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Thread: Common complaints for new prescriptions

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    Common complaints for new prescriptions

    I am fairly new to optics and am in a practice on my own without anyone to bounce questions off so this website is so wonderful. That being said, I have difficulty troubleshooting. Are there common complaints with new prescriptions that are clues that this is just something that the patient has to work through or when do you figure out that something requires a remake/new rx.

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    OptiBoard Professional ThePinkRanger's Avatar
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    Welcome to Optiboard. This question is so broad and there are so many variables at play. But check out the Tips On Dispensing thread. It's maybe the 2nd thread from in General Optics. Lots of great hints in there.

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    Master OptiBoarder Mizikal's Avatar
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    Yes, they have a wide range and very. I think it sounds more like you need to work on troubleshooting so here is what I do. Common complaint things aren't clear. Honestly have them wear them for a couple of day but after that. Check and make sure the glasses were odered correctly.The script entered correctly. Then to the lenso to varify the RX. That is usually done when the glasses come in but people like to see you verify it. The check the adjustment vertex, face warp and pano. That is were I start.

    What problems are you running into?

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    Quote Originally Posted by nellster View Post
    I am fairly new to optics and am in a practice on my own without anyone to bounce questions off so this website is so wonderful. That being said, I have difficulty troubleshooting. Are there common complaints with new prescriptions that are clues that this is just something that the patient has to work through or when do you figure out that something requires a remake/new rx.
    First thing, get them to be more specific than "these aren't right". Do they mean they actually can't see stuff, or do they mean they feel unfamiliar and side-effect-y?
    If they can't see, do they mean distance vision or reading? And how well should they see; are they expecting their previous best VA 0f 20/100 to be miraculously 20/20? Do they mean they can't see using a particular posture or viewing angle (like their old glasses may have trained them to use)? A common complaint is reading working distance; their old glasses focus at 20-25 inches, and the new ones at 16 inches, so they're holding the print at the wrong spot. Is the new Rx clearly an atypical change from the old one? Cylinder changed from with-the-rule to against-the-rule? Substantial increase (or decrease) in anisometropia? Why would there be something more than an ordinary change? Without some anomaly in the Rx or (even better) specificity from the patient, you have no starting point.

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    OptiBoard Professional Kujiradesu's Avatar
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    Quote Originally Posted by nellster View Post
    I am fairly new to optics and am in a practice on my own without anyone to bounce questions off so this website is so wonderful. That being said, I have difficulty troubleshooting. Are there common complaints with new prescriptions that are clues that this is just something that the patient has to work through or when do you figure out that something requires a remake/new rx.
    As has been said your question is pretty broad, however troubleshooting is one of my favorite things to do so I'll try to answer broadly. I start by asking the patient to describe as clearly as they can what it is that they are experiencing and how they think that differs from how they "should" be seeing. This description can give you the meat for your ultimate diagnosis of their problem, it invites them to quantify their problem rather than just saying "I cant see right". However I only go to this after its apparent that there is a problem. When I have someone try on their glasses for the first time I invite them to try them out: "So, just take a look around, does everything look nice and clear to you." If they say yes then you're good, but if they seem a little hesitant I may say: "Due to the difference between your old prescription and your new prescription, you may have a bit of an adjustment period. For right now, Id like you to just notice if things are sharp and in focus. It may seem a bit strange at first, but this will pass with time as your brain becomes used to the new prescription." And finally if they've been wearing their glasses for more than half the day, say they pick up their glasses at 5pm I might say: "Seeing as your eyes are used to your old prescription things might seem a bit strange or off when you're wearing your new glasses, but that is normal. At this time of day your eyes are not really ready for your new prescription, so I would say to wear your old prescription home and for the rest of the night. Then in the morning when your brain has had time to reset put your new glasses on and wear them all day. If after a week you are still experiencing that strangeness please come back and see us." Not sure if I've conveyed this, but my main thrust when trying on a new RX is that perception is in the brain mostly, if a person has been wearing an old RX all day that old RX is what "right" looks like to them. So I just try to reassure them that its a quirk of perception that their best correction (according to their DR) doesn't look "right" because they're used to their old RX. TL;DR: Wear them for a week and see if you get used to them.
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    The main one to watch out for is a +0.50 change. Their old glasses will usually feel sharper in the distance.

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    Quote Originally Posted by Robert_S View Post
    The main one to watch out for is a +0.50 change. Their old glasses will usually feel sharper in the distance.
    Yes!

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    Quote Originally Posted by Kujiradesu View Post
    As has been said your question is pretty broad, however troubleshooting is one of my favorite things to do so I'll try to answer broadly. I start by asking the patient to describe as clearly as they can what it is that they are experiencing and how they think that differs from how they "should" be seeing. This description can give you the meat for your ultimate diagnosis of their problem, it invites them to quantify their problem rather than just saying "I cant see right". However I only go to this after its apparent that there is a problem. When I have someone try on their glasses for the first time I invite them to try them out: "So, just take a look around, does everything look nice and clear to you." If they say yes then you're good, but if they seem a little hesitant I may say: "Due to the difference between your old prescription and your new prescription, you may have a bit of an adjustment period. For right now, Id like you to just notice if things are sharp and in focus. It may seem a bit strange at first, but this will pass with time as your brain becomes used to the new prescription." And finally if they've been wearing their glasses for more than half the day, say they pick up their glasses at 5pm I might say: "Seeing as your eyes are used to your old prescription things might seem a bit strange or off when you're wearing your new glasses, but that is normal. At this time of day your eyes are not really ready for your new prescription, so I would say to wear your old prescription home and for the rest of the night. Then in the morning when your brain has had time to reset put your new glasses on and wear them all day. If after a week you are still experiencing that strangeness please come back and see us." Not sure if I've conveyed this, but my main thrust when trying on a new RX is that perception is in the brain mostly, if a person has been wearing an old RX all day that old RX is what "right" looks like to them. So I just try to reassure them that its a quirk of perception that their best correction (according to their DR) doesn't look "right" because they're used to their old RX. TL;DR: Wear them for a week and see if you get used to them.
    These are exactly the things I say to patients when initially dispensing. It is extremely important to explain to the patient that the eyes and brain need time to adapt to a new prescription or lens style. Be sure that you clearly explain to the patient the nuances of using their glasses if they are new to multifocals. I've found it helpful to encourage these patients to practice focusing on objects at different distances (i.e. while watching TV, glance down and read a magazine for a few seconds, then glance back up at the TV. Then, glance at something arm's length away and find how to bring that into focus.). This helps them develop eye and neck muscle memory.

    If, after a week or so of wear, the patient comes back and still complains of issues, I follow this process:
    1. As Kurjiradesu said, ask thorough questions to try to best understand what the patient expected or wanted, and at what distances they see well or poorly.
    2. Take the glasses back to the lensometer and verify prescription, PD and optical center or fitting height, marking up PALs for centration and using the lensometer to mark OC/PD. (I can't stress enough--marking up the lenses makes assessing patients' issues much easier!)
      -> if prism is present, verify that the prism is correct at the PRP or OC.
    3. After marking up the lenses, ask the patient to put the glasses back on and check positioning, panto, and vertex distance, making sure that the vertex distances are equal for both eyes. Also check the faceform; if a frame is too wrapped, it can narrow a patient's usable field of view and create peripheral distortion. *However,* some lens designs are surfaced to take faceform into account, so tread carefully when adjusting faceform.
    4. If anything that you can possibly adjust looks off (say, seg too low, nosepads adjusted unevenly, panto is severe or not enough), make adjustments and ask the patient to respond.
    5. If a patient complains of eye strain or the sensation of 'pulling,' check that the PD and OC are correct. If no OC was taken, take one and remake the lenses. If the lenses are well centered in front of the patient's eyes, ask the them more about their daily habits; if wearing SV and using handheld devices or reading up close much of the day, suggest upgrading to an anti-fatigue lens. (I have several pairs of glasses with different kinds of anti-fatigue lenses. I've tried every kind that I'm aware is on the market, and I love them for how much better my slightly myopic eyes feel at the end of the day.)
    6. Base curve intolerance can manifest in a few ways. In my experience, patients say they feel dizzy or experience a fishbowl sensation when wearing their glasses. In these cases, it may be prudent to remake and match the base curve and material of a previous pair of well-tolerated glasses.
    7. If vision at a certain focal point is blurry, use trial lenses over the patient's glasses to assess if a prescription change may be needed. For patients whose prescription has changed a non-trivial amount, find out if there are medical conditions that may affect the patient's vision. (I see plenty of diabetics who come back for Rx re-checks because their sugar levels were not well controlled at the time of their initial exam.)
    8. If a patient complains generically about clarity and the prescription checks out, assess whether the material in the new lenses is appropriate for their prescriptions. Poly especially is prone to creating aberrations and distortion that is not well tolerated by some patients (especially with anything more than moderate astigmatism). Also, recommend adding an AR coating if internal reflections or other glare are bothersome to the patient. If the lenses have AR and the patient complains of glare, check if the lenses are crazed.
    9. If a patient complains about peripheral distortion, whether in SV or multifocal, assess how decentered the lens is within the frame. If the patient's PD is narrow compared to the frame size, distortion complaints are more likely. Avoid this by fitting frames that center the patient's eyes. (Be careful not to choose frames for which the patient's PD is too wide!)
    10. If a progressive wearer complains of swim or a wavy effect, adjust the frame so that the PAL fitting cross is positioned slightly lower. After that adjustment, if the patient has trouble accessing the reading portion, add panto.
    11. For lenses in which the PAL or lined multifocal yields a short or cut-off reading area, recommend a re-style to a frame that allows more room for reading *or* change the multifocal style to one that allows for full reading area. If the reading area is not cut-off, but the patient complains that it's difficult to read, try adding some panto. Otherwise, especially for younger presbyopes/low adds or those used to wearing short corridor PALs, remake and switch to short corridor.
    12. For PALs that the patient complains do not have enough intermediate vision area, adding slight panto may offer some relief. When complaining specifically about computer vision, remind the patient that a PAL is not a perfect solution for all uses, and recommend a computer pair (either SV or office-style progressive). If the patient is not concerned with computer use as much as day-to-day intermediate vision needs, consider a longer corridor lens (as long as the frame and fit will allow).


    These are the most common issues I come across. I am also still pretty early in my optical career (almost 5 years in), and visual issues stemming from anisometropia, keratoconus (not so much fun to fit glasses for) or other more complex conditions can be difficult to troubleshoot. Don't be afraid to call your labs for advice.
    One more edit: Lens company reps, though they may be shilling their products while meeting with you, can be very helpful in educating about lens types and products available. I have had several training meetings with Hoya, Essilor, IOT, and Unity reps, and while I've learned a lot from them, the greatest benefit for me has been deducing which products are sensible and which are BS.

    For the veteran opticians out there, please offer any criticism or advice pertaining to what I've said.
    Last edited by andshewas; 11-17-2016 at 03:53 PM. Reason: edited to make easier to read

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    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    Welcome to Optiboard!!!

    I think you need a basic trial lens set. Which you can buy easily enough.

    I'm afraid you may have opened on your own a little too soon with this being your first question on Optiboard. Your learning curve may prove expensive.

    Also searching our forums probably has this and many other questions already answered many times in the past.

    Now someone hand me the newbie wet whipping noodle!

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    Steal this idea I have loved using for 8 years: hang a manual phoropter on a wall of your practice, tape a 10' (20' equivalent) eye chart to the wall in front of the phoropter with good office (ambient) lighting and before you cut any lenses, neutralize the Rx they are wearing (have them bring it in if they forgot it)-then take them to the phoropter and show them their new Rx in AMBIENT light. Toggle between their present Rx and the new Rx and.....listen. Patients will tell you if they will like what you make them. You will cut down on your re-dos, ferret out Rx errors and provide a service on-line can never do. I call this the RX CHECK and have patients (and families of patients) come in specifically for this service.

  11. #11
    One eye sees, the other feels OptiBoard Silver Supporter
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    Quote Originally Posted by andshewas View Post
    If a progressive wearer complains of swim or a wavy effect, adjust the frame so that the PAL fitting cross is positioned slightly lower. After that adjustment, if the patient has trouble accessing the reading portion, add panto.

    For lenses in which the PAL or lined multifocal yields a short or cut-off reading area, recommend a re-style to a frame that allows more room for reading *or* change the multifocal style to one that allows for full reading area. If the reading area is not cut-off, but the patient complains that it's difficult to read, try adding some panto. Otherwise, especially for younger presbyopes/low adds or those used to wearing short corridor PALs, remake and switch to short corridor.
    Increasing the panto tilt effectively lowers the near/intermediate zone. Decreasing the wearer's vertex distance does the same. The near zone width is increased in both cases.
    Attached Thumbnails Attached Thumbnails Panto.png   Vertex.png  
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  12. #12
    Manuf. Lens Surface Treatments
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    Blue Jumper our forums probably has this and many other questions already answered ..............

    Quote Originally Posted by Uncle Fester View Post

    I'm afraid you may have opened on your own a little too soon with this being your first question on Optiboard. Your learning curve may prove expensive.

    Also searching our forums probably has this and many other questions already answered many times in the past.


    Make sure your measurements are correct before ordering the job from a lab. If you are not sure double check.

    When you get the job back check it out if it corresponds with you double checked order, also double check that one, and if it all matches you should have a pretty correct job to deliver and a satisfied customer.

    As Uncle Fester suggested search OptiBoard posts for related issues.

    All the best.

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    Thanks for the replies. I have gotten good advice from my lab representatives and been a little more confident. I was a lab tech before this and trained a little with an optician who was retiring and now I am on my own so I have apprehension from time to time and don't want to waste peoples money. The advice was great.

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    I do have a specific question at this point. I have a patient who is complaining of limited distance with the new physios. He claims he can see better in the distance without the glasses which was not the case before. New script is OD: +1.50 -0.75x015 OS +1.75 -0.75x165 2.00 add Last pair was a quarter weaker both OD and OS for sphere power, quarter weaker in reading and comforts vs physio. I explained that he will be able to see better in the distance vs close but again, he claimed this was not the case with the last pair. He has to bring the glasses down further to get better distance however when I remeasured, his measurement should have been two higher??? this makes no sense to me. I truly don't feel that I can lower the fitting height and in fact, feel like I should raise it. Wouldn't this make the distance even worse if he feels like he needs to lower the frame to see better???

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    What's up? drk's Avatar
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    You have to start at the beginning. Get the refraction re-checked. Fit the frame properly. Mark the progressives on pupil center. That will solve the problem.

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    Quote Originally Posted by nellster View Post
    I do have a specific question at this point. I have a patient who is complaining of limited distance with the new physios. He claims he can see better in the distance without the glasses which was not the case before. New script is OD: +1.50 -0.75x015 OS +1.75 -0.75x165 2.00 add Last pair was a quarter weaker both OD and OS for sphere power, quarter weaker in reading and comforts vs physio. I explained that he will be able to see better in the distance vs close but again, he claimed this was not the case with the last pair. He has to bring the glasses down further to get better distance however when I remeasured, his measurement should have been two higher??? this makes no sense to me. I truly don't feel that I can lower the fitting height and in fact, feel like I should raise it. Wouldn't this make the distance even worse if he feels like he needs to lower the frame to see better???
    Any chance that your measurements are with "table posture"? You induce "normal" posture by controlling the patients chin angle while seated, when the patient actually is a chin-up kind of person. Observe the patient while standing/walking - is he/she raising the lenses by raising the chin? Is the vision really better when the patient lowers the specs, and are they lower through posture change, or sliding down the nose (which also changes vertex and panto/retro)? Most trouble-shooting guides advise increasing panto, but patients used to any retro at all are sensitive to its loss.

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    Master OptiBoarder rbaker's Avatar
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    Quote Originally Posted by drk View Post
    You have to start at the beginning.
    The real beginning is a thorough knowledge of ophthalmic optics and a thorough knowledge of the opticians craft. Ideally, today one would receive the rudiments in a 2 year formal academic environment or by sitting at the feet of an optician guru for a couple of years. Otherwise, lotsa luck. Lotsa luck to your employer and lotsa luck to those who come to you for eyewear.

    Sorry if I sound mean and nasty but it's just my nature. I do not envy you in your present position. OptiBoard, while a neat resource will not be of much value in troubleshooting but, what the heck. It's all you got.

  18. #18
    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    More than once on an expensive re do especially I'll make a simple pair of distance only lenses edged into the existing frame. It's not unusual to hear the problem is still there but if it goes away the issue is almost certainly fit and/or progressive design.

    Sometimes even a trial lens frame will not produce real world answers.

    One of my favorite sayings comes from my retired doc who when refraction's proved consistently, powers that were not tolerated, he'd tell the patient in a good nature way- "Well, there's the chair world and the real world!".

    And when I'd put a patient in a new "upgraded" design that fails (cough-Comfort-cough) with a wink and a nod I'd ask them- Who are you going to believe? The optical engineer or your own eyes!
    Last edited by Uncle Fester; 12-13-2018 at 01:58 PM. Reason: tweak...

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