Progressive troubleshooting!!?$#%###

[vinmcmahon]

Progressives can be great, but when a customer/patient returns with a complaint, what tips to the optiboarders have for addressing this? Sure we check pds seg hgts, pantoscopic, facial wrap and prescription. But what are the finer points of getting to the heart of the matter, assuming the prescription is accurate and approptiate for the patient? What is the sequence of events you will follow TOMORROW to address this perplexing issue?

Thanks in advance,

Vin McMahon

[chip anderson]

Depends on what the complaint is.

If they say the can't see at distance: Have them turn the head down or up and see if va improves if it does: Either the Rx is wrong or you have the seg too high or low.

Check head postion when the patient is standing, looking straight ahead and at rest (not propted up or standing at attention). Head positon can mean a lot.

If patient can't read try rasing glasses, see if they turn their head down (as opposed to eyes down) when reading, no one can read through the top of glasses.

Even if pantoscopic angle is "correct" some folks are happier with a little more or less.

Ask if this the patient's first pair of bifocals or the first pair of PAL's. See if the patient is attempting to "adapt" by keeping the glasses on top of the head or in the dresser drawer except when reading is required. No one "adapts" if they don't leave the glasses on the nose.

If patient complains of brick sidewalks with a strange pattern in the layout, increase pantoscopic angle.

Chip

[johntricity]

Doc, As Chip said " it depends on the comnplaint". I have done a lot of progressive troubleshooting and the most important Tip I ever got and trained Opticians on is the "Mirror Trick". I'll try to explain it here, please call me if you need further explination.

The "Mirror Trick" starts by marking the progressive lenses with the fitting cross and the reading circles. The marks must be clear and easy for you to see. With the patient sitting across for you at a dispensing table, have the patient hold a hand mirror at the same position as a reading card. Place a large dot ( 5m/m) in the center of the mirror with a marking pen.
have the patient hold the mirror in the reading position and look at the dot, then you tilt the mirror towards you as you look in the mirror you can see the patients eyes in the mirror reflection and determin if they are looking though the reading circles or if the reading circles are to wide or too narrow. the most common mis alignment seen is one eye will be looking though a circle and one won't.
At this point you can move either or both reading circles to their correct position and go backwards to determin the P.D. needed on the reorder. I can probally explain this better on the phone. please don't hesitate to call me at 866-487-3406 John Z.

[Robert Wagner]

Hi Johntricity

Thank you for a "new" style in troubleshooting PAL wearers!

I will be using your technique when it's necessary.

Thank you again!
Robert
:D

[Robert Martellaro]

I would have the optician read or re-read "Expect the Unexpected" or the "Zen and Art of Dispensing Ophthalmic lenses." It goes something like this... The Tao of dispensing involves pondering the fate of the glasses, the client, and the optician. A dialog with the client involves deep listening followed with the deep personal knowledge of varying PAL designs followed by a through study of the preambles of Murphy's Law culminated with deep meditation.

Robert

[aaron]

Doc,

I know for myself the most important thing in dispensing progressives is the lifestyle questions you ask the patient.

While it may seem like you have a basic understanding of the patient, if they come back with a problem with everything seemingly fine, it may be neccesary to dig a little deeper into their SPECIFIC complaint. Maybe it is a lack of vision while they are driving or a problem at their work station etc... There is always a SPECIFIC complaint. But it is truely an art form to draw out of a patient, that which they may not even be aware of.

I had a patient who had never worn a multifocal of any kind and had a very low add. This would normaly be the ideal candidate for a PAL. But the dispenser didn't quite dig deep enough into the patients specific expectations. She reads very large spread sheets over the span of an entire desk, has a computer about 12 inches away from her face, and used to wear monovision glasses??? Needless to say it has been a nightmare that could have been avoided by the optician talking just a bit more about her expectations and working enviroment. Then the answer would have made itself clear. There is no ONE pair of glasses to solve her woes. She has to have multiple pair.

While a PAL is truely an incredable inovation, it is NOT the one pair of glasses that fixes everything that many would like you to think it is. This has almost always been the problem every time I have had a redo. (accept of course for the occational bo-bo).

Hope that helps in terms of solving the day or weekafter problem.

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[Homer]

vinmcmahon said:
.... But what are the finer points of getting to the heart of the matter, assuming the prescription is accurate and approptiate for the patient?

While you don't have to assume the prescriptrion (that is the lenses) is accurate because you can verify that, you can't assume the prescription is appropriate.

It would be very interesting to know more about the RX, lens type and use.

I have often seen in my few years of filling OD and OMD Rx's that the patient is not happy with what the doctor has presumed to be "appropriate". I think it's the contact lens guys who came up with the term 20/happy. That applies to glasses too. I have often had to "adjust" the Rx. (OH GOD! don't tell anyone I said that!) in order to get the "happy" part of the equasion.

It would be great to hear what you have discovered so far.

[Texas Ranger]

John, thanks for the "mirror trick" deal, that could help some. it's an interesting thing that all of the refractive factors on done on straight line plane; sphere lens, cylinder lens, add lens, even in the trial frame; when no multifocal can duplicate that visual environment, and yet there can and sometimes are clients that have some muscle anomoly that causes the line up in the near area to not be normal; maybe we should be doing that mirror test "before" we put them in a PAL. but I can't imagine move a complex distance rx pd to compensate for the near line up. any other suggestions? Now, the one big assumption I see when trouble shooting is that some opticians must surely "assume" that folks have uniformly positioned eyes, NOT. measure monocular pd's and monocular seg heights, then double check them, and then trust it... had an OD who runs a franchise store nearby, send me a pt last week to "adjust his glasses", his staff had been unable to satisfy the man. been back 7 times, and they had the attitude, "oh, it's you again?" well, he's wearing PALs, and to properly adjust them, it's important to spot the dots, then they turn out to be 10 degrees up nasal rotation each eye, so I called the doc, told him I was sneding him back, and why, he just said"all I wanted you to do was adjust them..." well, he did go bak, the doc found the problem and got it fixed; hasn't called me back about it....

[rolandclaur]

I have a little bit of a variation on that mirror trick.. What I do is I mark the pupils and the appropriate verification circles... then I have the patient stand up and look at a piece of material.. I get on my knees and I try and see if I can their pupils through the circles.. of course this puts me in an akward position of looking up their nose if they have boogers.. but oh well ... and if there is some variation in the inset for reading.. i adjust the p.d accordingly while still working under A.N.S.I. standards for horizontal decentering... hhmmm hopefully i make sense.. i'm sleepy

[rolandclaur]

Also, I have these over refracting spheres that came with the Acuvue Bi-focal trial fitting set that the doctor received.. They come in power spheres of +.50, +.25, -.25, and +.50.. I place them over the lens in accordance to which area they are having trouble seeing.. They are pretty small and only about 7 mm in diameter and I know that I am probably doing some of the doctor's leg work, but if they can see better through the over refractive spheres..at least the patient is a little more secure in the direction they need to be headed with their progressives.. I have done this numerous times before I got fired at Wal-mart in the pst 4-5 months and every single time I did it and they saw better, the doctor changed the RX..