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Thread: Distance good, reading good, intermediate bad. A progressive puzzle.

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    Master OptiBoarder AngeHamm's Avatar
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    Distance good, reading good, intermediate bad. A progressive puzzle.

    I have a patient, let's call him Stan. He's presented me with a poser.

    Here's his old RX from May 2009:
    -1.75 -0.75 x082 +2.50
    -2.00 -0.75 x099 +2.50
    Varilux Comfort, Poly, Transitions Grey, Crizal Avance. Vertical alignment is perfect, OS OC is just a touch wide, but well within tolerance.

    Here's his new RX from December 2011:
    -1.25 -0.75 x073 +2.50
    -1.50 -0.75 x097 +2.50
    Varilux Comfort 2DRx, Poly, Transitions Grey, Crizal Avance.Vertical and horizontal alignment are spot-on.

    So my excellent doctor pulled his distance RX back a bit and I put him in a progressive with a wider reading and intermediate area. But Stan is having problems. He is complaining that his distance is clear, his reading is clear, but his intermediate is too hard to find the focus in. He's coming in today for a new refraction. The only substantial change from the old lenses to the new is that sphere power change, but I have a hard time imagining that that would affect his intermediate and not his distance or near.

    I have to admit to being a bit stumped. He's worn a nearly-identical PAL design for years, so I can't think that's the problem. His add hasn't changed, nor has his cylinder changed appreciably. I wanted to throw the problem out to my OB homeys today. He comes in at 420 this afternoon (EST). Any thoughts?
    I'm Andrew Hamm and I approve this message.

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    Independent Owner kcount's Avatar
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    I had this same issue last summer.
    Take a look at the new Rx, the sph is half the add. Thus the patient is Plano at intermediate. Of course the glasses are not working at intermediate. Any power you give him will resul in the patient saying the vision is better without the glasses at te computer. My suggestion, either educate the patient to this or bump the dist Rx back up.
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    OptiBoardaholic
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    the patient is Plano at intermediate
    The cylindrical correction (-0.75) is still there so it's not Plano.

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    ABOM Wes's Avatar
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    Assume your excellent doctor got the current rx correct.
    That means his real intermediate is OD: pl -.75, OS: -.25-.75
    To effectively reach this power in his old rx, he would be looking much lower in the pal, into the wider reading area.
    Perhaps he has trained himself to do this over time as his rx changed from 2009? Is he a heavy intermediate user?
    If so, he may have to either be re-trained, or fit with something that allows more intermediate use at the expense of near, or you could give him a trifocal which would allow clear vision at all distances.
    Wesley S. Scott, MBA, MIS, ABOM, NCLE-AC, LDO - SC & GA

    “As our circle of knowledge expands, so does the circumference of darkness surrounding it.” -Albert Einstein

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    OptiBoardaholic
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    Is the DRx lens frame and/or POW optimized (i'm not familiar with the lens)?

    If it's made with a shorter progression zone to optimize gaze lowering it could reduce the intermediate zone width.

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    Master OptiBoarder AngeHamm's Avatar
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    Quote Originally Posted by kcount View Post
    I had this same issue last summer.
    Take a look at the new Rx, the sph is half the add. Thus the patient is Plano at intermediate. Of course the glasses are not working at intermediate. Any power you give him will resul in the patient saying the vision is better without the glasses at te computer. My suggestion, either educate the patient to this or bump the dist Rx back up.
    The only wrinkle in this hypothesis is that the same -0.50 was lost in his reading, which he claims is fine. And his distance, which he claims is fine.
    I'm Andrew Hamm and I approve this message.

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    Optimentor Diane's Avatar
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    Trial him with single vision with the intermediate and see if the complaint is the same. Put him in front of a computer, etc.

    Diane
    Anything worth doing is worth doing well.

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    Independent Owner kcount's Avatar
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    Quote Originally Posted by Nikolay Angelov View Post
    The cylindrical correction (-0.75) is still there so it's not Plano.
    True, but the -0.75 is negligable to over all Rx satisfaction. Change this around if the patent had an add that read +1.50 they would forever take their glasses off and say the vision is better without. Why? because the viewing are in a PAL with an Rx near plano is too restrictive. The patient may have some blur sRx but has a near infinite reading area. The same hold true with intermediate. Just because we can quatitatively measure the need for an Rx doesn't mean the patient finds that Rx satisfactory. Barry Santini actually wrote his Masters paper in this very issue. (yes, I actually read papers when people send them to me)

    Quote Originally Posted by AngeHamm View Post
    The only wrinkle in this hypothesis is that the same -0.50 was lost in his reading, which he claims is fine. And his distance, which he claims is fine.
    Actually his reading power is now +0.50 stronger than before.

    Old Rx Near:
    +.75 -0.75 x082
    +.50 -0.75 x099

    New Rx Near
    +1.25 -0.75 x073
    +1.00 -0.75 x097

    I wouldn't be suprised if the chart showed they were ~20/25 Dist and J1 with the old rx. They probably the same with the new Rx. The only difference is the 'need' of the glasses to focus at the defined length (ie computer distance).

    Quote Originally Posted by Diane View Post
    Trial him with single vision with the intermediate and see if the complaint is the same. Put him in front of a computer, etc.

    Diane
    Yep, then break from work early for a cocktail.

    Nikolay, the Drx is a POW compensated Comfort. Given of course they sent in the POW measurments in which case they are "sorta' POW compensated". On another note, why do a compensated lens on so little of a cyl? I hvae yet to have a patient state any marked improvement in vision without first haveing >1.50cyl. exception being emerging presbyopes with their first PAL. (ie: my wife)


    Trust me on this one, I have already been down this road and pulled alot of hair out. (which as you can see from my picture is a difficult thing to do.) Not to mention the remade lenses.
    Last edited by kcount; 01-27-2012 at 11:58 AM. Reason: caught an error.
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    Ange:

    Stan, the man is 3 to 4 years older than he was in 2009, and his presbyopia is evolving, even tho no add change..........Either give him a seperate set for occupation, hobby, use with a very generous intermediate, or a trifocal.

  10. #10
    Master OptiBoarder AngeHamm's Avatar
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    You guys are fabulous. This is the power of community, professionalism, and the internet at work.

    Stan is coming in in about 30 minutes. I'll let you know what we do.
    I'm Andrew Hamm and I approve this message.

  11. #11
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    Wes is on the right track. Stan doesn't have enough room in the intermediate corridor at the distance he sits from his computer.

    Stan needs an Office lens.

  12. #12
    OptiWizard Yeap's Avatar
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    is your patient a heavy intermediate user? what i use to do here will be investigate the lifestyle such as how much time he spend on computer or any instrument that he need to operate during his working hour? if so usually we will fit with a occupation related solution such as a extended reading glasses or single vision that suite to his need.
    Yeap


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    ABOM Wes's Avatar
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    So what happened with Stan?
    Wesley S. Scott, MBA, MIS, ABOM, NCLE-AC, LDO - SC & GA

    “As our circle of knowledge expands, so does the circumference of darkness surrounding it.” -Albert Einstein

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    Manuf. Lens Surface Treatments
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    Redhot Jumper The intermediat is narrow.....the power increases fast ...................

    It is very simple ............at a 2.50 add the patient is in another category --------> old, older or real old.

    The intermediat is narrow.....the power increases fast and the head position has to move little by little to find the right spot. Many of the old people do have mobility problems, the head bent forward and lots more.

    They do not care that much anymore about wearing PALs, as the first hand choice of PALS is to make you look younger, but at a 2.50 add the face is seeded with wrinkles, so put them in a flat top and you will see they will be happy customers.

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    Quote Originally Posted by Chris Ryser View Post
    It is very simple ............at a 2.50 add the patient is in another category --------> old, older or real old.

    The intermediat is narrow.....the power increases fast and the head position has to move little by little to find the right spot. Many of the old people do have mobility problems, the head bent forward and lots more.

    They do not care that much anymore about wearing PALs, as the first hand choice of PALS is to make you look younger, but at a 2.50 add the face is seeded with wrinkles, so put them in a flat top and you will see they will be happy customers.
    There are many people with 2.50 adds in their mid 50's. I wear a 2.50 add and I am certainly not old, I'm 55. My face is not seeded with wrinkles.

    My progressives have a very useable intermediate area. I think a lot of the problems that people have their computer screens too high so they have to tilt their head back to see the screen. If the screen is low enough progressives often work well at computers.

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    Considering the decline in minus power, I would bet he is overplussed now even for reading but with the early development of cataracts the reading overplus is tolerable but not so much at intermediate as the overplussing in interemediate further narrows the width of field and might be more agravated by the positional development of the cataract.

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    The Comfort was designed before computers become common, its emphasis is entirely reading, after all its competition was ST-28's so any intermediate was in improvement over the ST-28. The intermediate is incredibly narrow.

    The New Comfort did move the corridor slightly, so he is losing binocular symmetry. To make it worse he is trying to find his old power, which is not where he is used to it.

    This is really a lens design issue, not an RX issue. You may want to consider another lens.

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    Manuf. Lens Surface Treatments
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    At the end they are still all the same ...............................

    Quote Originally Posted by sharpstick777 View Post

    This is really a lens design issue, not an RX issue. You may want to consider another lens.


    That is the perfect answer and solution for this thread. PALs are PALs and they have their limits even if the manufacturers design and redesign the power and distortion areas can not be overcome. At the end they are still all the same with tiny small differences, but they fetch a mighty dollar and that is why we have to move them.

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    ABOM Wes's Avatar
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    Quote Originally Posted by AngeHamm View Post
    You guys are fabulous. This is the power of community, professionalism, and the internet at work.

    Stan is coming in in about 30 minutes. I'll let you know what we do.
    Hey, Stan is 2 weeks late!
    Wesley S. Scott, MBA, MIS, ABOM, NCLE-AC, LDO - SC & GA

    “As our circle of knowledge expands, so does the circumference of darkness surrounding it.” -Albert Einstein

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    Quote Originally Posted by Chris Ryser View Post
    At the end they are still all the same with tiny small differences, but they fetch a mighty dollar and that is why we have to move them.
    Chris, I know you don't personally like progressives but plenty of people wear them happily and see great with them. That is the reason I sell them, not because they cost more then bifocals.

    I don't think you believe me when I say I see really well with my progressive glasses and have no issues with them. I never notice any "distortion" either. And it's not just me-lots of people do well with them.

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    Doh! braheem24's Avatar
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    Stan was using his .50 under-corrected reading zone for intermediate.

    Once corrected he did not like having to use the intermediate channel for the computer.

    In case it's not solved, drop him to a +2.00 ADD and everything will be better except J1.

  22. #22
    ABOM Wes's Avatar
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    Quote Originally Posted by braheem24 View Post
    Stan was using his .50 under-corrected reading zone for intermediate.

    Once corrected he did not like having to use the intermediate channel for the computer.

    In case it's not solved, drop him to a +2.00 ADD and everything will be better except J1.
    That's what I thought...

    Quote Originally Posted by APBOD View Post
    Wes is on the right track. Stan doesn't have enough room in the intermediate corridor at the distance he sits from his computer.

    Stan needs an Office lens.
    Quote Originally Posted by Wes View Post
    Assume your excellent doctor got the current rx correct.
    That means his real intermediate is OD: pl -.75, OS: -.25-.75
    To effectively reach this power in his old rx, he would be looking much lower in the pal, into the wider reading area.
    Perhaps he has trained himself to do this over time as his rx changed from 2009? Is he a heavy intermediate user?
    If so, he may have to either be re-trained, or fit with something that allows more intermediate use at the expense of near, or you could give him a trifocal which would allow clear vision at all distances.
    Wesley S. Scott, MBA, MIS, ABOM, NCLE-AC, LDO - SC & GA

    “As our circle of knowledge expands, so does the circumference of darkness surrounding it.” -Albert Einstein

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    Master OptiBoarder AngeHamm's Avatar
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    Sorry, guys. I wrote a long response two weeks ago and posted it and it vanished into the ether.

    Turns out Stan had a slew of other issues that he couldn't be bothered to share with his optician once he was in the doctor's chair. Changed his RX but kept him in the same lens style. The doctor and I are very skeptical that changing his lens style--which he's been wearing for a decade--is the solution to his problem. I'm pretty sure he just needs an RX tweak and is being all engineer about it.

    The part that made me feel good is that, in mid-exam, the doctor came to the lab and asked me to do a re-check lot of details that I had already worked on the day before. It was a nice moment of synergy in the office; both of us examining the same issues in the same order with minimal communication.
    I'm Andrew Hamm and I approve this message.

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    Master OptiBoarder AngeHamm's Avatar
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    (Also: the guy barely uses his computer, which renders a lot of his complaints kind of weird.)
    I'm Andrew Hamm and I approve this message.

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    Quote Originally Posted by AngeHamm View Post
    The doctor and I are very skeptical that changing his lens style--which he's been wearing for a decade--is the solution to his problem. .
    Actually, Varilux did that for you. The Comfort 2 is a more radical change than they have let on. The loss of intermediate in the new Comfort lens is a common report, I trouble shoot about 40 RX problems a week. Please update us though if you were able to fix his issues.

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