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Thread: Help please

  1. #1
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    Help please

    Have a 55 year old female. Old Rx from 2017 is
    OD: -9.75 -2.50 019 +2.25 6BD
    OS: -12.75 -2.25 163 +2.25 6BU
    Has a pd of 24.5/26.5. Her old frame is a 48 eye,15 bridge with a B of 29.5. She was in Hora Array 1.67 VL with seg of 19

    New RX from 2019
    OD: -9.75 -2.50 023 +2.25 5.5BD
    OS: -12.00 -2.50 164 +2.25 5.5BU
    Pd was made with 24.5/26 and frame info 48 eye, 15 bridge with a B of 32.3. Put her in Hoya Array 1.67 VL with seg of 18

    Her old glasses work great, however she won't even take her new glasses. She complains that the OD is wrong and won't wear them. She says the distance is just blurry. I've already remade the glasses 4 times with no success, so this will be number 5. Had her in twice for RX check, double checked pd's, prism reference point, seg's and everything. Doc is thinking if we can't figure it out just to go back to her old RX. During the RX she definitely prefers less prism, but I'm out of ideas on what to do. Any idea's of something to try would be appreciated.

  2. #2
    Master OptiBoarder CCGREEN's Avatar
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    4 degree axis change on a 250 cyl for right eye is a lot. I assume no complaints about the left? 250 cyl and 1 degree of change pt accepts it? I would see if the Dr would bless a axis of 21 and in 3 months go to 23 if he feels that is the axis needed.

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    What's up? drk's Avatar
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    Holy crap what a trainwreck!

    Pd = 50? Is she a dwarf?

    12^ vertical? Whaaaattt?

    3D ansio?



    And FOUR remakes? And you're still going at it?

    Reality is, even a frame change can throw stuff off. Just a few degrees of face form or panto or vertex can upset the apple cart. (She WOULD eventually adapt.)

    If she's a "normal" personality-type, MAKE her take the glasses and try them. She needs you more than you need her. Someone like this should stay with one provider and never, ever change care.

    If she's a "nut-job", give her the refund and run away and be glad.

    A Hail-Mary: she's probably not at all binocular, and clearly the right eye is the dominant eye. Try passing about 3 of those prism diopters off onto the left eye.
    Last edited by drk; 06-26-2019 at 07:24 AM.

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    Master OptiBoarder AngeHamm's Avatar
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    Quote Originally Posted by drk View Post
    Try passing about 3 of those prism diopters off onto the left eye.
    If her old RX had 6/6 prism and the new one is 5.5/5.5, I don't think changing to 6/3 is going to help.
    I'm Andrew Hamm and I approve this message.

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    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    Self delete.

    Ooppss vertical!

  6. #6
    One eye sees, the other feels. OptiBoard Gold Supporter
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    Quote Originally Posted by bta89 View Post
    Have a 55 year old female. Old Rx from 2017 is
    OD: -9.75 -2.50 019 +2.25 6BD
    OS: -12.75 -2.25 163 +2.25 6BU
    Has a pd of 24.5/26.5. Her old frame is a 48 eye,15 bridge with a B of 29.5. She was in Hora Array 1.67 VL with seg of 19

    New RX from 2019
    OD: -9.75 -2.50 023 +2.25 5.5BD
    OS: -12.00 -2.50 164 +2.25 5.5BU
    Pd was made with 24.5/26 and frame info 48 eye, 15 bridge with a B of 32.3. Put her in Hoya Array 1.67 VL with seg of 18

    Her old glasses work great, however she won't even take her new glasses. She complains that the OD is wrong and won't wear them. She says the distance is just blurry. I've already remade the glasses 4 times with no success, so this will be number 5. Had her in twice for RX check, double checked pd's, prism reference point, seg's and everything. Doc is thinking if we can't figure it out just to go back to her old RX. During the RX she definitely prefers less prism, but I'm out of ideas on what to do. Any idea's of something to try would be appreciated.
    The new frame has more B, but the new pupil height is lower (2mm AC). This usually signifies a frame that is sitting to high, and consequently too far out from the cornea (vertex distance), with increased levels of chromatic aberration and distortion. For reference, my minimum target is 4mm above center. The larger B also increases the lens thickness (the prism is on the vertical meridian) for more distortion, weight, and thickness. I suspect the new frame is causing most of the discomfort.

    The narrowest IPD I've measured for an adult is 54mm. Occlude the fellow eye if strabismic.

    There should be unequal pupil heights due to the prism, unless the eyes are naturally uneven in the opposite direction.

    Hoya's 1.70 index will have noticeably less chromatic aberration (improved on and off-axis acuity) than 1.67, if the blank thickness is sufficient. 1.60 would be best.

    Hope this helps,

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

  7. #7
    What's up? drk's Avatar
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    Quote Originally Posted by AngeHamm View Post
    If her old RX had 6/6 prism and the new one is 5.5/5.5, I don't think changing to 6/3 is going to help.
    What DO you think is going to help?

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    Master OptiBoarder AngeHamm's Avatar
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    Quote Originally Posted by drk View Post
    What DO you think is going to help?
    I don't know. It's a seriously screwy RX. But if lowering the prism caused the patient to complain, I don't see how lowering it more will make her more comfortable. I suspect they're going to end up going back to the old RX and light a candle for St. Ryser.
    I'm Andrew Hamm and I approve this message.

  9. #9
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    Keep in mind that HOYA's Array lenses are free-form lenses. I notice you didn't mention anything about position of wear measurements in the OP, so if (like Robert says) the frame is positioned significantly differently on her face, the Rx compensation can absolutely cause interference here, especially if you haven't indicated the measurements and your lab used the standard set.

    Using the Array as a variable length may also be causing you an issue. At a 19mm fitting height, they're giving you a longer (albeit very slightly so) corridor as compared to the 18mm fitting height, which may be helping to keep oblique astigmatism out of her natural line of sight. Combine that with an axis spin in her OD, a larger frame that likely sits further from her face, and likely differences in Rx compensation, and you may have a perfect storm of teeny little details coming together to cause a bigger issue.

    What's the fix? Well that may be quite a challenge now considering how many times your patient has been back to the office. I'll give you my take as if it were the first time we were troubleshooting, just after the patient came out from her first Rx check.

    First, I'd check frame adjustments, making sure the positioning is similar in her new frame to her old frame. Next, I'd take position of wear measurement for the new frames, then make sure to indicate them on the lab order. Also on the lab order, I'd pick the corridor length instead of using variable. After adjusting, the frame will likely sit lower on her, so the fitting height will likely increase. I'd pick either the 13mm or 15mm fixed length, depending on her visual needs.

    Finally, and perhaps most importantly, I would manage the patient's expectations. There's been a lot of little changes across the board with her. It's completely reasonable to expect adaptation. I'd have her take the glasses after the remake, and don't wear them out of the office. I'd have her start fresh with the new glasses first thing the day after dispense (especially if she picks them up late in the day), and don't switch back to the old pair. I'd tell her that on the first few days, things like strain, fatigue and headaches are completely common, especially considering where her Rx is and where it has changed. What we are looking for is improvement to those challenges. I'd finally tell her to give them a solid two weeks, and if she notices no improvement, then come back. I'd tell her all of these things before even ordering the glasses, then re-iterate them at dispensing.

    As for where your patient is now? Well, honestly I would be talking to the office manager and possibly practice owners to determine at what point we pull the plug and refund her. Good luck with this one.

  10. #10
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    It seems obvious to me a recheck is in order...2.50 cyls as a rule don't swing that far

  11. #11
    What's up? drk's Avatar
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    Quote Originally Posted by AngeHamm View Post
    I don't know. It's a seriously screwy RX. But if lowering the prism caused the patient to complain, I don't see how lowering it more will make her more comfortable. I suspect they're going to end up going back to the old RX and light a candle for St. Ryser.
    My wild guess would be to see if she's looking through less prism, maybe the optics would be better in her better eye.

  12. #12
    Master OptiBoarder OptiBoard Silver Supporter Barry Santini's Avatar
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    If the price is lowered enough, there are no expectations to manage.

    B

  13. #13
    What's up? drk's Avatar
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    If the price were, like, totally totally lowered, then there'd be no one to take care of the eyes. There'd be absolutely no expectation of 21st century science and medicine, nor anyone to dispense it.

    We'd be blind, but we'd have fat wallets.

    But at least we wouldn't have disappointed patients.

  14. #14
    Master OptiBoarder OptiBoard Silver Supporter lensmanmd's Avatar
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    It’s all about 20/good
    I bend light. That is what I do.

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    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    When in a hole STOP DIGGING!!!

    Put the latest re do lenses in a tray. Tell her we'll give it one more try- After a week call her and tell her these are spot on but because of rx changes must be worn 2 to 3 weeks before the office will regretfully refund her money.

    Rotate the OD back to 19 as much as possible and wrap and panto the crap out of the shelf adjusted "new" rx.

  16. #16
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    Thanks for all the help. Unfortunately I had the day off yesterday when she came in for her RX check and once again I didn't get to help her, I've only dealt with her at dispense. I will keep everyone updated as to the final try if it works or not.

  17. #17
    Compulsive Truthteller OptiBoard Gold Supporter Uncle Fester's Avatar
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    As you keep digging.....on dispensing maybe get an Essilor progressive verification tape and position the hole over the pupil and see if distance is clear and only blurs when the rest of the lens is involved.

    fwiw- I'm glad I'm not the only one this happens to;)

    Hang in there!!!

  18. #18
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    The ARRAY is an IOT lens if I am not mistaken, with the ray tracing going into that lens accurate POW is beyond just necessary - especially with that RX. That is an awful lot of remakes, have you measured and checked vertex wrap and panto and what the values were entered prior to surfacing.

  19. #19
    Master OptiBoarder AngeHamm's Avatar
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    Quote Originally Posted by Tallboy View Post
    The ARRAY is an IOT lens if I am not mistaken, with the ray tracing going into that lens accurate POW is beyond just necessary - especially with that RX. That is an awful lot of remakes, have you measured and checked vertex wrap and panto and what the values were entered prior to surfacing.
    And BC.
    I'm Andrew Hamm and I approve this message.

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    Quote Originally Posted by Tallboy View Post
    The ARRAY is an IOT lens if I am not mistaken, with the ray tracing going into that lens accurate POW is beyond just necessary - especially with that RX. That is an awful lot of remakes, have you measured and checked vertex wrap and panto and what the values were entered prior to surfacing.
    It's a Hoya lens.

  21. #21
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    Quote Originally Posted by jefe View Post
    It's a Hoya lens.
    yeah I know it is but I thought they were using IOT designs for that lens, it was their FBS design as opposed to their other higher end dual side designs. I could be wrong but I swore a hota rep told me that 5 or so years ago. Either way my suggestion is the same

  22. #22
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    Ended up doing
    OD -10.25 -2.50 019 +2.25 6BD 25.5 pd
    OS -12.00 -2.25 163 +2.25 6BU 27 pd
    HOYA Array VL 1.67 seg 17

    The patient picked them up and seemed to enjoy the new lens. She didn't have any issues when she first put them on and haven't seen her yet. Maybe it was the fact that I told her the doctor wanted her to try them for several days before he would see her again. Glad that is all over. Lesson learned, don't change anything next year for her.

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    Now go and have a cold beer, you earned it.

  24. #24
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    I lied, didn't end up working, boo

  25. #25
    Master OptiBoarder OptiBoard Silver Supporter
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    Quote Originally Posted by bta89 View Post
    I lied, didn't end up working, boo
    What are the client's complaints?

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