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Thread: Interested In FFSV Options For Anisometropic Amblyopic Patient With a High Cyl

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    Interested In FFSV Options For Anisometropic Amblyopic Patient With a High Cyl

    Hey everyone. I've got a... rather demanding patient... that wants "the best" FFSV lens. He's a anisometropic amblyope with a high cylinder in one eye. OS is mild myopia and cylinder. OD is moderate hyperopia with high cylinder (-4.75).

    What FFSV options do you think would be best for this patient and why?

    I'm looking for the best and broadest array of options, FFSV, front and back, or just one surface FF and the other aspheric w/ & w/o POW compensation, and w/ & w/o design customization (ex. Zeiss i.Scription).

    The frame is semi-rimless, extremely thin and light. a Lightec-Morel frame. I can get the exact model if you need it.

    The patient said that the best optics is his first priority. Their second priority is the thinnest lens possible, given that the frame is so thin.

    He literally said "Money is no option" without being asked about cost, so apparently the implication is that he wants the best possible lenses regardless of price, so nothing is off the table.

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    Quote Originally Posted by Lelarep View Post
    Hey everyone. I've got a... rather demanding patient... that wants "the best" FFSV lens. He's a anisometropic amblyope with a high cylinder in one eye. OS is mild myopia and cylinder. OD is moderate hyperopia with high cylinder (-4.75).

    What FFSV options do you think would be best for this patient and why?

    I'm looking for the best and broadest array of options, FFSV, front and back, or just one surface FF and the other aspheric w/ & w/o POW compensation, and w/ & w/o design customization (ex. Zeiss i.Scription).

    The frame is semi-rimless, extremely thin and light. a Lightec-Morel frame. I can get the exact model if you need it.

    The patient said that the best optics is his first priority. Their second priority is the thinnest lens possible, given that the frame is so thin.

    He literally said "Money is no option" without being asked about cost, so apparently the implication is that he wants the best possible lenses regardless of price, so nothing is off the table.
    For FFSV, I would consider the IOT. We have realized more success with the IOT, including wrap. Question for you is, which lab do you partner with for this?

    I ask, b/c this looks like an iseikonic candidate, and Bad *** in California may be able to help you.

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    The lab we are partnered with can provide from most major manufacturers that offer FFSV, IOT is unfortunately not one of them. Other options that can be suggested?

    Patient is aniseikonic, absolute differential magnification between the eyes is ~4.8% (left eye magnifies, right eye minifies), but declined any interest in handling the issue. Apparently he has tried to address this before and hated the outcomes.

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    Quote Originally Posted by Lelarep View Post
    The frame is semi-rimless, extremely thin and light. a Lightec-Morel frame. I can get the exact model if you need it.
    The exact Rx would be more helpful. Toss in the old Rx for good measure, and any other history that is pertinent, VAs, age, etc.

    He literally said "Money is no option" without being asked about cost, so apparently the implication is that he wants the best possible lenses regardless of price, so nothing is off the table.
    Consider contact lenses, with spectacle lenses over as needed.

    Best regards,

    Robert Martellaro
    Roberts Optical Ltd.
    Wauwatosa Wi.
    www.roberts-optical.com
    ~~~~~~~~~~~~~~~~~~
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    What's up? drk's Avatar
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    This case is complicated.

    First, just because the patient "wants the best", it doesn't mean anything other than he's motivated to get the best vision, and will spend money. It doesn't mean there IS a "best" for him. Don't let his eagerness set your agenda.

    Second, without such things as:
    His history
    His refractive error
    His BCVA
    His binocular status

    it's going to be impossible to determine what exactly this guy would benefit from, and what is just wasted time, money, and effort.

    It's highly doubtful his OD even knows what he's doing in this case.

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    Ok, hopefully this is enough info.

    Old Rx (from 3 years ago, patient isn't very good about coming for yearly exams):
    OD: +3.75 -4.75 x 075
    OS: -1.25 -0.75 x 118


    New Rx:
    OD: +3.50 -4.75 x 078
    OS: -1.50 -0.75 x 115

    BCVA: 20/25

    Patient is male, 39, nominal medical history, reported to have worn glasses throughout childhood, but stopped wearing them from adolescence until mid-20's where he apparently found he could longer compensate without them. History shows that he is a functional myope, records provided from previous OD show that OS sphere was plano as a teenager, OD sphere was +4.75. There is no record of problems with fusion. Patient basically used only his left eye after he stopped wearing corrective lenses due to amblyopic suppression. Binocular vision is reported as problematic and limited. Gross depth perception is acceptable, but fine depth perception appears to be non-existent beyond about 10 feet. Patient reports gross "depth from motion" (that's what is written in the record, I've always called it dynamic depth perception) is acceptable, record indicates patient reported, "I can tell the difference between a ball coming at me that is thrown from 10 feet away or two feet away" but finer function is apparently almost non-existent "I couldn't tell you, if a ball was coming at me, if it was 6 feet or 4 feet away from me at a given moment" patient also reports "I couldn't catch a ball if my life depended on it. If someone throws something to me, I have a general idea where it is going to land, but that's it. Also, if I throw something, I can gauge generally where it will land, but with absolutely no precision or accuracy" Patient reported inability to see anything in "hidden image/Magic Eye books" and has very limited ability to experience 3D movies and television and feels severe eyestrain when doing so.

    Let me know if you need anything else, I should be able to provide it.

    Quote Originally Posted by Robert Martellaro View Post
    The exact Rx would be more helpful. Toss in the old Rx for good measure, and any other history that is pertinent, VAs, age, etc.

    Consider contact lenses, with spectacle lenses over as needed.

    Best regards,

    Robert Martellaro
    Record indicates that contact lenses with corrective lenses was discussed with patient, patient declined this option, indicating they had absolutely no interest in it.
    Last edited by Lelarep; 03-19-2019 at 01:09 PM.

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    IMO pick your favorite POW compensated design FFSV lens design, take and input the required measurements, and go with it. I prefer IOT as well, but ask 12 people what they think the best car is and you will get 12 different answers. I doubt it makes a lot of difference in this case. However a narrow rectangular frame would be best. The shorter the B measurement the better.

    On a side note, did you get the OD/OS backwards? I've never seen anyone put OS on top.

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    Quote Originally Posted by Kwill212 View Post
    IMO pick your favorite POW compensated design FFSV lens design, take and input the required measurements, and go with it. I prefer IOT as well, but ask 12 people what they think the best car is and you will get 12 different answers. I doubt it makes a lot of difference in this case. However a narrow rectangular frame would be best. The shorter the B measurement the better.
    My favorite is Zeiss Individual SV, but I wanted to get more opinions to see if there are better options for this case, or if I was missing anything.

    Quote Originally Posted by Kwill212 View Post
    On a side note, did you get the OD/OS backwards? I've never seen anyone put OS on top.
    Yes, I did. Thank you for that. Corrected.
    Last edited by Lelarep; 03-19-2019 at 01:16 PM.

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    What's up? drk's Avatar
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    There are mixed messages, there.

    1. He had anisometropic amblyopia/ he has 20/25 acuity in both eyes..
    2. He has no fusional issues/ he has no stereoacuity.

    I would venture that his binocularity is screwy on a fine scale. His gross stereo is probably fine. He must be a central suppressor, however.

    I would not do an iseikonic design because 1. duh, he doesn't like it. 2. duh, it will make the OS quite thick. 3. I doubt at this point he'd get any fusion from it, anyway. Maybe if he were treated younger.


    Your best bet, as I see it, is just to make a nice set of digital SV. The left eye doesn't even need an atoric, of course, and that's his dominant eye. But the right would benefit in the horizontal VF, and heaven forbid he's a "close the left eye then close the right eye" compare-er (and he sounds like that type!).

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    Quote Originally Posted by drk View Post
    ...Your best bet, as I see it, is just to make a nice set of digital SV...
    Any in particular you'd recommend, or you agree with Kwill that it's sort of 6 of one and 1/2 a dozen of the other.

    Quote Originally Posted by drk View Post
    ...and heaven forbid he's a "close the left eye then close the right eye" compare-er (and he sounds like that type!).
    I get a strong sense you are correct.

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    Any other opinions on this, or you all pretty much see it the same way, excluding IOT as the #1 for FFSV, it's basically of 6 of one and 1/2 a dozen of the other as far as the rest of the FFSV option out there for this individual?

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    I wish I knew the answer to that!

    I would imagine all FFSV designs are different, but "less different" than PAL designs.

    But I would also imagine that it's a less heavy lift than PAL design.

    We know from that past that aspheric SV lenses have different rates of (eccentricity?), and a Sola Spectralite would be different than a Essilor 1.67 ASV. So we can assume that the digital atorics have the same uniqueness.

    But the lens geeks at Zeiss or IOT or Hoya, or Seiko, or Shamir probably have all the smarts needed to make a good design.

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    Quote Originally Posted by drk View Post
    But the right would benefit in the horizontal VF, and heaven forbid he's a "close the left eye then close the right eye" compare-er (and he sounds like that type!).
    I see that frequently, and have to tell them to cut it out. Is there someone on the web telling folks to check their vision with one eye closed to establish if the eyeglasses are designed/fabricated properly? It's somewhat like buying a new pair of shoes, standing on one foot to see how they feel.

    Quote Originally Posted by drk View Post
    We know from that past that aspheric SV lenses have different rates of (eccentricity?), and a Sola Spectralite would be different than a Essilor 1.67 ASV. So we can assume that the digital atorics have the same uniqueness.
    Sola's SV lens had two levels of flatness/asphericity- regular ASL and flatter ASL+.

    But the lens geeks at Zeiss or IOT or Hoya, or Seiko, or Shamir probably have all the smarts needed to make a good design.
    Keeping in mind that the original iD, Definity, and others had no optimizations, except for splitting the adds or cyls. Even the Auto 2 was/is a fairly dumb lens, with an Rx tweak but a mostly static progressive design. Call the manufacturer for specifics, also asking for a copy of the clinical trials, if any.

    Another concern is how compromised the design becomes when the Rx is at the margins, the >10 DS and >4 DC or prescribed prism type RXs. In some cases, especially with prism, I'm finding that traditional grinds significantly outperform the realtime software on free-form platforms.

    Best regards,

    Robert Martellaro
    Last edited by Robert Martellaro; 03-21-2019 at 03:08 PM.
    Roberts Optical Ltd.
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    The main reason he said he wanted to go FFSV is to try and eliminate the oblique aberration he sees in his lenses, mostly OD, as much as possible because he apparently find it quite annoying.

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    Quote Originally Posted by Lelarep View Post
    The main reason he said he wanted to go FFSV is to try and eliminate the oblique aberration he sees in his lenses, mostly OD, as much as possible because he apparently find it quite annoying.
    There should be better off-axis performance, especially if his present lenses are low Abbe and/or a non-optimized design. The difference for some brains might not be obvious though, especially when the complex Rx is in one eye only. Moreover, distortion can't be reduced with the above methods, unless you can reduce the vertex distance over his previous eyeglasses.

    Best regards,

    Robert Martellaro
    Roberts Optical Ltd.
    Wauwatosa Wi.
    www.roberts-optical.com
    ~~~~~~~~~~~~~~~~~~
    Science is a way of trying not to fool yourself. - Richard P. Feynman

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    I am an amblyopic hyperope-presbyope with -3.75 cyl in one eye, who has been wearing an XFit for a few years, but recently changed to the SHAW lens for amblyopia and I have NEVER seen better than with this SHAW lens (in progressive edition). The OD can prescribe specifically for ampblyopia and/or anisometropia. We use Cherry Optical.
    Last edited by FANCYEYE; 04-19-2019 at 06:21 PM.

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    He's 39, so must have a small add? I'd therefore recommend a Zeiss Digital Individual - 1.74 with an 0.50 add. This will give him excellent distance vision plus an improvemnt at near versus his old glasses.

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    Quote Originally Posted by Lelarep View Post
    Patient is male, 39, nominal medical history, reported to have worn glasses throughout childhood, but stopped wearing them from adolescence until mid-20's where he apparently found he could longer compensate without them.. Patient basically used only his left eye after he stopped wearing corrective lenses due to amblyopic suppression.

    it's nice that he's so concerned with this vision now and putting the pressure on you to make it work. However, glasses may not be the the only option to repair his vision. Is he seeing an ophthalmologist and or neurologist?

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    Quote Originally Posted by Oscar View Post
    it's nice that he's so concerned with this vision now and putting the pressure on you to make it work. However, glasses may not be the the only option to repair his vision. Is he seeing an ophthalmologist and or neurologist?
    I agree, but we work with what patients bring to us. He's seeing both.

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    Following up on this one. We just recently gained access to IOT when we added another lab with whom we work. General consensus is that they are still the superior choice for FFSV?

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    I wonder why he'd see an ophthalmologist and a neurologist?

    I wonder how we can ever judge what atoric lens design is the best? We have no way to compare. :(

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    Quote Originally Posted by drk View Post
    I wonder why he'd see an ophthalmologist and a neurologist?
    The original patient mentioned? Apparently neurovascular issue that led to ocular complications, from what the file said. From what was written it seemed like complications of an unknown AVM that suddenly presented basically overnight. There are notes from neuro, optho, neuro-optho, etc... it goes on and on.

    Quote Originally Posted by drk View Post
    I wonder how we can ever judge what atoric lens design is the best? We have no way to compare. :(
    I don't think an objective comparison for FFSV is reasonably possible, what goes into these various designs is so complicated no one but the best lens people understand them these days. it basically comes down to what people have heard regarding the various lens types dispensed as has been reported back by patients that have worn them. With enough data, one can get a fairly good idea, in a subjective sense, if one is better than another. Since we just got access to IOT, I wanted to make sure people still see them as providing a superior experience before we started moving in that direction. Last thing anyone wants to do is go in a certain direction and it actually provides an inferior experience. That's a good way to have some rather unhappy patients.

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    Best approach is reduce binocular rivalry by:

    1. Frame Choice: Size and pupil placement
    2. Definitely Shaw lenses
    3. If some rivalry /binocular tension remains, consider the Commet approach and use a 10-20% tint in the non dominant eye.

    B

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    Quote Originally Posted by Barry Santini View Post
    Best approach is reduce binocular rivalry by:

    1. Frame Choice: Size and pupil placement
    2. Definitely Shaw lenses
    3. If some rivalry /binocular tension remains, consider the Commet approach and use a 10-20% tint in the non dominant eye.

    B
    I don't think 2 and 3 are very good advice given

    "Patient is aniseikonic, absolute differential magnification between the eyes is ~4.8% (left eye magnifies, right eye minifies), but declined any interest in handling the issue. Apparently he has tried to address this before and hated the outcomes."

    and

    "Binocular vision is reported as problematic and limited."

    and

    "amblyopic supression"

    Attempting to restore binocular vision at this point is going to cause more problems for the patient. Shaw lenses have their place, this isn't it IMO.

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