Progressive for an Engineer in fluid dymamics...different adds...

[Uncle Fester]

Very personable 78 year old scientific engineer (retired) presents a challenge to say the least.

Not happy with other attempts (plural!) not made by me, to make new lenses work as well as his old rx, where he has mixed an old lens creating different adds for very close near (circuit boards). He is in Zeiss which we do not deal with but silly me impressed him with my razzle dazzle explanations of what he was trying to do and I was baffled as to how he was making the "comfortable" rx work.

Cataract surgery 2018 OU

Complaint of blurred vision distance and near

Old/current frame is a very large square Accuflex 57-18

2018 lenses only outside rx
R-.75 -1.50 x100
L-1.75 -.50 x75 add +3.50

2021 lenses only outside rx
R-.50 -2.00 x74
L-1.25 -1.50 x77 add +2.75

2022 Our OD's rx
R -.50 -1.75 x109
L-2.00 -1.50 x74 add +3.50

My B&L Vertometer reading (add from etchings)
R0.00 -2.00 102
L-1.00 -1.50 85
add R +3.50
add L +2.75

He was not comfortable with matched adds when dealing with <10 inches. He does not want to wear jewelers loops or sv.

He swapped the right lens from the 2.75 to the old +3.50 and finds the mixed adds work well. I'm thinking he's subconsciously working monocularly.

YIKES!

He's VSP and Walman will not make Zeiss so what to do?

I'm being up front suggesting we keep the same mixed but comfortable rx (to heck with my doc's changes) in a new large square frame (the paint is wearing off from his old pair) so there is no change. Remember he's had issues when new rx's are created.

Now everything will match except the design.

If that is a problem we can throw something against the wall to see if it sticks with a n/c one time VSP redo to another available design and/or rx change.

If that fails he is not averse to going out of pocket for private pay Zeiss lenses with an understanding there will be no refund for any of these charges and by process of elimination the vision issue is internal or beyond my skill level to fix.

At least that's how the electric optician is going to roll on this one.

Wish me luck!!!

PS If he was a type A personality and gave me grief over this initial visit I would put my foot down and tell him to go elsewhere. Ya gotta know when to hold em and know when to fold em. Preferably before the flop so I'm out my ante (time) as this initial visit took an hour.

PPS His VSP is calendar year so we can go wild with changes then depending on feedback from this conservative approach.

[drk]

1. I never mix designs. Too sloppy.
2. I never go with more than a 1/2D PAL difference (if ever!). Too much room for trouble. Nope.
3. Cataract surgeon was pretty crappy in leaving him with that much surgical monovision, no matter how "nice" he was. Stupid technique. Sorry, not sorry. Plus, all...that...cyl...to boot. Makes the monovision even more pointless.
4. Grandpa is a little to blame, as well...he OK'd the monovision, probably. And he obviously didn't opt for any refractive upgrades. So he's not really a victim. Just to set the expectations, all around.
5. Dealing with things @ 10" (that's 25cm or +4.00, for you and me) is UNREALISTIC. That's a specialty pair of glasses, not a feature of a general purpose pair. (Not the least of which because it's tough to be binocular @ 25cm for any period of time...prism would be beneficial.)

BuT siNCe GrANDpa wANTs MaGIC glasseS, and since the horse left the barn with the surgeon riding, just spread the pain over distance and near zones.:

OD -0.50 -1.75 x 109 +2.50
OS -1.50 -1.50 x 074 +3.00
(OS has -0.50 disparity in distance zone, effective add OS is +3.50 with a 1D disparity in acuity and a 1/2D difference in PAL width.)

Should be trial framed. Probably would consider a short-ish corridor fit high as possible because of (minimal but not zero) aniso, and because the corridors will be goofed up a.) because he has intermediate in the left eye through the distance zone, already, by serendipity due to design, and won't need a corridor, and b.) because he will be progressively disparate as he looks down through unequal add build-up. That would be yuck, anyway. Digitally compensated design is a must, of course.

[Uncle Fester]

As the patient is new to the office I will be much more comfortable in January recommending we try to work with the new rx which we all know should be used but how it's tolerated is the big question due to his history of unhappiness in the past.

I do like your suggestion drk and will keep it as I further work with my new Doc over my idea to proceed as I think will work best for now.

[Uncle Fester]

Just dispensed the glasses with a positive reaction and I think we are almost there.

After discussion we decided on this rx:

R-.50 -1.75 x109 add +3.50
L-2.00 -1.50 x74 add +3.00

The distance is good using our new OD's rx and I tried drk's suggestion of not differing the add by more than .50 to a mixed reaction. While the near is ok a trial lens over the near of +.25 and +.50 has him saying "slightly" better.

I sent him home with a +.25 and +.50 uncut blanks and an admonition to not rush into a change and wear them for a week or so but I have a feeling the right add is going to need to be further tweeked under the VSP one time redo.

I was very relieved to have him comfortable in the Via Elite 2 as I have often found switching out of Zeiss designs an issue.

My guess is he'll be calling me next week for the change.

A rare exception to the norm but I suspect I will have a patient for as long as I'm around.

[Uncle Fester]

The verdict is in and after trial lens over the right with a +.25 or a +.50 at home he found vision was not better than what we made.

Phew!

Managing expectations and taking the time to create and explain options proved successful!!!

He'll be back for another pair using a new VSP in January.

[Robert_S]

�� congrats on traversing this minefield.

I suspect very few individuals in the world could have dealt with this as successfully.

And thanks for sharing as it's a useful case study.

[Barry Santini]

This Rx screams for the Shaw Lens.

[Uncle Fester]

Just curious Barry what do you charge for a Shaw lens?

I assume no office can guarantee the result and even the site says it is not a 100% successful but what is your success rate?

I haven't made one but I may offer it outside his VSP that is now available as he'll understand the underlying concepts and mathematics better than I can and may give it a try as private pay.

https://shawlens.com/the_shaw_lens/the_science/

https://shawlens.com/aniseikonia/amblyopia/