Progressive Problem

**Leo M** · 09-10-2003, 10:01 AM

Hi I am new to this board, just found out about it a month ago. I am an Optician for 28 years and have run into a problem and thought I would seek some advice. I have fit a gentleman with Varilux Comfort, first pair of glasses. RX R Plano-0.50X020
L Plano-0.25X175 +1.00 Add OU. He sees fine out of his left lense but not his right. His near field of view in the right is very narrow. I have adjusted, made new lenses, changed height( now 20mm ) and had the Doctor re-check the RX. He still has the problem. What to do? Panamic? Slight oblique axis? I don't know. Any sugestions? Thanks for any help.

**Diane** · 09-10-2003, 11:08 AM

Leo,

First of all...welcome.

Next...give us some information.

It appears that you have probably verified accuracy of Rx, measurements, lens fabrication quality, etc.???

What is his best V/A both corrected, uncorrected, near and distant? What type of work does he do? Monoclular PD's? I know that you mentioned current fitting height, but why did you feel that you needed to change it? What was it originally? Frame size and shape? A, B, and ED measurements could help... Vertex distance, and tilt? Lens material? Which is his dominant eye? Does he have a posture problem/neck problem?

The Comfort is a good PAL. (Ensure that the lens is laid out correctly, not cut off at nasal.) Double check monocular PD. There could be a vast difference and that created the narrow field on the right. Before changing styles, I would absolutely, verify EVERY parameter on the lenses, and recheck each measurement.... and the fit.... But the Panamic could give him a wider near field of view.

Diane

**Leo M** · 09-10-2003, 11:36 AM

His monocular PD is 32/32 and I have checked it 5 times hoping I had made a mistake. The frame is a rectangular shape 50-20 with a B of 36 ED 51. I raised the height by 1mm thinking he might gain a little in width. He sees 20/20 near with the glasses on, without I am not sure. He owns he own appliance business, sales and service. The lense is plastic with anti- scratch coating(TD2). I have not played with the tilt since the problem was in one eye, maybe I should have. Hope this helpes.

**Homer** · 09-10-2003, 02:17 PM

My first impressions:

This person has had basicly good vision all of their life; perhaps this is his first pair of glasses and he would probably feel "hemed in" by glasses in general and bifocals in particular so PAL's can be even more restrictive unless he sees obvious benifit. Could be too soon to try to help him with near work.

Secondly, my rule of thumb is that the fitting cross will often be about 4 mm above the center of the vertical measurement; ie., 22 mm or more. If this person is wearing them for reading only and does not feel the need for them otherwise, then the hight should be 2 to 4 mm higher yet - perhaps a much as 26.

Suggestion: you might be 1 to 2 years early in addressing the presbyopia unless there is some other reason. When he comes in frustrated and asking for help the PAL (many good brands of PALS IMHO) will likely work. Perhaps you use a Zeiss RD or Office or something else for the first pair and treat them as sophisticated reading glasses.

Good Luck !

**Judy Canty** · 09-10-2003, 03:06 PM

I'm sort of with Homer on this one. I think that fitting height sounds like the real culprit. I have not been pleased with Comfort at less than 21 or 22 high. If that's what works in the frame, then I would recommend Panamic rather than Comfort. How long an adaptation has he had? Often patients come in within just a day or two when they really need as long as 10-15 days to retrain the visual system.

**Robert Martellaro** · 09-10-2003, 05:53 PM

Leo,

Sounds normal to me. My understanding is that pals are designed for binocular vision and that you can't evaluate the quality of near vision by holding your hand over one eye and then the other, but with both eyes open with the nose pointed at the object on the downgaze. If you have the fitting cross on the pupil and the 180 line is on axis, I would tell him that it is normal to see an asymetry in the image field at near with one eye at a time, and to read with both eyes open.

Robert

**Pete Hanlin** · 09-10-2003, 08:06 PM

Considering this is his first pair of glasses, there are a few things he'll be getting used to...

First, while the cylinder is minimal, it is a new component of his vision. In fact, so are the reflections and minor distortions that are inherent to optical lenses.

Second, I would venture to say this gentleman has moderate to good intermediate and near vision without near correction- this tends to lessen the motivation to wear the correction.

What about vertex distance? Sometimes adjusting the frames to sit even a mm or two closer can really help with width of field at near...

**chip anderson** · 09-10-2003, 09:30 PM

What has the patient done to "adapt?" If he just puts them on to read he will never adapt and would be better off with half glasses. If you can tell him to put them on his nose and leave them there except when sleeping for two weeks, I'll wager his "problem" will go away in less than five days.

Chip

This of course assumes that all the other things mentioned in the thread have been checked and verified and you haven't got a cheap lab that used brand x bifocal O.D. (because it was in-stock) and brand y O.S. (because it was in stock and you were in a hurry).

**Rich R** · 09-11-2003, 01:10 AM

Leo,

Maybe one eye does not converge much when reading, experienced that a couple times in last 15 years, had them put their chin up and look through reading part of glasses to spot monocular near p.d.
It's a long shot.
Rich R.

**varmint** · 09-11-2003, 02:20 AM

Sorry Pete,
I've been wearing prog lenses for over 8 years now and the only ones I've had problems adjusting to were varilux panamic & comfort. I finally can wear the comfort after I put lots of panto tilt on them,(chipped a lens doing it) but I still find myself hunting for a good reading area, especially when I am measuring PD's & seg hgts. I have had better success with other designs and find it hard to honestly push Varilux even though a good friend of mine has taken over as mgr our local Essilor lab.
As far as Leo's pt, I agree with most other responses here that it is more of an adaption problem on the pt's part. His Rx is borderline necessary & the limitations of any lenses compared to natural vision are difficult to accept as they grow necessary.

**Corey Nicholls** · 09-11-2003, 06:40 AM

Might I suggest checking the near visual point as Rich R sugested. The easy way to do it is-

Mark the near centres on both lenses.

Get a mirror and put a mark (dot or cross) on it.

Sit down with the client sitting opposite you with the mirror between you (place the mirror about 40 cm from their eyes).

Get the client to look at the mark on the mirror while you look at their reflection to see exactly where they are looking through the lens at near.

Even after all of this, give the specs heaps of facial bow, and heaps of panto tilt.

Hope this helps.

**Deepak** · 09-11-2003, 07:53 AM

I am with Robert Monterro,also try adpter lenses in right eye.

**Homer** · 09-11-2003, 05:41 PM

you may be trying to correct a measurable visual deficincy but not a perceived deficincy. A little bit of over-kill here.

Trade him up to a pair of +1.00 ready-made readers until he gets frustrated with the situation - probably take a year or two.

Then work on the patients that really need your help and expertice .... today.