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Thread: PAL non-adapt and variable insets

  1. #1
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    PAL non-adapt and variable insets

    Hi all,

    I'm experiencing a bit of head-scratcher.

    Have a px who presents with:
    OD +1.00/-0.25x67
    OS +1.00/-0.25x92
    Add +2.25
    Distance PDs R 31.5 / L 35.5
    Near PDs R 29.5 / 32
    White-collar desk top worker

    He's worn our indoor PALs or occupational progressives for the past 2 years and has been really happy with them.

    Given his relative new experience with multifocal lenses, we decided a soft-er design was appropriate given his needs (he wanted to have a carry-along pair to work when he forgets his indoor PALs).

    He came back within a few days of pick up to complain that his intermediate and near weren't sharp and very narrow. We explained the nature of the multifocal choice to him again and explained that we can opt for a different design to cater more for his distance and near but would yield on the intermediate.

    I'm surprised he didn't complain about his distance as well. So I am thinking, before remaking the glasses, could his case be that he requires a variable inset PAL given his very imbalanced PDs and variable insets which would require varying umbilical angles as he's viewing down into intermediate and near (hence he's problem with intermediate and near, but not distance?)

    And if so, of the 3 labs we use, only 1 design implements the variable inset (Nikon See Wide). Does anyone have a similar experience?

    What is everyone's thoughts?

    Thanking you in advance

  2. #2
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    The inset difference is going to be about .2mm, I don't think that is your problem. I would say unrealistic expectations, lens design, and possible fitting errors, are the culprits. Also that is a tough Rx for just occasional wear.

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    Physio DRx is a lens I have used with people who want more intermediate zone with some success.

    But if you are used to having a NVF lens for working on the computer... a more standard progressive, even a fancy digital lens will still feel worse for working on the computer. That's just the compromise you have to give up when you incorporate three visions (Distance, intermediate and near) vs two (Intermediate and near)
    Last edited by NAICITPO; 04-29-2022 at 05:21 PM.

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    Master OptiBoarder rbaker's Avatar
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    Quote Originally Posted by eyemechs View Post

    He's worn our indoor PALs or occupational progressives for the past 2 years and has been really happy with them.
    What is everyone's thoughts?

    Thanking you in advance
    You can't improve an asymptomatic patient. Let sleeping dogs lie.

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    Quote Originally Posted by Kwill212 View Post
    The inset difference is going to be about .2mm, I don't think that is your problem. I would say unrealistic expectations, lens design, and possible fitting errors, are the culprits. Also that is a tough Rx for just occasional wear.
    Fitting is spot on.
    The insets are: R 2 and L 3.5. Making the variation 1.5mm. Could that be significant enough?

    And what makes you say that the Rx makes for difficult occasional use?

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    I was going to stay out of this, but…..
    Patient is a habitual specialty lens wearer wanting a PAL to try to do the same. Even with an intermediate biased design, this is a lose/lose situation.
    Tell the pt to stick to comp PALs for work, needs a second pair for general use, and not expect the same from an everyday PAL.
    This has nothing to do with inset. Pt needs a wide intermediate and near for work. Period.
    I bend light. That is what I do.

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    Quote Originally Posted by lensmanmd View Post
    I was going to stay out of this, but…..
    Patient is a habitual specialty lens wearer wanting a PAL to try to do the same. Even with an intermediate biased design, this is a lose/lose situation.
    Tell the pt to stick to comp PALs for work, needs a second pair for general use, and not expect the same from an everyday PAL.
    This has nothing to do with inset. Pt needs a wide intermediate and near for work. Period.
    lensmanmd, I respect your input. It's why I pay a subscription to be included in a community who can be critical and correct errors in my knowledge.

    He knows that it shouldn't be as good as his indoor progressives, however it's significantly narrower and has poor VA at near and intermediate? Rx and all fit parameters have been triple checked.

    Is this really just an expectations thing?

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    I would expect it is. He’s expecting his PAL to work the same as his occupational PAL. It never will. Heaven forbid when his add changes by 1/2D, and the corridor narrows more.
    I bend light. That is what I do.

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    Frame panto would be my first thought on this one? Have you tried increasing it? And how does it compare to his previous pair?

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    Quote Originally Posted by lensmanmd View Post
    I would expect it is. He’s expecting his PAL to work the same as his occupational PAL. It never will. Heaven forbid when his add changes by 1/2D, and the corridor narrows more.
    +1

    Computer PALs are so much more forgiving.

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    Quote Originally Posted by eyemechs View Post
    Fitting is spot on.
    Trial frame the full near Rx. If the VA is good in the trial frame the fitting, or lens design, is off. If the VA in the trial frame is not good, the Rx is off. Start with the easiest solution.

    Quote Originally Posted by eyemechs View Post
    The insets are: R 2 and L 3.5. Making the variation 1.5mm.
    How do you figure? 3.5 would be very strange inset value considering to provided information. I assume these are measured near PDs? Inset is based on Distance PD, Working distance, Stop distance, and distance power at 180. The eyes are a fixed distance apart and the near object is at a fixed point in space. Inset is a mathematics formula. Assuming a stop distance of 27.5mm and a 40cm working distance, there is 2.07mm of inset needed for the right eye and 2.34mm for the left.

    Inset is not the problem.


    Quote Originally Posted by eyemechs View Post
    And what makes you say that the Rx makes for difficult occasional use?
    A new-ish glasses wearer, in their 50-60s I assume, habitually walks around with +1.00 uncorrected distance Rx and is happy, is not a great candidate for general purpose PALs IMO. If he has a desire for better distance acuity, and wants to wear glasses full time, then I would be willing to give it a go. Occasional use of a +1.00 +2.50add new wearer is not a likely recipe for success.

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    OptiBoardaholic KrystleClear's Avatar
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    Quote Originally Posted by NAICITPO View Post
    Physio DRx is a lens I have used with people who want more intermediate zone with some success.

    But if you are used to having a NVF lens for working on the computer... a more standard progressive, even a fancy digital lens will still feel worse for working on the computer. That's just the compromise you have to give up when you incorporate three visions (Distance, intermediate and near) vs two (Intermediate and near)
    ^^^ I second this. Most of my office worker patients have been happy with the Varilux Physio Drx... BUT if he's used to a specialty lens, there's a good chance he won't like anything but that. Sometimes they're wanting too much from one set of lenses and the expectations are too high.
    Krystle

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