As a paid speaker I have not been sponsored by any companies mentioned in this lecture • I am not a consultant to nor an employee of any ophthalmic company. • Robert Lee, OD Western University College of Optometry OptoWest 2012 2 “Why not just recommend bifocals?” Chair side recommendations Proper PAL Fitting and Measurement Patient education Dispensing Know How Troubleshooting Follow up Communication z“New presbyopes have just as many problems in adjusting to bifocals as to progressives. They’re just different kinds of adjustments.” Irvin M. Borish, O.D., D.O.S., LL.D., D.Sc Nancy Smith, a 42 year old patient needs her first multifocal correction. How would you convey the message to Nancy? “Nancy, you are getting older and your eyes don’t focus like they used to…” “Nancy, because you are having trouble seeing up close you need…” Remember Nancy Smith the 42 year old? She needs education on PALS…What do you tell her? “There is distortion that you will have to adapt to…” / “You will not be able to see out of the corners of your lenses…” / Nancy Smith the 42 year old, who by the way is in marketing is thinking…Hmm… Distorted, can’t see out of the corner of the lenses… / Have to adapt to them… / Would anyone in their right mind want these lenses??? REALLY?…IS THERE A BETTER WAY TO PROMOTE PALS!!! “You will LEARN how to use your new lenses. I (or the doctor) wear progressive lenses and love them…” “I will show you how to use them…” Notice I didn’t say ADAPT or HAVE TO GET USED TO THEM… Pt. PD = Frame PD Pt. PD < Frame PD Offer a kinder and gentler way… Mrs. Smith, you are too YOUNG to wear bifocals… “I am recommending a lens WITHOUT BIFOCAL LINES that allow you to see NATURALLY at all distances.” “They’re called progressive lenses and are CUSTOM MADE for your eyes. You have heard of HD TVs? These are HD lenses that will give you the best vision.” Select a frame where the frame PD = patient PD. Why? For the pt. new to wearing glasses: “The top of the frame should be at or below your brow line.” “The width of the frame should be about the width of the widest part of your face.” “Your eyes should be centered in the frame.” Pt. PD = Frame PD Pt. PD > Frame PD Pt. PD = Frame PD What frame dimension is most critical? What may be the PAL optical consequences of a poor frame selection? Anticipate what the pt. may complain about. Pt. PD < Frame PD Pt. PD = Frame PD Pt. PD > Frame PD Choose another frame with a deeper “B” dimension 2. Choose another frame with a deeper “A” dimension 3. See if the frame will work with a short channel PAL 4. Suggest the pt. use a FT28 bifocal 1. Adjust the frame before taking fitting height measurements Vertex distance Pantoscopic tilt • Most frames have a slight amount of “positive” wrap Negative wrap results in a narrow field of view and should be avoided… Although wrap does move the optical axis it also brings the lens periphery closer… Fit lenses as close to the face as possible DOTTING CENTER PUPIL What are some errors that lead to inaccuracy? DOTTING CENTER PUPIL What are some errors that lead to inaccuracy? Not being on the same Taking the Measurements Pupillary Distance Why not a PD rule? Check the vision quality using a distance obj near reading card… level as the patient (parallax) Not directing the patient where to fixate Where should the pt. fixate? Measure the monocular pupillary distances OD/OS for distance (infinity) and/or 40 cm. Measure with both the patient’s eyes open If the patient see double or has strabismus, occlude each eye using the lever found on the top of the pupillometer. Confirm the frame is still adjusted… Check the centering on the pt. using the tape markings (don’t wipe off prior to dispensing!) Recommendations to assist learning Demonstrate to the patient: Recommendations to assist learning Parting words of wisdom? : Distance vision @ eye level , looking straight “Let us know if you have any problems…” ahead Near vision in the lower part of the lens by lowering eyes and slightly raising head if needed All head & eye movements should be carried out SLOWLY AT FIRST “If you can’t get used them, please come back…” PAL non‐adapts are a big pain for both you and the patient: Inconvenience of multiple trips back to your office Staff and doctor time Patient loses confidence with your office “I tried progressives once, they are bad…” “The distortion will go away after a few weeks…” “Mrs. Smith, this is Dr. Lee’s office calling to see how you are enjoying your new glasses” Can you anticipate this patient’s complaint? How do you avoid misfits? (be proactive) Follow up phone call 1 week after dispensing Are you crazy?! Why would I want to invite complaints? The majority of misfits can be solved by frame adjustment rather than remaking the glasses. Fitting Cross should be over center pupil and needs to be raised Cross is temporal of pupil center on the right eye What is the next step? DOTTING CENTER PUPIL Anticipate what the pt. may complain about. If fitting cross is too high? If too low? Adjusting the pantoscopic tilt has an effect on the height of the fitting cross… +2º tilt = ‐1mm height ‐2º tilt = +1mm height Increasing pantoscopic tilt also increases the field of view thru the reading add Be careful when decreasing pantoscopic tilt however… Many offices report success rates of up to 98% How the few failures are handled is critical Don’t tell the patient the manufacturer is replacing the lenses Tell them YOU will replace them “Mrs. Lee, because I want you to be completely satisfied…” Stand behind what you recommend Brand name manufacturers provide replacement guarantees Non‐adapt PALs are replaced with bifocal or trifocal The pt. states he wears vertical prism in his PAL Rx. Your clerkship doc asks you to check the Rx for vertical prism. How do you do it? . 1. Now what?? 2. 3. 4. . . Your pt. is an experienced PAL wearer. She complains of the new PAL reading area being smaller than her previous PAL even though it is the same PAL type. What is your diagnosis? 5. Semi‐circle Fitting cross Dot below fitting cross Temporal engraved circle Nasal engraved circle Fitting height too low 2. Frame needs more wrap 3. Monocular PDs are off 4. Frame needs more pantoscopic tilt 1. Your new optician needs help with this pt. complaint: “ “In order to read clearly I need to raise my chin or lift the glasses” What is your diagnosis? Fitting height too low 2. Frame needs more wrap 3. Monocular PDs are off 4. Frame needs more pantoscopic tilt 1. Remake the lenses with a higher fitting height 2. Give the frame less pantoscopic tilt 3. Widen the nosepads 4. Bring the right temple closer to the face 1. 52