ten Reason why I said I am sensitive to poly and base curve changes, and said something's wrong with my new Rx...............

10) "I memorized the wrong chart, online, therefore I think I flunked my eye test"

#8 made me snort and I startled the patients in the waiting room thankyouverymuch. I needed this to start my day right. :)

[Caroline]

Thanks for the replies, everyone. Pt is 49 years old, so it could be the even slight Rx change. Someone obviously told him at some point in the past that he was sensitive to poly and base curve. He is a fragile and delicate flower, so *shrug*.

He took them home last night, wearing the old specs. I told him to wear the new ones all day today. He has to bring his son in for a CL check tonight, so we'll see what he says. I'll keep you all posted.

Thanks for this, I needed it!

Top Ten reason's why I said I am sensitive to poly and base curve changes............
1) I am a mensa 7 year old........
2) I am a nerdy 12 year old and a change in base curve.........magnifies my zits.
3) I am a anal retentive 17 year old, and I read it on Fbook, that poly is bad, big time!
4) I am 27 and I think I am way cooler in CR39. OOOOOkley says so, with Iridium.
5) I am 40 ish and in presbyopic denial.................and in the midst of a divorce settlement, therefore everything in the room is unclear.
6) I really like you............I'm sure that if I say: "Uh Oh" ... you will invite me back for followup.
7) I really meant to say: "You look great today, but something's wrong.......you don't have a ring on that pretty finger!" But, I see you have one already.
8) I am a 35 year old, and I am sensitive to paint drying, and grass growing as well.
9) I really liked being under-corrected, 'cause I stare at my i-phone all day long, even when I'm driving..............

And the Number Ten Reason why I said I am sensitive to poly and base curve changes, and said something's wrong with my new Rx...............

10) "I memorized the wrong chart, online, therefore I think I flunked my eye test"

[King of the Lab]

Considering he is a new patient, and all the answers above seem valid, including Uncut's Top Ten Letterman List, maybe he is just using BS excuses (Sensitive to poly and BC w/ a moderate RX) he was fed at a less adequate office.

[Robert Martellaro]

Good points as always, Robert. But the typical red/green balance test is predicated upon discovering beforehand the best, unaccomodatively-biased acuity *monocularly*, and therefore the only adjustment is to reduce actuity in one eye to achieve balance. Even if the new Rx can be shown to balance accommodation, if the changes presents a delta that upsets the patient's habitual state, which in this case may just be semi-mono vision yielding comfortable indoor acuity, their reaction is classically expressed as such. The reason I don't think it is base curve is that I fool with base curve changes all the time in FF SV, and these don't elicit the above responses. Or at least when they say the new eyewear feels strange, it is usually accompanied by the comment that it is sharp.

b

Upsetting my client's habitual state seems to be a given whenever there's a change in Rx! I'll have to read up on this if I'm going to engage you with anything more useful. I think it's a sure thing that the BC and lens geometry are not related to the symptoms, and that accommodative anomalies, primarily the inability to relax accommodation is the most likely culprit (see below).

Thanks for the replies, everyone. Pt is 49 years old

Your welcome, Caroline. I see that there is no add for near. Does your client wear his eyeglasses when reading? Is he an avid reader? Does he perform above average frequency or sustained near tasks? Any chance that he stares at a desktop monitor all day long while wearing the eyeglasses?

[Barry Santini]

As I am sure Robert will back me up here, I would employ 'flippers' to cross-test the Rx change, both old to new and new to old. This alone should help point the way.

b

[uncut]

As I am sure Robert will back me up here, I would employ 'flippers' to cross-test the Rx change, both old to new and new to old. This alone should help point the way.

b

Barry has the best method of approximating the effect of old vs new rx.......that being said his old Rx would make great reading glasses for his age.

Presbyopic denial, by both the prescriber and the patient is painfully evident in this situation.
It is rare to see a 49 year old male that isn't at least +o.50 to +0.75 presbyopic by Friday p.m. or in poor light. Bet you he removes his glasses a lot to "read" during the day as well, therefore exacerbating his accommodative ability.