At our wits end!!

[Chris2012]

Subject: Patient Complaint- Late 70's in age.

The patient was examined by Doctor # 1 on 7/13/2016. After the exam, he chose 3 pair of glasses, a clear pair, a sun pair and a safety pair.
At dispense, the patient immediately began complaining of poor and distorted vision, swimming of images, etc. I offered to let him take the glasses home to try to adapt but he declined and requested that he be re-examined, but by another doctor at the practice. He stated that he would call back to schedule with another doctor. The tray was tabled pending that call.
It wasn’t until March 17^th of 2017 that he did finally make it back in to be re-examined by Dr. #2. Dr. #2 was aware of the original issues and, ultimately, came out with a different Rx for the patient. We remade one of his glasses in the new Rx. The vision was better but there were still complaints of nausea and swim, as well as angles that were not at 90 degrees, curved in passenger side mirror, steering wheel was leaning away from him at the top of the wheel. He attempted to wear for about a week but came back with the above complaints.
I analyzed his new and old glasses and discovered that besides the Rx, which was only slightly different, that EVERY other marker was EXACTLY the same; PD, Segment height and Style, Material, OC, BC, Face Form, Vertex Distance and Pantoscopic Tilt. Dr. #2 double checked everything again and came to the same, original conclusion regarding his Rx and suggested the patient attempt to wear a bit longer.
The patient came in about a week later and stated that he still is uncomfortable in his glasses and feels he is unable to wear them and gave themback to me. He stated that he will see his eye specialist and try to obtain a new Rx from him, but may not be back. He handled all of the issues he experienced politely. I told him I would forward his complaints to the doctors to see if there is another solution.
Dr. #3 agreed to re-refract him. His Rx was virtually the same as Dr. #2. A new optician here stated that she had measured the lenses for asphericity and determined that the patient’s original lenses were aspheric. I, however, did not come to that conclusion. She appeared to have only used a thickness caliper to determine this, while I used a standard lens clock at several different points on the front curve of the lens. Also, I’m not aware of an aspheric poly 7X28, clear or polarized. I have no reason to suspect he's faking the symptoms either.
I also called the original place where they were ordered and they confirmed that the glasses were standard spherical lenses.
Is anyone aware of this alternate method to measure asphericity and do you have any other ideas as to what could possibly be the issue? We’re stumped and we hate to just write him off and say "sorry".

[jpways]

Do you know the pt's rx prior to all of this happening (or even rx change between rx 1 and 2) was there a change in cylinder power and/or axis?
Or to make it easier to look at can you list all the rxs you have preferably rx when pt enter your office then rx 1, 2, and 3.

[Hayde]

I’m not aware of an asphericpoly 7X28, clear or polarized

Me either

Is anyone aware of this alternate method to measureasphericity and do you have any other ideas as to what could possibly be theissue?

Nope, the reason being demonstrated in your anectdote: it doesn't work. How can a curvature be deduced from only a thickness measurement? Need to shake down your coworker for her logic there.

It sounds like your troubleshooting checks were thorough, so my next supposition is the Rx change. New nausea and weird angles could suggest a bump in cyl &/or axis change? If that were the case, hopefully the doc would be more communicative to you and the patient about the expectations.

Good luck!

Edit: jp beat me to it! (He's so fast, that must be why his brain hurts....)

[JuliaG]

Is it a SV lens or progressive? We have had issues as of late with a certain one, in a number of patients, that sound similar.

[Uncle Fester]

New pair of shoes syndrome. Common in eyeglass wearers where nothing fits and feels like an old pair of shoes.

As much as I'd like to say I've never had a patient who I couldn't make happy I'd say a tiny one in a thousand will never be able to be made comfortable in anything other than what they have worn for years; even if the new rx produces better "chair" vision. As one of my doc's says- "There's the chair world and the real world", my guess is he is one of these.

How long in the old pair and rx?

Anyone besides me chuckling over calipers proving asphericity?

[Chris2012]

Came in wearing:
0rig. : +2.50 -3.00 x 100 +1.25 -1.50 X 070 CC: Blurry Vision, OS worse than OD
Doc1: +2.00 -2.75 X 091 +0.50 -1.50 X 103
Doc2: +2.25 -3.00 X 090 +1.25 -0.75 X 090
Doc3: +2.25 -3.00 X 090 +1.00 -0.75 X 086
Having typed it all out like this, it seems obvious that the OD Axis and the OS Cyl/Axis should be the issue, but it's been confirmed 3 times now in the exam lane. He prefers it over any attempt to revert to his old Rx. Not sure if it's just psychological at this point now, as he was unhappy with his initial experience with Dr. #1 and that Rx was clearly incorrect (or would that be UNclearly? lol)

[Chris2012]

When I considered the physics of checking asphericity with thickness calipers, I'm sure that there is a marked difference in the thickness that would be measurable with some type of device. But to accurately measure and then determine the slope/curve from the thicker center bubble to where it quickly drops off and then slows toward the periphery would take at least a micrometer or something even more precise and accurate. You would also have to measure from center to periphery in exact increments AND plot the results on some kind of graph then connecting the dots to see if there is a curve. So yes, obviously that wasn't done. And I had to chuckle.

[braheem24]

You changed his axis over 10 degrees in each eye.

3 doctors and 2 opticians thought that's not the problem?

he has a 3 cyl and he's aniseikonic, don't change the axis without expecting adaptation issues and dint increase the aniseikonia without expecting adaptation issues.

[Hayde]

he has a 3 cyl and he's aniseikonic, don't change the axis without expecting adaptation issues and dint increase the aniseikonia without expecting adaptation issues.

Yep, not sure glasses can do much for this guy. late 70s is tough to persuade to switch to CLs though.

Odd the three docs aren't giving you a heads up if you all work at the same practice. You must really be hard to get along with, Chris. :P

[Chris2012]

You changed his axis over 10 degrees in each eye.

3 doctors and 2 opticians thought that's not the problem?

he has a 3 cyl and he's aniseikonic, don't change the axis without expecting adaptation issues and dint increase the aniseikonia without expecting adaptation issues.

Of course we thought that was the problem, it obviously isn't, thus the reason we're posting on here. As I stated above, in numerous attempts to revert to his old Rx or closer to it, the patient pushed back to the new Rx. He loves them in the exam lane and when we trial frame it as well. Admittedly, those methods are limiting due to the small aperture size of the phoroptor and the trial lenses. We've got over 100 years of optical experience working on this one PLUS I've enlisted the expertise of a former teacher and Master Optician that's been doing this for more than half a century. What I'm trying to find is someone that may have some ideas beyond the standard/normal trouble shooting suggestions that solve this problem. I'm leaning towards the "new shoes" response on this guy or, due to his first less-than-steller experience, the psychological effect is that nothing will feel right. This is beyond an adaptation issue unfortunately.

[Chris2012]

Odd the three docs aren't giving you a heads up if you all work at the same practice. You must really be hard to get along with, Chris. :P

HEY!! YOU HAVE NO IDEA WHAT YOU'RE TALKING ABOUT!!! I'M THE EASIEST GUY I KNOW OF TO GET ALONG WITH!! Just kidding, lol. Yeah we're all discussing this particular case and we're all just confused. I really think it's something deeper than the Rx.

[Hayde]

I think we're confused too, Chris. What symptoms are not explained by aniseikonia?

[optical24/7]

You changed his axis over 10 degrees in each eye.

3 doctors and 2 opticians thought that's not the problem?

he has a 3 cyl and he's aniseikonic, don't change the axis without expecting adaptation issues and dint increase the aniseikonia without expecting adaptation issues.

This^

Just because it's confirmed by refraction and trial lens does not mean there won't be adaptation problems. If the patient won't wear long enough to try to adapt I'd suggest not changing the axis this much, maybe half. The only other question I'd ask is if there is any thickness difference.

[braheem24]

The 10 degree axis change is his problem and the small aperture in the trial frame and phrototer is masking it.

Give him half the change now and half next year.

What he needs and what he can adapt t are not always synonyms.

[Tallboy]

I've dealt with similar things a hundred times. I also think its the 10 degree axis shift on a -3.00 cyl, which also is the eye he would be looking at the passenger side mirror. I see this from local ophthalmologists offices from time to time, but thankfully not from our in house ODs.

He obviously is a difficult patient to deal with, and probably has preconceived notions that its "not going to work" before he puts them on. But its still the 10 degree axis shift, I'd bet a 6 pack on it.

[Hayde]

I think we're confused too, Chris. What symptoms are not explained by aniseikonia?

Actually, I'm being too broad. The axis change isn't necessarily a fusion problem--the disorientation is possibly monocular.

[lensmanmd]

Besides the axis change, 90º not being true and trapezoidal speaks of a vertical prism issue. Bad combination. No add in your follow up suggests SV, which points to OC differences.
My thought is, RX was made a tad off in the original and your patient accommodated. New RX is most likely correct, but your patient will need to be gently weened into it a few degrees at a time, including the OC.

[Chris2012]

Thank you to all the posters that offered up intelligent ideas! We'll continue working this with the help of some of your insights.

[becc971]

20/20 vs. 20/Happy

That much cyl isn't going to like that kind of axis change. Just because it's right in the chair doesn't mean its going to work for him. put him back at his old RX, at least the axis, and you'll probably see significant improvement.