Friday, December 24, 2010


A retired professor came to your practice complaining of not comfortable while wearing his new pair of progressive glasses. He had tried to adapt with the glasses for 1 month but still cannot see clearly at far. He also reported of seeing better at far with his chin up. However, after adjusting his spectacle, he still does not satisfy with his vision.

This PBL relates to Ocular Disease & clinical Optometry.



  2. Does he have any ocular or systemic diseases?

    He just had been diagnosed of having Diabetes Mellitus recently.

  3. Is this the first time he wears this type of progressive lens?

    Not the first time, no problem of adaptation previously.

  4. Whats his ref. error?

    Distance:-2.00D/-1.00DCx 95
    Add: +2.75

  5. Did the marking points on the lenses coincide with the patient’s eyes?

    A little bit misalign; nose pad had been adjusted to overcome this problem. Still, patient not satisfied with his vision.

  6. For all group 3 PBL, please ask me for further infomation..

    Please state our keyword & Learning issue in the end of this discussion..

    This PBL discussion ends at 4.00pm today

  7. the trigger can be posted here.

    This trigger is much related to my thesis, really.

    This is common in first time wearers. Many research was done. Have a look at this figure.

    Freeman and Evans (2010); Hrynchack (2006)

    Majority of 88.1% spectacle non-tolerance were presbyope – 53 years old.

    1938 lenses were dispensed
    Non-tolerance: PALs = 7.4%
    Vocational lenses = 4.8%
    Single vision lenses = 2.0%
    Bifocal lenses = 0.8%

  8. does the RX prescribe for distance and near accurate?

  9. may be, he has chin up because the distance RX is not accurate. may be it is overcorrcted for distance and seeing through intermediate portion is much clearer

  10. is his sugar level stable during the refraction done? if im not mistaken, the RX is variable in DM patient. thus,repeated refraction is needed.

  11. as u hv said earlier, adjustmend has been done but the complaint is still there. i guess there must be something wrong with the power for distance.

  12. Do you have any figure regarding the patient's pupil hight and the frame height? Patient had also been wearing spectacle previously, is the current spectacle frame height and previous spectacle frame height similar?

    Maybe the patient had changed the type of frame.

  13. @nurlizzz

    Yes..It is due to what? In the 1 st visit, the optometrist found -2.00 D/-1.00x95, but in the 2nd visit, it is changed to -3.00/-1.50x95..

  14. since the patient have been recently diagnosed with diabetes, the unsatisfied vision is due to fluctuating refractive error. The current distance portion may not satisfy his vision thus he need to use the middle portion. I agree with norli that in this condition, the refractive error needs to be recheck and monitoring the sugar level might help.

  15. @Nurul Atikah

    Of course the type of frame changed.. from SV to PAL..

    A little bit misalign ( the height displaced only aroung 0.5mm) ; nose pad had been adjusted to overcome this problem. Still, patient not satisfied with his vision.

  16. @siti zahirah

    his blood glucose level is not under control..

    So, whats our learning issues?

  17. What type of progressive lens does the patient wear?
    Varilux Comfort.

  18. agree with norli, atikah n zahirah...

    most probably chin up due to misalign pupil height of his PAL(maybe decentered down, dats why he need to chin up to align the pupil and the OC)..

    however he still not satisfied when adjustment being done. it is most probably due to the fluctuating refractive error because of DM.

    how about finding from optometric examination like slit lamp and fundus examination?


    here we try to come out the tentative diagnosis:

    -fluctuate refractive error due to DM

    learning issues:

    - mechanism of relationship between DM and refractive error..
    - further optometric examination to be performed.
    -design & dispensing of PALs.

  19. salam sir, do u have the pic of his progressive lens?

    may i know the details of his actual pupil height, pd, and the finished pupil height of the progressive lens.

  20. @hidayah

    I want to add some learning issues for your guys

  21. learning issues:
    1) the pathophysiology of DM affecting refractive errors.
    2)the management:when and how to prescribe correction.
    3)Prevalence of DM with presentation of ocular pathology in Malaysia.

    these are some of my opinion..:)

  22. Hypothesis
    He has uncontrolled Diabetes Mellitus Type II.

    Learning issue
    • Diabetes Mellitus Type II.
    • The complication of uncontrolled diabetes to the eye; cataract, glaucoma, retinopathy, blindness.
    • General consideration in prescribing, especially among diabetic patient.

  23. @rohaila

    Sorry, i don't have the pic. As I've said in previous comment, his height was displaced only 0.5 mm...A little bit misalign; nose pad had been adjusted to align it..

    So, it is not because of misfitting of PAL.okay

  24. @The Traveler

    the RX is fluate due to unstable glucose level of DM patient. when the glucose level increase, serbitol level in crystalline lens will also increase. due to that Rx is fluctuate.

  25. learning issue:

    1) common problems faced by wearers
    2) guideline to handle uncontrolled diabetic patient (refraction specifically)

  26. so that means we need to discuss refractive care for diabetic patients..right?

  27. @azuwan what do u mean by '..presbyope-53 y.o.' ,azuwan? is it people with that age is more prone to have this problem?

  28. came across this when searching for pbl.. cool!! ;)

  29. Hi, I am an optometry student in south africa. I was just reading your blog and the comments made on this case. I was wondering how you would dispense to a diabetic patient? Do u prescribe spectacles with the prescription you found, even though the patient vision fluctuates?

  30. @Anonymous

    Thank you on your question..but in next comment, hope you can put your real name instead of comment as Anonymous.

    It's an Problem Based Learning discussion.. In clinic, we shall not prescribe any Rx for uncontrolled DM case.

    This professor spectacle is prescribed by an Optician at Retail Optical Shop..after the professor not comfort with his spectacle, then attended to our Optometry Clinic..So, when an Optometrist at IIUM interviewed patient's general health n perform extensive exam., he found that this patient has DM..

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