This one has us all stumped

[tigerlilly]

Forgive me Optiboarders, for I have sinned. It's been a long time since my last posting. I swing through to read and lurk, but haven't taken the time to join in for quite a while. I even carelessly let my silver status expire! What's my penance?

We've got a really weird one we're dealing with right now. Nice guy, not a screamer or a special snowflake, but he has issues with his glasses. What he described initially sounded like cyl change intolerance, even though his Rx change was so slight. We took out the cyl change per dr and remade them but that didn't make much of a difference. I verified Rx as entered, PD, Rx as made, etc. and found nothing wrong. I compared faceform/wrap in old vs new, panto/retro frame size & shape and even called his old Dr to get details. That optician was super nice and helpful, agreeing that he was not a typical problem patient. She verified material (high index, which we had not done as cost was an issue for him), their PD matched ours, no previous prism, they hadn't specified a base curve per dr or per previous glasses... Nothing jumps out as the smoking gun. He now described a pulling OS, so we verified mono OC to get rid of any possible induced prism, changed material (eating the cost difference as a courtesy) and doc changed his Rx completely back to what he had previously. At pickup they seemed much better, but later developed the same problems after wearing them for 10 - 30 minutes.

He came back in today, and I verified everything again on the remake. Rx is dead on, blah blah blah. He said something new: they're almost too clear, like 3D. I've had that with off-axis polar, but not clear lenses. He did better when putting them on upon waking, and the effects would take longer to materialize, but it still happened. Old glasses are less than two years old and now the exact same Rx. After a little while he feels a sensation like the lens is pulling his eyebrow down lower, which is a new one for me - it's usually the floor that's moving or tilting, not the patient's face. I verified that our OC measurements were correct and that the lab had followed instructions. I played around with adjustments, and giving him a decent amount of faceform helped measurably, but didn't fix it entirely.

I initially wondered if it was buyer's remorse or a mind change on the frames, but he loves both frames and refused a change. He also doesn't want a refund - I offered several times after the first remake didn't do it for him. He's patient, polite, doesn't seem crazy, and I want to find a way to fix this for him to he can be happy and comfortable. Any ideas from the brilliant, experienced peanut gallery around here?

Sorry, apparently my plus key is dead. Rx is plus 3.50 -0.50 x 132 OD, plus 3.50 -0.50 x 055 w/no add

[uncut]

Hi tigerlilly!

I would check two things physical, those being vertical OC placement, and then observed vertex distance change(physical slippage), like make him sweat!
Try to determine eye dominance, is it OS? What changes did the rejected Rx create? More +?.....the patient may describing a spontaneous squint.
I would check for a mental case of infatuation of a staff member, lastly.


Cheers,

uncut

[Robert Martellaro]

We need the client's age, old Rx, old and new lens specs (base curves, refractive indexes, and if available, vertex distances), and ocular health.

Possibilities include sensitivity to an increase in magnification due to changes in center thickness, and latent hyperopia.

[Jubilee]

I am wondering about the image size. Thickness, base curve, and the use of aspheric design could affect the image size being seen. Even if he has not been sensitive to it in the past, doesn't mean that a threshold might have been met.

[Barry Santini]

Still always wondering why any Optiboarders would submit an information phrase like "old PD matches new PD"?

B

[tigerlilly]

Because if somehow we're using a PD that's vastly different than what he'd adapted to wearing, that's a possible factor. We can (and did) double check our current measurement on our end, but verifying with his previous provider when getting other info isn't a bad thing. We can't all be you, Barry.

Thanks for the suggestions, guys. He's late 30s/early 40s, the current Rx I've listed is the old Rx and now the new Rx, and he's in a 1.67 high index lens. Current glasses do have a smaller A measurement, but it's not dramatically different in the new ones. B is the same as current. Old ones are also aspheric, as are new lenses. He's been wearing glasses for about ten years and has never had an add power. Lens thickness is comparable in old vs new. I'm at home and don't have BC.

[mshimp]

Hi tigerlilly!

I would check two things physical, those being vertical OC placement, and then observed vertex distance change(physical slippage), like make him sweat!
Try to determine eye dominance, is it OS? What changes did the rejected Rx create? More +?.....the patient may describing a spontaneous squint.
I would check for a mental case of infatuation of a staff member, lastly.


Cheers,

uncut

+1. I would also add to spot optical centers and check while on patients face to truly check horizontal and vertical centration. And the last point that uncut said can also be true!

[kentmitchell1961]

what material is he in now as high index was too costly?

[Barry Santini]

Because if somehow we're using a PD that's vastly different than what he'd adapted to wearing, that's a possible factor. We can (and did) double check our current measurement on our end, but verifying with his previous provider when getting other info isn't a bad thing. We can't all be you, Barry.

Thanks for the suggestions, guys. He's late 30s/early 40s, the current Rx I've listed is the old Rx and now the new Rx, and he's in a 1.67 high index lens. Current glasses do have a smaller A measurement, but it's not dramatically different in the new ones. B is the same as current. Old ones are also aspheric, as are new lenses. He's been wearing glasses for about ten years and has never had an add power. Lens thickness is comparable in old vs new. I'm at home and don't have BC.

Wasn't meant to be derogatory to you. But matching PD with conventional lenses is about prism imbalance, whether it complements an unprescribed phoria, or has become habitual.

The key is to uncover the difference. And thinking in PD terms isn't gonna do it. That's all.

B

[chaoticneutral]

I had a Special Snowflake in just last month complaining of the very same 3D vision issue. She had a high minus lens. We put her in a 1.74 lens with crizal avance and she complained of chromatic aberration in the periphery of the lens. I think I started a thread on optiboard about a chromatic dragon. I saw it, she complained about it, we spent hundreds of dollars on remakes trying to fix it and we ended up refunding the lenses and wishing her luck. It could be abbe value and index conflict if there is an AR coating on the lens. Some people are highly sensitive to it. As a side bar, this Argentinian chick I worked with was sensitive to her -.25 ou rx. It gave her headaches.....but I digress. Double and triple check your BC, if their split (say 6 od 8 os) it could cause an almost unidentifiable problem. And PS everyone can be Barry =P

[Robert Martellaro]

Because if somehow we're using a PD that's vastly different than what he'd adapted to wearing, that's a possible factor. We can (and did) double check our current measurement on our end, but verifying with his previous provider when getting other info isn't a bad thing. We can't all be you, Barry.

Thanks for the suggestions, guys. He's late 30s/early 40s, the current Rx I've listed is the old Rx and now the new Rx, and he's in a 1.67 high index lens. Current glasses do have a smaller A measurement, but it's not dramatically different in the new ones. B is the same as current. Old ones are also aspheric, as are new lenses. He's been wearing glasses for about ten years and has never had an add power. Lens thickness is comparable in old vs new. I'm at home and don't have BC.

This client may need multifocals. Likely if they perform frequent near tasks. Symptoms match. Shuffle this back to the doctor for a cycloplegic refraction if it was not performed, or for consultations if it was.

Or use the old Rx if they were non-symptomatic and do it all over again in one year (or sooner!).

[Paul Smith LDO]

It would be interesting to know the OC location; both vertical and horizontal, in front of their eyes in both their new and previous set. Base curve on both. As I understand, both lenses are described as aspheric but might one be an atoric design. The methodology at this stage is more of a process of elimination.

[Uncle Fester]

Just to satisfy the obvious when everything matches and before spending even more money...Magic shelf them for a week to see if same symptoms present.

Dispense the new pair while promoting the "placebo" effects he's sure to notice!

Sometimes the problem is not in front of the face but between the ears.

No doubt that the explanation could be rx related but we all have stories of how the magic shelf worked wonders just not usually with someone who is nice and patient. My favorite is when the same pair of glasses produce new and different issues.

[tmorse]

Just to satisfy the obvious when everything matches and before spending even more money...Magic shelf them for a week to see if same symptoms present.

Heh heh... up here in Canada we call it the 'dark drawer treatment'.

[LandLord]

2 things I can guarantee you. 1) he's not imagining it. and 2) the answer to your problem lies in the old glasses. There is something wrong with them that he got used to. Find it and you can counsel accordingly. Good luck.

p.s. I absolve you of all your sins.

[tigerlilly]

Thanks for all the input. It gave me food for thought to discuss w/the doc and helped me make sure I'd not overlooked some kind of glaring possibility, as well as giving me some new ideas. I especially liked the suggestion that he might be hanging around due to an infatuation. Totally not true (he was nice to me but not that kind of nice, and the doc is old enough to be his mother!) but the doc and I had a good giggle.

I had upgraded his to 1.67 high index and ate the cost in an attempt to help him, ordered lenses with a mono OC and verified that the lab had done it properly, blah blah blah. I finally talked him into a refund on Saturday. Whatever was going on was beyond the scope of what I can diagnose and fix, and it was best for all of us to send him on his way with his money. It bugs the crap out of me when I can't fix or figure out a problem, but we'd reached the point where resistance was futile. Interestingly enough, as I was doing the paperwork for a refund, I was mentioning the cycloplegic refraction suggestion, and he shared that he's had a floater in that eye for a few years. It would have been helpful to know that earlier, but since he has no issues with the old glasses I'm guessing the answer is probably more along the lines of LandLord's idea.

Thanks again for the help and the ideas, guys. I always appreciate the support and knowledge I can find here.

PS - Barry, I was being serious, too. You're a well known, well respected master optician with more expertise and knowledge than most of us will ever have. What seems simple or obvious to you isn't necessarily either to everyone else. That's why Optiboard is so great - the masters and the lifers mingle with the noobs and the learners, for the betterment of the whole optical community.

[sharpstick777]

What was his Visual acuity before and with the new pair? I would never trouble shoot any issue without knowing that. Where the old pair aspheric? are the new aspheric? new frame? Are the new pair changing panto and vertex even if both are the correct OC and PD?
How old was the old pair?