Patient:  D.A., age 51

Occupation: Scientist - cancer research.

• Uses computer 6+ hrs. per day.
• Also performs fluorescent microscopy.

Hobbies: Running and skiing

History:  Currently wearing DW SCL for past 4 yrs.

Ocular health:  Unremarkable

General health:  Unremarkable, except allergic to thimerosal, penicillin and mushrooms.

Chief complaint:  "Unhappy with near vision when wearing CLs and SV reading Rx over lenses."

Subjective refraction:

• OD -3.50 -0.50 X 030 20/20 Add +1.75 20/20
• OS -3.25 -1.25 x 180 20/20 Add +1.75 20/20

Keratometry:

• OD 44.75/45.25 @ 90 Do
• OS 43.62/44.87 @ 90 Do

Slit lamp exam: Lids, lashes conj. and corneas were unremarkable.

Lid position: Lower lids 1+ mm below limbus. Upper lids 2+ mm above pupil (mesoptic).

Pupil size:  5mm, OU

Dominant eye: Right eye

Diagnostic lens: OD 7.54 BC/ -3.50 Sph/ 9.2 Dia / 7.8 OZ Oxyflow 30 design GP

Single vision:  OS 7.67 BC/ -3.75 Sph/ 9.2 Dia / 7.8 OZ

Lens performance:

• Visual Acuity: Dist. 20/20, OD, OS & OU
• Near 20/20, OD, OS & OU w/ +1.75 spectacles over CLs.
• Riding position: High riding lid attached position with minimum apical clearance.

Initial fitting:  Since the patient had not worn rigid lenses, the fitting was designed in two phases and the part involved single vision GP’s with the +1.75 reading spectacles for near tasks. The patient successfully adapted to the new lenses and returned after four weeks for the bifocal fitting.

Diagnostic bifocal fitting:   Diagnostic fitting with aspheric and fused GP CLs rode high causing compromised distance vision. Finally diagnostic LifeStyle GP aspheric provided adequate distance vision (20/25, OU) and near vision (20/30+,OU).

Discussion:  The patient performs a great deal of near (reading reports) and midrange (computer) tasks. The best bifocal design is the Aspheric type which will give good near and midrange performance.

Initial bifocal:

• OD 7.60 EQ / 7.44 BC / -3.12 / +1.75 Add / 9.5 Dia / 8.4 Cap / .14 Ct
• OS 7.80 EQ / 7.64 BC / -2.87 / +1.75 Add / 9.5 Dia / 8.4 Cap / .14 Ct

Lens performance:

• Visual Acuity @ Distance OD 20/25, OS 20/30, OU 20/30
• Visual Acuity @ Near OD 20/25, OS 20/25, OU 20/25
• Lid attached fit with minimum apical clearance

Follow-up data:

• Patient experienced allergic response to Boston solutions and was switched to Allergan / Lobob products that resolved sensitivity problems.
• After two weeks of wear with the multifocal, patient complained of two problems: Lack of clear vision at near and some difficulty with driving vision.

Lens changes:

• Increased add powers up to +2.25 were attempted but mid and distance vision decrease was experienced. Attempts to use modified monovision were unsuccessful.
• Patient was refitted with an EZ Bifocal Aspheric / Annular design w/ a +2.25 add which gave improved near vision but excessive lens movement / poor centering caused interference with distance vision. Attempts to utilize modified monovision were unsuccessful.

Final lens change: The patient was next refitted with a Tangent Streak No-Line Aspheric with the following specifications:

• OD 7.55 FBC/7.39TBC -387 / +2.25 Add / 9.50 Diam / .15 Ct
• OS 7.65 FBC/7.50TBC -3.50 / +2.25 Add / 9.50 Diam / .15 Ct

Lens performance:

• Dist. VA 20/20- OU, 20/20-OD, 20/40-OS
• Near VA 20/25- OU

Summary: Patient is happy with the final modified monovision effect and has adapted to using the lenses for most of her daily needs. An increase in patient motivation and understanding of how to use the lenses have been part of the success.