# Optical Forums > Ophthalmic Optics >  Latent hyperope issue

## Sam Pelican

34 year old patient with an rx of O.D +325-100x150,  OS +425-250x42. She is a latent hyperope in poly with an AR. Her  newest glasses have about +.50 over her last rx. 
She is having problems adapting to the lenses. Of course her distance is not as sharp as she would like and she has issues with glare, almost like the light is much brighter than before. She does like the new for reading but does not like the distance. Any suggestions ? We discussed 1.67 vs poly and maybe the new saphire AR. vs the Alize. The Dr. is reluctant to reduce the rx due to her reading issues. Any advice will be appreciated.

Bruce

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## chip anderson

Don't use Poly!

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## musicvirtuoso

I don't think this is a simple issue of dispersion (not even knowing what material she had before, it's probably not enough of a change to cause this non adapt - maybe unless coming from glass - i.e.: the poly may not be the problem).You may be faced with another redo with arbitrary changing of material. I'd be interested in seeing the entire previous Rx. Also, are the glare problems only happening at night? What are the BC's of each of her glasses? And I'm assuming there aren't any defects in the current coating and that she isn't [newly] experiencing this in her old pair. 

Doctors are much less likely to lay off plus power than minus if they can help it (most plus, least minus), so that's probably the last resort. 

I don't pretend to be Darryl Meister, but hopefully I can add to the discussion.

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## wmcdonald

How sure are you this is a latent hyperope? Every patient will have some level of tonic accommodation, and the +0.50 may be exactly the problem. If they are truly a latent hyperope, they will slowly relax and get used to the extra plus, which is probably what is going to happen. If not, the plus is probably excessive, an indication they are not a latent hyperope. Remember, if you add extra minus, the patient will accommodate to correct it. Any extra plus will cause blur. Good luck with the patient.

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## fjpod

Reduce the plus at distance by .50 and give her a .75 add progressive.  She'll love it.

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## Sam Pelican

To address the previous rx the patient started at this clinic in 2004. Rx was OD+200-50x150, OS +350-250x37. She has had +.25 changes about every other year since. She has been in poly with AR from the start. She did fine with her previous rx which was only +.25 less, but  the reading wasn't as good. I suspect it is related more to these lenses than the rx but I can't find anything that I can attribute it to. I did suggest trying a progressive but neither she or the Dr. embraced that idea.

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## fjpod

Tell them to wake up and smell the coffee.

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## Robert Martellaro

> How sure are you this is a latent hyperope?


I believe the only way to know for sure is to compare the wet and dry refractions.




> Reduce the plus at distance by .50 and give her a .75 add progressive. She'll love it.


And there are plenty of really good PALs that are available in that power. 




> I did suggest trying a progressive but neither she or the Dr. embraced that idea.


She didn't like hearing that? How 'bout a wrinke or two and a little sag?! The doc probably didn't want to hear it from her also. The distance should come around in a couple days, 2 weeks max. Otherwise split the difference and have her come back when she can't take it anymore, about 6 to 12 months according to her history. You could also Rx readers, but the PITA level is high. If she get's to *****y and whiny then tell her about your widowed client with no family that has advanced AMD. Good luck.

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## Craig

> How sure are you this is a latent hyperope? Every patient will have some level of tonic accommodation, and the +0.50 may be exactly the problem. If they are truly a latent hyperope, they will slowly relax and get used to the extra plus, which is probably what is going to happen. If not, the plus is probably excessive, an indication they are not a latent hyperope. Remember, if you add extra minus, the patient will accommodate to correct it. Any extra plus will cause blur. Good luck with the patient.


Great Post.  What does Tonic mean?

Craig- the supporter of quality eduction and husband of Kelly, who is now on the COA review team for opticianary programs.

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## Craig

> To address the previous rx the patient started at this clinic in 2004. Rx was OD+200-50x150, OS +350-250x37. She has had +.25 changes about every other year since. She has been in poly with AR from the start. She did fine with her previous rx which was only +.25 less, but the reading wasn't as good. I suspect it is related more to these lenses than the rx but I can't find anything that I can attribute it to. I did suggest trying a progressive but neither she or the Dr. embraced that idea.


Aspheric Trivex is the friend of all + patients!!!

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## Robert Martellaro

> What does Tonic mean?


Tonic accommodation? The amount of accommodation during the resting state.

http://medical-dictionary.thefreedic.../accommodation

Note the table towards the bottom that shows the increased accommodative demands for a myopic CL wearer.




> Aspheric Trivex is the friend of all + patients!!!


An atoric design might be better choice when you consider the OS cyl and axis.

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## Barry Santini

> Aspheric Trivex is the friend of all + patients!!!


If that's the case, then I'm thinking a FFSV in 1.6 should be as good, with better cosmetics

B

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## Sam Pelican

Good stuff, A little more info on this patient. Her cyclopegic refraction has her at  OD+350, OS+450. She didn't like her previous rx and like I said, she likes the new for reading but her issues are with the distance and glare mostly from bright lights as in large store. Does a 1.67 with a sl-1 tint make any sense. Or would an AR like the Saphire with a bit less reflection make enough diff. She does still manifest at OD+300, Os +400 but the doc wants to see her adapt to the extra +.25. He wants to try the 1.67. Due to the modest increase in her rx and the fact that the material and AR are the exact same it has me a bit perplexed.

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## Barry Santini

WHY OH WHY would you make her adapt to the extra +0.25???

WRONG!  Hyperopes always like less plus...always.  Also, what does her corneal topography look like aroud the central 2.3 to 3.5mm?

B

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## wmcdonald

> Great Post. What does Tonic mean?
> 
> Craig- the supporter of quality eduction and husband of Kelly, who is now on the COA review team for opticianary programs.


Muscle tone.....as in ciliary muscle. I am pleased to hear of your work for the COA. It is a worthwhile organization, and needs good people.

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## wmcdonald

> Good stuff, A little more info on this patient. Her cyclopegic refraction has her at OD+350, OS+450. She didn't like her previous rx and like I said, she likes the new for reading but her issues are with the distance and glare mostly from bright lights as in large store. Does a 1.67 with a sl-1 tint make any sense. Or would an AR like the Saphire with a bit less reflection make enough diff. She does still manifest at OD+300, Os +400 but the doc wants to see her adapt to the extra +.25. He wants to try the 1.67. Due to the modest increase in her rx and the fact that the material and AR are the exact same it has me a bit perplexed.


 
She is not longer considered a latent hyperope, as I suspected. Average tonic accommodation is about +0.50D according to Borish's text, and this just validates it. What she is experiencing is not related to material properties, and is refractive. She may relax, but it is not likely at her age.

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## Uilleann

Ha she ever worn contacts?

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## Robert Martellaro

> she likes the new for reading but her issues are with the distance and glare mostly from bright lights as in large store.


If the light sensitivity has a history then you'll probably need to tint (gray or brown over pink). If new, then it could be caused by over-plussing, or changes in lens curves or position. 

If you determine the best course of action is multifocals- call them anti-fatigue lenses and she won't know what hit her.;)

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## Sam Pelican

Remember I am the messenger not the refractionist. At this point the rx is not going to change. I need to make a change using the current rx that I hope will address some of her issues. I will use a high index lens, probably aspheric, with probably a different AR. I realize these may not be the cause of her trouble but I have been instructed to make a change to attempt to help her. So that being said what does the collective feel will be the best lens and coating given the rules I have to play by.

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## Barry Santini

Sam:

The RX is the problem, and not addressing this will result in unsatisfactory, band-aid solutions.

Barry

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## trifoil

customers will say anything when they want their money back  .....just because the 'script changes  0.5 DS does not necessarily mean that the customer will notice a benefit

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## WFruit

I agree with Barry about the root cause of the problem.  However, since you've stated you're stuck with the Rx, Trivex or 1.60 with A/R is your best bet.  There is less aberation from both than 1.67.

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## Sam Pelican

Thanks for the input. I ended up using aspheric trivex. We'll see in the next couple of days after she picks them up. I'll let you know how it works.

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## bhess25

using aspheric will flatten out the lenses. with that extra +.50 they may have changed the b.c. to an 8 base. now I'm not a big believer in the base curve monster because I've played around with b.c. for as long as I've been in optics, but what I've noticed is that with a + Rx flatter will open up the O.C.. Its possible that the "brighter" image could come from tighter focal point of incoming light. flattening out the B.C. might help to soften this a little, and reduce the harshness of the lens. and if you move into a double aspheric trivex material it will go even flatter and should soften it up more. I understand that the typical hyperope will not notice a change in Base curve as easily as a myope, however I have had a similar issue in the past and flatter seemed to work out pretty well. I think if you clock the old lenses you'll find a 6 base curve, and the new ones you'll find them to be 8 base. I think if you drop back down to a 6 base the problem may be resolved.

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## Sam Pelican

Well as the collective brain trust seemed to state the change in lens material did not solve the problem. After another re-check the Dr. decided to back off on the plus and we are going to try the Essilor anti-fatigue lens. She definitely prefers less plus for distance but seems to like it for near. As much as I scoffed at the anti-fatigue lens when I first heard about it, it seems like the perfect solution to her problem. We will be choosing a new frame better suited to the lens and fitting her next week. I will post an update after she gives them a try.

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## wmcdonald

You will find the slight over-plus was the issue, not the lens design. Changing to this design and the change in power will solve her problem, but I suspect there are many designs that would suffice with the correct Rx. Good luck!

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## Sam Pelican

Well I don't know what the previous post had to do with anything else in this thread but I do have the results of the latest change. The Dr. ended up reducing the plus by .25 diopter. We used the Essilor anti-fatigue lens  which has +.60 "add" built into the bottom of the lens. She has worn them for about 10 days now and is fairly happy. The distance is great and the glare issues are gone even though the lens material is poycarb. She is still not thrilled with the near but was not given good instructions when she picked them up (I was gone that day). Overall she is happier than any of the other lenses she has tried throughout this latest round of stronger rx's. Am I sold on the "Anti-fatigue" lens. Not really but I will need to see a few more in action. I will add anything new if it comes up.

P.S. Just finished watching Boston shut out the Canucks. I'm not a big Vancouver fan and am pulling for one of the original 8. GO BOSTON!!

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## fjpod

> Ophthalmic suspension will be satisfactory. Generic For FML 0.1% 5ML SOLN (Fluorometholone) is used to treat inflammation in the eye caused such as allergies, and infections.


hmmmm...

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## chip anderson

Why did you stick with poly?    I had a patient that just today who had issues with both Poly and trivex.  Different issues but each had effect of making most of the eye chart un-readable.    
When you know a product or material has issues, why try to *technology* around the problem?

Chip

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## Sam Pelican

Well I had a series of problems to deal with. First I wasn't sure the material was the problem. I was always suspicious of the rx, and being a new employee at this office I was mostly following Dr orders. she had worn poly for about 10 years without trouble, we tried trivex without any better results which pretty much led us back to the rx. So everyone has their pet materials favorite lens designs etc. just how many lenses are you willing to throw  at a problem hoping to solve an issue when the exact problem is not even known. I felt the solution chosen, given the the issues I had no control over, gave us a chance to resolve the issues. The results although not as overwhelmingly positive as I had hoped for has the patient happier than anything we have tried up to this point.

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## DragonLensmanWV

Technology won't help a bad Rx.

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## chip anderson

Every case that I have thought to be latent hyperopia has required more not less plus after a short period of wear.  Especially true in contact lens patients.

Chip

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## sharpstick777

> Of course her distance is not as sharp Bruce


I think you are trying to solve too many issues at once.  If he distance is not as sharp straight on, you probably have power issues.   Warren's points are good too, she may not be a latent hyperope.  Most OD's rarely do wet and dry refractions on an adult patient, and even if she was, over correcting distance to solve a reading issue will not work in 6 months to a year, so if you fix it now with expensive SV she will be back soon even angrier.  The progressive is the best choice really, it will last her longer.

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