This has me completely flummoxed

[jpways]

Here's what I know:
New RX -9.00
-9.00
Add: 2.25
Lens: Autograph III 15 1.74
BC VA (Phoropter): Distance: 20/20 OU Near: 20/20 OU
PDs:
D: 30.5 32.0
N: 28.5 29.0

Old RX
-9.25 -0.50 x 175
-9.25 -0.75 x5
Add: 2.25
Lens Autograph III 15 1.74
CC VA (at most recent exam):
Distance: 20/20 OU
Near: 20/30- OD 20/40 OS
PDs:
D: 30.5 32.0
N: 28.5 29.0

At exam pt complained that her distance was slightly blurry (her old glasses are extremely scratched) and that they had to raise their chin excessively to see her computer clearly
The patient has grade 1+ nuclear cataracts OU, there was no change in the maturity of the cataracts from the previous exam. She also has grade 1 pinguecula OU.

With this current pair of eyeglasses the patient has been in 6 times since picking up these glasses and I've run out of things to try.

1st visit
pt. said that nothing is clear at intermediate (had to raise her chin to get her computer clearer, but not clear) near VA 20/40 OU
distance VA 20/40- OU, I measured the base curve of both her old and new pairs and they are measuring within 0.5D of each other, I checked POW values vs. original order and they are pretty much the same (VD was measuring 1 mm shorter OD, wrap and panto were 1 degree different each). I checked it vs. her old glasses and I did have to decrease wrap by 1 degree, the patient's VAs did not change. I scheduled her for a re-exam.

2nd visit
Dr. re-examined her, first behind the Phoropter and then by trial lensing, in both cases the patient preferred the new rx over her old rx though he did add -0.25 DC at 5 degrees to the left eye. BCVA (both Phoropter and trial lens) D: 20/20 OU N: 20/20 OU
So, I send back the glasses to be remade with the new rx and POW measurements.

3rd visit
Patient presented the same complaints as the first visit, I recheck the prescription again, matched to ANSI standards (5 degrees cylinder off OS). Check for distortions under a polariscope, there was nothing unusual for a progressive (a little shadowing at the lower temporal periphery, but otherwise no color) VAs still 20/40 at distance and near. So, we ordered a new frame.

4th Visit
After mounting the lenses into the new frame and matching the adjust to the older frame, I check VAs again, no better, no worse. There was one odd thing that occurred the patient said that the nasal side of the lens was clearer than the central or temporal portions of the lens. I recheck PDs and they're 0.5mm different at distance in each eye so I send them back to the lab to have them check them. The lab guru called (sorry I don't know what else to call him, he's not the lab manager, but the director of education and he's the one the lab manager asks for a second set of eyes when we complain about something and the lab manager was out, so it went to this gentleman's desk). He rechecked them within the frame and after taking them out of the frame and he couldn't find anything wrong. I tell him to send the glasses back, because I hope him remounting them made a difference

5th Visit
Ok I was a little surprised by this, she now has both the central and nasal clear, but periphery is blurry, I did find when I increase panto and tilt it did seem to increase her field of vision, but she always comes in after working all day so at this point I'm past the fatigue point and I tell her to take them home and try to build up wearing time if she need to.

6rd visit (today) patient still has to raise her chin to see the computer. I check VAs 20/40 OU at near. It's 20/40- at distance though the patient stated that she seemed to strain to get that (joy something new). So I first decrease wrap until it was negative (I went until the thickest edges look to be on the same plane) no improvement. So, I then increase wrap to 10, it did make things worst. So, I decrease it back to 4 (measured value) I then increase and decrease panto, neither made her distance or near better or worse.

I'm now out of ideas anyone else have something else I can try. This is a long time patient, this is the first time in 21 years that we've had this many problems, so I can't exactly cut and run with this patient.

[pknsbeans]

How old is she?

[jpways]

How old is she?

57

[pknsbeans]

My thought:
just increase the add on her old Rx. Granted, that doesn't solve why her reading is poor out of the new Rx since the reading power will essentially be the same between them, but it would help the distance likely and sometimes that gives the wearer a little mental "boost" to see better close.

If you dip lenses in front of her new pair to make it the same as her old pair and it makes her distance better, then just bump the add.

It sounds like you did everything in your power for this to be successful. I would kindly mention to the Dr that the patient sees better in the distance with their old pair.

[Robert Martellaro]

1st visit
pt. said that nothing is clear at intermediate (had to raise her chin to get her computer clearer, but not clear) near VA 20/40 OU distance VA 20/40-

The chin lift is normal when using a desktop monitor. Consider task eyeglasses.

The poor VA at near (and off-axis in general) is likely due to chromatic aberration, ameliorated by using a less dispersive lens material. I use 1.60 refractive index- thicker, but roughly the same weight as 1.74.

Shamir's fixed 18mm has a corridor that is short enough to get the full add at 25 to 30 degrees down (12.5mm to 15mm below the primary gaze), with less chance of disrupting the distance vision compared to the fixed 15mm due to less chance of plus pwwr creeping into the pupil zone, and possibly due to decreased higher order aberrations. The Zeiss Individual 2N would also perform well here, with slightly better distance performance for some folks.

Hope this helps,

Robert Martellaro

[Kwill212]

Do you have the POW measurements and the Compensated Rx?

I don't think this is the root of the problem, but how did you measure the NPD? 2mm in the right and 3mm in the left? With that much minus, and hopefully a close fitting frame, I would expect it to be closer to 3mm total.

[Hayde]

Great notes, jp.

I'd give Pk's strategy 3:1 odds of doing the trick with regard to mitigating her head-lift complaint. The fact that her [reading] acutities in her old specs drop atrociously supports Robert's theory of chromatic aberration, in my opinion.

You'd think it shouldn't be necessary, but often times having them switch back and forth between their old pair at the computer while troubleshooting helps demonstrates Robert's point that all PALs do this, including their old ones. Sometimes a Px romanticized their memory of the old specs and dispelling it under controlled conditions is the only solution. (If they still prefer the old, even more support for Pk's add bump.)

Kwill brings up an important consideration---for these powers POW figures are crucial. With all the frame replacement, I haven't seen mention of zyl v. metal and vertex shifts. Even with changes of vertex input at lens order, it's still up to us to change lens power orders accordingly.

Looking forward to hearing how this turns out! Keep us posted!