Some prescriptions are easy. But some are challenges. Unusual facial features, special work and hobby requirements, and other factors call for unique prescriptions. These cases take time, skill, and ingenuity. Eyecare Business asked several eyecare and eyewear professionals how they solved their difficult Rx problems.

Defying a Drooping Lid

The Problem:

Richard Kattouf, O.D., owner of Advanced Eyecare in Warren, Ohio, had a 3-year-old patient who had been born with a congenital problem. One of her lids drooped so severely that it covered most of the pupil in that eye and she could barely see out of it. Due to the disuse of that eye, she had also developed amblyopia.

The Solution:

"This was a severe case of ptosis (drooping lid) that was affecting the little girl's vision. Since surgery had been ruled out by the girl's parents, we recommended a ptosis crutch, which is a curved, plastic-covered wire that lifts the lid through tension," Kattouf explains.

"It's mounted to the nose pad of a plastic frame, and gets tucked into the fold of the eye when the glasses are on. With the ptosis crutch -- in addition to wearing proper correction and doing some orthoptics -- the girl was able to use both eyes together."

Havoc from Height Differences

The Problem:

When a 54-year-old actuary came to consult with Steve Gradowski, O.D., owner of Omaha Primary Eye Care in Omaha, Neb., the patient was seeing double. His diplopia (double vision) was not surprising, considering the fact that one of his eyes was approximately four millimeters higher than the other. He was having more and more difficulty seeing, especially at work, where he looked at numbers all day. In addition to the diplopia, the patient had eye strain and moderate-to-high nearsightedness, with a small amount of astigmatism. On top of all that, he was also presbyopic. Prior to seeing Gradowski, he had been fitted with a lined bifocal.

The Solution:

"We fitted him with a no-line bifocal with unequal segment heights," says Gradowski. "The right eye had a 24mm seg height, and the left was 20mm high. We also added prism to help compensate for the imbalance. Two weeks after wearing his new glasses, the patient came back in and reported that there was a marked reduction in eye strain and little or no diplopia."

Multiple Maladies

The Problem:

When Anne Hersh, co-owner of Block & Zuckerman Opticians in West Orange, N.J. saw a post-brain tumor surgery patient, she was happy to hear that the woman's brain tumor had been benign. But the surgery had left the woman with other problems -- paralyzed facial nerves and severe asymmetry in her skull and facial features. The patient needed to be fitted with her first pair of bifocals, but as a result of the paralysis, one eye didn't lower when she looked down. And due to the asymmetry of her skull, frame fitting was extremely difficult.

The Solution:

"The patient wanted a bifocal with no line, but we knew that a progressive lens was out of the question. Instead, we gave her a blended segment with minimal distance correction," Hersh reports.

"That worked fine. The biggest challenge was finding a frame that fit, because as a result of the surgery, the mastoid bone behind her ear was gone and her skull was recessed about two inches. Most frames were not suitable. They were too rigid or had spring hinges. We needed a frame we could really work with, and chose a highly malleable frame instead. That worked just fine."

Head-Hugging Help

The Problem:

The post-surgical patient wasn't the only person who presented a challenge to Hersh and her staff. She tells of a 4-year-old child with a very severe problem. He had been born with only one ear, and Hersh needed to find a way to fit him with a frame that would stay securely on the patient's head.

The Solution:

"We drilled a hole in the top of a plastic frame, took the temple bend out of that part of the glasses, and found thin elastic that we dyed to match the child's hair," she says.

"We needed two pieces of elastic to stabilize the frame. One piece went through the temples and connected across the back. Another went across the top of his head. The boy's mother masked the elastic by tucking it under his hair."

Upside Down Viewing

The Problem:

The anesthesiologist who visited Jim Mulligan, co-owner of Bouquet Mulligan DeMaio Eye Professionals in Cleona, Pa., was desperate to find a solution to his problem. He was slightly nearsighted and had an add power of 1.25.

As an anesthesiologist, he had to bend over his patients to monitor their breathing, then look upward to read their vital signs on the nearby monitor. He had never found a pair of glasses that allowed him to see those distances clearly.

The Solution:

"We decided to fit him with a lens that is basically designed for computer users, but we turned the lens upside down to accommodate the ergonomics of his job," Mulligan reports.

"The lens has two distances -- intermediate and near. In normal wear (for computer use), the top is generally used for about 36-inch viewing distances; the bottom for 16- to 18-inch viewing distances.

"We plugged the plus power into the top and the minus power into the bottom. We fit him with a deep frame that had ample room for both distances. The B dimension on the frame was probably 54mm, and I put the seg slightly above the center for him so he had good field of view in both areas."

Tiny Patient, Big Problem

The Problem:

A 6-month-old infant who could barely see was brought to Mulligan's office. When she had been born prematurely she had needed a lot of oxygen, which is common with preemies. Too much oxygen has a tendency to elongate the eyes, pushing the retina back and inducing extreme nearsightedness. The parents had taken her to several optical chains, but no one had been able to fit her with glasses.

The Solution:

"I special-ordered a frame called A Child's View from Pumucle, a German company," says Mulligan.

"The frame consisted of a tiny front -- maybe two inches wide -- and very short temples --maybe one-and-one half inches maximum. It had no bridge; we hand-carved one. At the end of the little temples were holes through which we slipped a pink Croakie which came with the frame. We sized the strap and sewed it into the temple holes so the frame fit her like a mini goggle.

"To minimize lens thickness as much as possible, we designed the lenses in a high index fashion by using bi-concave grinding. We put a -10 on the inside surface and about a -8 on the front surface. From a cross section view, the lens looked like an hour glass. We ground it down very small. It's about a 32mm size.

"Without the glasses, the baby's focus distance was probably only about three inches, but with them she was able to notice things and react to them as she developed. The parents were thrilled with the results," Mulligan concludes.

As these examples illustrate, finding the right solutions for challenging eyewear prescriptions takes time and effort. But the results can change patients' lives -- help their golf game, improve their performance at work, enhance their appearance, or allow them to see the world more clearly. EB