# Optical Forums > Progressive Lens Discussion Forum >  progressive lens with a lot of intermediate

## Scrumblydumpus

So I have a patient who is complaining and insisting on a redo on his new progressive rx because the intermediate is not big enough.  I tried to explain to him the benefits of a computer lens, but he wasnt having any of it.

My biggest issue is, he is currently in a physio... one of my go to lenses for wider intermediates.  Anyone got suggestions for a PAL with a wider intermediate?

Our next try is going to be a GT2 I think.

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## lynnshewmaker

Definity also has a nice intermediate range, but physio would be our first choice.

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## Robert Martellaro

> So I have a patient who is complaining and insisting on a redo on his new progressive rx because the intermediate is not big enough.


Does he mean bigger vertically or horizontally? In other words, his he saying that he has to lift his chin to see the object, or his he saying he has to move his head to the right or left to keep the object in focus? 

If the latter, there's probably not much you can do beyond making sure the vertex distance is as short as possible. Some lenses spec out with wider corridors but the difference is minor- some people can see a difference, but most will not, myself included. 

If the latter, then a shorter corridor will help, although the consequences are a more dynamic/busy lens, with the potential for reduced distance acuity on-axis, and a much higher likelihood of off-axis distance blur.

If the object in question is a desktop monitor at essentially eye level, then there will still be some chin lifting going on, even with the shortest corridor lens, albeit much less so compared to moderately long corridors like the Physio. 

You might also want to look at the change in Rx; any increase in minus or decrease in plus on the distance will have a negative impact on the intermediate vision. If true, don't blame the decreased utility at intermediate on the lens design!

Hope this helps,

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## rinselberg

Want to gamble some money on an idea from someone who isn't an Eye Care Professional?

Look at the website for the atLast! lens:
http://www.atlastlens.com/

If you take the text on the website at face value, the atLast! lens is aimed specifically at this situation: A dissatisfied PAL wearer who needs (or wants) more or better intermediate vision.

The lens is new, so there has not been much discussion of it yet on this forum.

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## IndianaOD

Is the Autograph II out of the question?  Otherwise, have the patient decrease the monitor height if its eye level or higher.

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## Trevor D

Seems to be a blended round seg embedded into a progressive lens!

According to the wesbite, a lab in California named "Bad *** Optical" can supply you with it!  :p

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## For-Life

What was the patient wearing before?

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## rinselberg

> Seems to be a blended round seg embedded into a progressive lens!
> 
> According to the wesbite, a lab in California named "Bad *** Optical" can supply you with it!  :p


Bad As* Optical (make that last "*" into an "s")
http://www.badassoptical.com/

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## rdcoach5

Do not use the At Last for this patient. It has a very small vertical intermediate. It does have a wide horizontal zone but it is really only suited to someone who could wear a blended bifocal. It's a lot better blend without all the blur in the blend zone. I would guess the intermediate is around 3 mm or so in height. There is a wide distance zone and near zone but even our Pixel Optics Rep said not to use it for someone who needs a wide intermediate.

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## Happylady

I have a patient who is a pilot and he loves the Rodenstock Life lens. He's tried Definity and says the Life is better. He says the Definity is good but the Life has a bigger intermediate area. He is a hyperope.

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## DragonLensmanWV

> Is the Autograph II out of the question?  Otherwise, have the patient decrease the monitor height if its eye level or higher.



I have the Auto II and in my opinion, while I love them, the intermediate is the weakest part. Note that I have a 3.00 add though.

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## Scrumblydumpus

We talked to the patient & the doc and decided to lower his add and raise the seg a bit.  We are going to keep him in the physio, but if he still has trouble I may mention the raising the monitor idea.

I thought Shamir's big thing with the autograph series was to minimize intermediate to make near/distance as good as possible?

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## Happylady

> We are going to keep him in the physio, but if he still has trouble I may mention the raising the monitor idea.


Generally I find lowering the monitor is helpful with computer users. Having the screen too high is a common problem.

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## IndianaOD

> We talked to the patient & the doc and decided to lower his add and raise the seg a bit.  We are going to keep him in the physio, but if he still has trouble I may mention the raising the monitor idea.
> 
> I thought Shamir's big thing with the autograph series was to minimize intermediate to make near/distance as good as possible?



Hmm, if that's true I didn't know it.

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## Jubilee

You can specify the corridor lenght in a situation like this to have more vertical room in the intermediate.


A couple of other good computer lenses... For width of intermediate, Solamax. For length, the original Gradal Top. For those with Higher adds, have a longer corridor length will give them a true computer zone.

For lower adds, the short corridors work by bringing the magnification up higher in the lens.

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## rdcoach5

> We talked to the patient & the doc and decided to lower his add and raise the seg a bit. We are going to keep him in the physio, but if he still has trouble I may mention the raising the monitor idea.
> 
> I thought Shamir's big thing with the autograph series was to minimize intermediate to make near/distance as good as possible?


I have worn both the Physio and the GT2 as well as Kodak Unique and presently the Autograph 2. The GT2 is wider and the magnification is higher than the Physio or the Unique. The Autograph 2 is better than any of these in all ways, but it's more expensive.

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## john-atlanta

I felt the GT2 had a very narrow reading area, at least for me.  

The auto II has worked very well for me.  

The Indo Drive lens is basically a distance and intermediate lens, with minimal reading (kind of the opposite of an office lens which is near/intermediate). 

That might make sense depending on what you are trying to accomplish.

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## Fezz

> The Indo Drive lens is basically a distance and intermediate lens, with minimal reading (kind of the opposite of an office lens which is near/intermediate). 
> 
> That might make sense depending on what you are trying to accomplish.


 

:cheers::cheers::cheers:

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## barryh66

I have worn Physio, Gt2, Ziess individual, and Autograph II. I find the autograph II has the greatest usable area in every zone. So does it have the largest intermediate zone probably not but effectively it feels the largest.

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## sharpstick777

I have patients in the Definity who experience clear mid range across the ENTIRE width of the lens.  

I ask every patient at dispense to turn their heads left and right and read print at 18" and at 36", and let me know when it starts getting blurry.

In most cases the Definity has been the widest Progressive in the mid.

Sharpstick

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## Happylady

> In most cases the Definity has been the widest Progressive in the mid.
> 
> Sharpstick


I have a pair of Definity Shorts on right now. I have a 17 inch screen and I can see the entire screen with my glasses without moving my head. It is very sharp and clear. I do need to look directly at it, if I turn my head one side starts to blur out.

My distance is about a -2.00 and my add is a +2.25. The top of the screen is about even with my nose.

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## Uncle Double

> I tried to explain to him the benefits of a computer lens, but he wasn't having any of it.


I assume you mean Office and Online designs, or did you mean a single vision computer distance or bifocal computer/reading distances?

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## sharpstick777

I have 3 brand new lenses... Definity II, Auto II, and Lifestyle ID.

The Definity has clear midrange across the ENTIRE width of the lens, however, there is a slight magnification on the outsides of the mid. 

The other lenses have their plusses but the Definity is the only one with complete usabilty.

Sharpstick

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## rimlessglasses

Short corridor (14mm fitt height), really soft design, probably a free form would work well.. Will very much depend upon the Px's Rx and working distances though.  You may find reducing the add by 0.25 may be beneficial too again depending upon the Rx.  The other members seem to love the Autograph II we haven't got that as yet, still stuck with the original Autograph....which we see as a pretty good design

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## john-atlanta

Auto II blows away original Autograph, IMHO.

John

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## rimlessglasses

> Auto II blows away original Autograph, IMHO.
> 
> John


Can you tell me more, you have me rather excited!!!!  How many corridor lengths does it come in?

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## john-atlanta

> Can you tell me more, you have me rather excited!!!!  How many corridor lengths does it come in?


11, 13, 15, 18 in the fixed design.  Variable (my lens of choice) 11 and UP.

The power of this lens is not just the variable corridor length, but the "as worn" technology, the fact that they account for the frame shape in the design ("FreeFrame Technology") and the remarkable, astonishingly low level of distortion compared to others I have worn.  

I HIGHLY recommend this lens.  

Maybe Laurie could provide more detail.  Laurie to the forum,  LAURIE TO THE FORUM PLEASE!!!  :bbg:

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## Leyend

I guess it has nothing to do with lens design.

I have got the same complaints from young hyperopes(40-48) who has distant power over +1.00 ,since I encreased the Addition.

As they are used to the old Pals with low Add, wearing eyeglasses high up on the nose for more magnification does not cause so much discomfort. So he does for reading but he also gains wider intermediate distance.

What I usually did is to reduce distant power 0.25-0.5 D from the new prescription, Increase the Addtion 0.25 or keep the same if he does not do close work,widen the pd 0.50-1mm each side and place the fitting point 2-4mm. higher than the eye point.

Then adjust the frames to sit close to the face.

But this does not work if he is over 52 or the Addition is up to 2.25D.

He might not get the best out of Pals but it fits his needs.

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## Laurie

...I was busy in the shoe section, ; )

Two thoughts:

Catagory I: Multi-use PAL

Catagory II: Wide Intermediate Range, suitable for long hours w/computer.

Catagory I: 

Autograph II can be ordered in Fixed, where the 'corridor', or 'transitional zone' in the vertical is fixed. You can fit a fixed 11 at 11mm, for example, and the corridor/transitional area will be fixed. If you choose to fit the fixed higher (11mm fixed at 15, for example), you will not change the Intermediate, but will add to the amount of reading area in the vertical.

Autograph Variable: The corridor/transitional area/intermediate will vary, depending on seg height. A rule of thumb, is you will have approx. 5mm of reading area in the vertical meridian (i.e. no cutting off adds), and the length of the intermediate will vary in length. 

A quick tip:

Fixed: when you want to have clear control over the amt. of vertical mm of each zone: A bifocal convert, for example, will enjoy getting to the add right away, and can have more depth in their reading area.

Variable: new presbyopes, and dispensers who don't feel comfortable, or a need to maniupulate the parameters. The computer default will ensure that approx. 5mm full reading in the vertical meridian will exist, and contour the design based on additional information. Running parameters through additional software will keep within design criteria, as I mentioned in a previous post.

Finally,

Catagory II: 

It is my opinion that, if a client is spending ample time at the computer, they need occupational lenses. The Shamir Office Lens comes in two catagories as well:

Catagory I:

Molded front surface (digital mold, not ceramic-to-glass mold), traditionally surfaced back curves. The lens begins at total near power, and 'digresses' out to around 10-13 feet, depending on Add power. There are four 'dynamic powers' to choose from (how much regression, or deduction of plus towards the top)....I would let the lab choose, unless you have very specific working distance requests outside the norms...the 'top part' of the lens ends up being over-plussed by around +0.50 - +0.75 D, they are not meant to yield 20 ft. vision. By dumping the idea of 20 ft. focus, they gain the widest intermediate, edge-to-edge.

Order like a regular PAL...distance Rx and Add power, mono PD's, and mono fitting cross heights, center pupil.

Catagory II:

Office/Autograph II: this is a design that is custom manipulated per Rx. It is generated via freeform, entirely on the back surface. There are unlimited amounts of 'dynamic powers'/'digression of plus power' towards the top, with the Rx parameters run through 'eyepoint technology' (ray-tracing system), and 'freeframe technology' considers additional information, like the exact positioning of the lower eyewire under the pupil, not just the boxed 'B' dimension. It is best to send the frame to the freeform lab to digitally trace it beforehand.

In addition, you can give additional 'as-worn' measurements: distance to computer, angle of monitor above or below line of sight, designate sitting or standing, ect. Again, the computer software will default to norms if this info is not given.

These new technologies are evolving at a fast rate...alot to keep up with!

Hope this helps,

: )

Laurie

(incase I haven't 'disclosed' in a while, in addition to teaching optics full time 'GO HCC!'), I give CE's for Shamir.

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## always curious

> I have a patient who is a pilot and he loves the Rodenstock Life lens. He's tried Definity and says the Life is better. He says the Definity is good but the Life has a bigger intermediate area. He is a hyperope.


 


I always push for the Definity pal, with the patients. Not once have I had a Non-adapt. None of us @ the office have. I put my mom in it @ she loves it!  I am glad to see people talking about it.

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## john-atlanta

> ...I was busy in the shoe section, ; )
> 
> Two thoughts:
> 
> Catagory I: Multi-use PAL
> 
> Catagory II: Wide Intermediate Range, suitable for long hours w/computer.
> 
> Catagory I: 
> ...



Great post!  Does the new freeform office have the same requirements for fitting height ABOVE the pupils as the original office lens?  I have yet to incorporate the office style lenses into my practice and would love some feedback from the big brains on this board!

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## Laurie

> Does the new freeform office have the same requirements for fitting height ABOVE the pupils as the original office lens?


The fitting height should be center pupil, regardless if it is the original (digital molded) or the Autograph II in freeform.

John-Atlanta,

I know that you are in the presbyope club, as you mentioned wearing various PALs...

I would suggest your trying out an office lens...it is great for your work environment too!

: )

Laurie

(PS:  I will PM you with status of the other project we talked about in regard to a plot on your Element lenses)...

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## Grubendol

bumping to this to the top.  I have a patient who is a nurse working at podium desktops with the monitor at eye level.  She needs a full-time non-occupational progressive which will give her a high and tall intermediate.  I started her with a Comfort DRX and vision is good but intermediate height is too low.  

Any thoughts?  DRX short? 

I'll add that this is a redo through VSP choice unfortunately so some limtations do apply

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## Tallboy

In that case I would use a shortened corridor (a short(er) fit design DRX short would be fine) and back the add off, personally - she will be using the "near" portion on the computer but will be holding things further out to "read" as a trade off.  But a progressive is a poor choice for her if she is having that much difficulty.  Either try an office lens that gives up to 16-20ft of distance vision or a good'ol FT35

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## MIOPE

What if the patient convergence does not match the progressive design defaults?
Does that give the patient the feeling of a narrower corridor?
How usual could this be?

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## optical24/7

> bumping to this to the top.  I have a patient who is a nurse working at podium desktops with the monitor at eye level.  She needs a full-time non-occupational progressive which will give her a high and tall intermediate.  I started her with a Comfort DRX and vision is good but intermediate height is too low.  
> 
> Any thoughts?  DRX short? 
> 
> I'll add that this is a redo through VSP choice unfortunately so some limtations do apply


Certain situations can be solved through ergonomics, especially for those that refuse (for whatever reason) a task specific pair of glasses. Some patients can have improvement with an elivated chair. With this patient, see if she can put one of those workout steps at her standing work station. If she can elivated herself 4-5 inches it may make a big difference.

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## sharpstick777

> What if the patient convergence does not match the progressive design defaults?
> Does that give the patient the feeling of a narrower corridor?
> How usual could this be?


Great question!

Less than 2% of patients have a convergence that matches the 5mm default inset.  Most of our progressive patients have decreased near width and unwanted lateral prism (which creates eyestrain).  Most Free-form lenes follow the standard 5mm inset of traditional grinders, and use a corridor designed for low power myopes.

There are only a few lenses that address this, the Seiko: Surmount and Superior (to a lesser degree the Supernal), The Ziess Inidividual 2, and the Rodenstock Impression (not available in the US at the moment).

Near PD is the most important POW measurement, not only does it place the reading zone where is should be, I can if I am smart, realign the whole corridor to account for eyepath.  This is done by using a combination of RX and near PD to estimate the Axial length of the eye.  Knowing the axial length I can improve Ray Tracing, this near PD can also improve distance zones.

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## sharpstick777

The Seiko Surmount is the only reverse geometry lens available right now.  It flips the corridor to put the wide end toward the pupil, thus making the intermediate the widest portion of the lens.  Its not edge to edge clear in the distance, but its pretty good.  The Comfort is a reading emphasized design in all its flavors, the Intermediate will always be narrow.  I can never turn a wrench into a screw driver even if I cut it in half.  A short design will make her issues worse.

Use the Surmount WS version for add 2.00 and greater.  Order with near PD.  Fit on Center (don't drop).  You will be golden.




> bumping to this to the top.  I have a patient who is a nurse working at podium desktops with the monitor at eye level.  She needs a full-time non-occupational progressive which will give her a high and tall intermediate.  I started her with a Comfort DRX and vision is good but intermediate height is too low.  
> 
> Any thoughts?  DRX short? 
> 
> I'll add that this is a redo through VSP choice unfortunately so some limtations do apply

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## MIOPE

> Great
> Less than 2% of patients have a convergence that matches the 5mm default inset. .


If 2% are the ones that match the 5mm inset, it would be interesting to see percentage according to mm of mismatch.
Is there any study about this that you know?

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## Robert Martellaro

> bumping to this to the top.  I have a patient who is a nurse working at podium desktops with the monitor at eye level.  She needs a full-time non-occupational progressive which will give her a high and tall intermediate.  I started her with a Comfort DRX and vision is good but intermediate height is too low.  
> 
> Any thoughts?  DRX short?


If the DRX short is like the Physio short, which is more of a medium corridor, it might not be short enough to minimize posturing sufficiently. I'm not sure what's available with VSP so look for a design that has a fixed corridor length and a minimum fitting height of 14mm or so. 

Note Tallboy's recommendation of cutting the add to minimize rubbernecking. 




> What if the patient convergence does not match the progressive design defaults?
> Does that give the patient the feeling of a narrower corridor?
> How usual could this be?


Modern PALs vary the inset according to base curve or distance Rx, less inset for minus power and more for plus power. The only default I'm aware of is a 40cm work distance that requires a near PD value equal to about 94% of the distance PD, if there is no power at 180. All bets are off if there is a fixation disparity or a habitual head turn.

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## drk

> What if the patient convergence does not match the progressive design defaults? Does that give the patient the feeling of a narrower corridor? How usual could this be?


  I'm still not buying into this stuff.      

1. Convergence is entirely dependent on reading distance.  It can't "vary".  (Similar to "stimulus AC/A" for those so inclined.)

    2. If people like a longer reading distance, this needs addressed in the prescribing phase...lower add power.      

3. Fixation disparities/phorias are addressed by prism, not fancy inset/outset. ("Response AC/A for those so inclined).  (I mean it's possible, but that's crazy.  Near phoria would have to be a parameter on the individualized design, and even so the prismatic effect of variable inset is minimal for most lens powers.  Right?) 

4. I have no idea of what sharpstick777 is talking about re: axial length and convergence unless he's going to tell me about ocular centers of rotation etc. which sounds to me like angels dancing on the head of a pin.  But he knows his stuff.

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## Robert Martellaro

> Near phoria would have to be a parameter on the individualized design, and even so the prismatic effect of variable inset is minimal for most lens powers.  Right?


Minimal for most. But if the IPD is unusually narrow, the power is higher plus, and the add is over +2.50, the combined error can be consequential, especially as the eyes track through the narrow corridor near the blur boundaries. Remember this thread? PAL / PD Issue Thread.       

WRT Seiko lenses, here are Seiko's own astigmatism plots. The lack of horizontal symmetry implies a somewhat older fundamental PAL design, although some of the asymmetry is truncated when cut and edged, except with larger frames.

http://plasticplus.ca/wp-content/upl...t07601_4pg.pdf

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## drk

Hey, that's not an inverted pyramid...it's an hourglass.

Is it less hourglassy and more rectangular?  It ain't no "V".

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