Q&A
Ask the Labs
By Joseph L. Bruneni

Q. Unveiling the Truth
I attended your lecture at Vision Expo 2000 dealing with unusual approaches to task specific eyewear. We came across a problem that we are unable to solve. The patient had worn a particular progressive design for six years and was comfortable with it. The Rx was: 
R +1.75-0.25x180, L+2.50-0.25x180, ADD +2.50 o.u. The new Rx is: R+2.50 sph. L+3.00 sph / +2.50 ADD o.u.
This time I used the same frame, but put the patient in a different PAL design. After getting the new glasses, the left eye was O.K., but he reported that he was unable to see clearly when the right eye moved toward the temporal side. He defined it as a veil pulled over the eye.

We checked, and the lenses are correctly made in all respects. A week prior to this incident, the patient had purchased another pair of PALs by the new vendor, and is most comfortable with it.

So, the patient is comfortable with different size frames and yet all of a sudden has that problem of blurry vision at the temporal side of right eye in the old glasses. Any suggestions?

-Sphero Optical Co., Inc., 
Bergenfield, N.J. 

A.
Without seeing the lenses and patient, it's difficult to know. The patient got another pair of PALs by the same supplier that were fine, so the question is whether they were the same design, or just the same vendor.

That the problem only occurs in one eye suggests a problem with the periphery of the progressive. The description of the visual problem might suggest a retinal disorder, except that it only occurs with the one pair of glasses. Such a description does not seem to be related to the usual optical aberrations of PALs, but perhaps with the surfacing. The most common problems are blocking or surfacing waves, and those are hard to detect in the periphery of progressives because of the masking effect of the astigmatism.

-James E. Sheedy, O.D., PhD, clinical professor, Univ. of California, Berkeley

Q. Poly and Medicaid
 
Polycarbonate is always our choice for children, but in this state we are not permitted to use polycarbonate for Medicaid patients. Today, a Medicaid patient came in with an ophthalmologist's Rx marked "polycarbonate." Since we can't use polycarbonate, who has the legal responsibility if this youngster suffers eye damage from a broken lens?

A.
Most state welfare programs specify which lens materials can be used and rule that no substitutions are allowed and patients are not permitted to pay anything extra. You still have the obligation to explain the alternatives that are available to the patient and what you recommend.

For Medicaid patients, you have to further explain that polycarbonate is not available to them. Children are a real concern, but so are monocular patients who should also only wear polycarbonate. The general expectation is that, sooner or later, there will be a case of a lost eye with a Medicaid patient and the state will be sued. Like you, the state also has a responsibility and by precluding you from providing a viable alternative that is widely accepted throughout the industry, they stack the deck against themselves.

Where an ophthalmologist has specified polycarbonate, I suggest you file a "prior authorization" with the state welfare agency. When denied (as it most likely will be), send a copy of the denial to the ophthalmologist (keeping a copy in the patient's file) and ask which he prefers, glass or plastic. Unfortunately, all this takes time but it's your only option at this time.

-Pamela Miller, O.D., F.A.A.O., J.D. EB