Pal

Published in Australia by
The International Centre for Eyecare Education
First Edition 2002

Presbyopia Education Program 2002

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted in any form or by any means, without the prior permission in writing of:

ICEE Secretariat
PO Box 328
Randwick, Sydney
NSW 2031 Australia
Tel: (612) 9385 - 7435
Fax: (612) 9385 - 7436
Email: icee@ cclru.unsw.edu.au
1
TABLE OF CONTENTS
Introduction 3
Acknowledgements 4
Contributors 5
The optics of progressive lenses 7
PALs and visual physiology 12
Why use progressive lenses? 19
Progressive lens design 26
Determining patient suitability 46
Progressive lens marking 59
Dispensing progressive lenses 63
Delivery 87
Patient management 93
Case studies 107
References 114
2
INTRODUCTION
The Educators Presbyopia Education Program (EPEP) is intended to assist ophthalmic educators with
information and materials that may be useful in the teaching of refraction, dispensing, and prescribing for
the presbyope in ophthalmic schools, colleges, and other institutions.
The course of study includes:
Module 1 Ocular Anatomy and Refractive Errors

Module 2 The General Eye Examination
Module 3 The Refractive Examination
Module 4 Accommodation and Presbyopia
Module 5 Binocular Vision
Module 6 Ophthalmic Optics
Module 7 Spectacle Lenses
Module 8 Progressive Addition Lenses
The Modules contain most of the basic knowledge students will need as eyecare practitioners.
The teaching materials are intended to be in an easy-to-use format containing slides and suggested
accompanying text. The diagrams and photos provide visualisation for the concepts presented.
Craig Butler
Director, Professional Education
3
ACKNOWLEDGEMENTS
The International Centre for Eyecare Education (ICEE) was established to develop the global resources needed to provide
people everywhere with good vision and effective eyecare. Our role is to develop educational programs where they do not
exist, to provide resources where needed to help teachers teach, and to help people in need.
In the Presbyopia Education Program (PEP), we deal with a condition that affects 22% of the world’s population.
Presbyopia eventually affects everyone, yet the public understands little about it and is often resentful of this sign of middle
age. Many advances have been made in optical design of spectacles for presbyopia and it is important that eyecare
practitioners have the best correction options available. In many parts of the world the educational programs and product
availability are very rapidly advancing and ICEE, in this Essilor sponsored program, will bring information and materials to
help keep educators and practitioners up to date.
The goals of PEP are to help advance the refraction, dispensing, prescribing and patient management skills of practitioners,
particularly in the prescribing of progressive addition spectacles. The PEP for Educators will supply infrastructure and
materials for the teaching of refraction, dispensing and prescribing in relevant ophthalmic schools, polytechnical colleges
and other training institutions.
ICEE could not be successful in this endeavor without the assistance and generosity of a large number of talented and
dedicated people. To all those contributors of lectures, computer programs, videos and slides, we say thank you.
Your generosity of spirit will benefit many educators and students, and millions of patients throughout the world.
The Program was also very fortunate to obtain the services of many committed people in writing, designing, editing,
producing and distributing the modules. In particular, the staffs of the Cooperative Research Centre for Eye Research and
Technology; the University of Waterloo, Canada; the Cornea and Contact Lens Research Unit at the University of New
South Wales; and the International Association of Contact Lens Educators, have contributed substantially to this project
through the donation of time, resources and editorial support. The individuals involved are acknowledged in each module.
Essilor, one of the world’s leading ophthalmic companies, has generously funded this project. Their vision and commitment
to education and the community will help advance eyecare throughout the world. Their technical and professional services
staff have been extremely helpful.
All the contributors deserve recognition for their willingness to donate their knowledge, talent and time to the advancement
of international eyecare through this Program.
Brien A Holden
On behalf of the Management Committee of ICEE
4
CONTRIBUTORS
EDITORIAL CONTRIBUTORS PRODUCTION

 Editor  Major Contributor  Coordinator
David Wilson BEc, BA (Hons) Yvette Waddell (2)
Stephen Kwok PhD
Dip Ed, FNAO
 Coordinating Editor
 Contributors  Graphics
Chuan Ooi BOptom., MSc (Optom)
Stephen Kwok PhD Barry Brown (2)
Maria Wong, BA (1)
 Proof Readers Brad Ferguson, BVisCom (1)
Kylie Knox, BA(Comm) (1) Greta Spies (1)
Peter Fagan, BA(Hons), Dip Lib (5)
1 Cooperative Research Centre for Eye Research and Technology (CRCERT) Sydney, Australia
2 International Association of Contact Lens Educators (IACLE ) Sydney, Australia
3 International Centre for Eyecare Education (ICEE) Sydney, Australia
4 School of Optometry University of Waterloo Waterloo, Canada
5 Documentation Consultant Sydney, Australia
5
Progressive Addition Lenses
What are progressive addition lenses?

 A lens designed for presbyopes with
power gradually increasing from the

distance zone, through a progression
to the near zone.
6
The Optics Of Progressive Lenses
Even surface power of

single vision lens
Discrete power change

a in bifocal
c
Discrete power
changes in trifocal
Continuous change in
radius to produce
power change - looks
b like single vision lens d
7
Power Progression
Distance
Zone
Power (Dioptre)
Progressi
ve zone
(Intermed
iate Zone)
+2.50 D
PAL
Near +2.00/+1.00 D
+1.50 D Trifocal
Zone Bifocal
8
Optical Description
Spherical plot Cylindrical plot
9
Optical Description
a b
10
Power Progression and Vision
PAL Lens
Distance
Zone
Peripheral
Zone
Near
Zone
Intermediate
Zone
11
PALs and Visual Physiology
B A´
Fovea
B´
A
Foveal and extra-foveal vision: Objects A,B which are off the visual axis (to fovea) are imaged
on peripheral or extra-foveal points (A’,B’).
12
Physiological Considerations
Typical dioptric power (D) for
clear viewing of objects
Distance
Intermediate
Near
13
Zone of Clear Vision
Progressive lenses enable the presbyopic eye to see objects clearly in a

smoothly continuous fashion from distance to near distances, much like
the pre-presbyopic eye.
14
Head and Eye Movements
To reach the
position of interest
in the field of view, Vertical movements
the patient makes
a combination of Head tilt
head and eye
movements. These Eye
declination
can be
theoretically
separated into
vertical and
horizontal
Horizontal movements
components.
15
Usable Field of View
The usable field of

view is comprised of
head and eye
movements as
shown here for the
horizontal plane.
Head
movement
Eye
rotation
16
Binocular Vision
Binocular vision:
As the patient’s gaze is lowered

for near objects, the eyes
converge to maintain a single
binocular image. The
progressive lenses should
ensure that this is maintained for
different object distances from
the eyes, as illustrated by the
lines.
17
Peripheral (Extra-Foveal) Vision
Peripheral vision:
The PAL design should
ensure that objects in the
periphery of the visual
field are easily fused. The
distribution of prism in
each lens should also be
balanced for binocular
viewing. Corresponding
areas in the two lenses
(denoted by the same
pattern) should provide a
similar level of vision.
18
Why Use Progressive Lenses?
Height on
lens (mm)
Distance
+4 0%
-8 50%
Intermediate
- 14 80%
Near
- 20 100%
% Reading add power (2.00 D)
19
Intermediate Vision
(a) Bifocal (b) PAL
Intermediate vision:
(a) Poor head position as a consequence of the eyes searching for the best
focus in the bifocal’s limited range of intermediate clear vision. (b) Using the
intermediate portion of a PAL enables more natural head position.
20
Intermediate Vision
Working
distance
67 cm
40 cm
21
Bifocal lens Progressive lens

The bifocal lens (left) can disrupt the patient’s view with visual disturbances (arrows) when the eye
crosses the boundary of the near seg. The progressive lens (right) has no such problem and enables
a smooth transition between different reading distances. 22
Advantages of progressives
 A complete range of working distances
 Improved appearance
Bifocal lens with noticeable segment Progressives: the transitions between

boundary (arrow). power zones are invisible. 23
Advantages of progressives Benefits for the patient
 The lenses look like single vision
lenses and don’t have the ugly line/s
 A complete range of working on the lens.
 distances  They allow the patient to look at
 Convenient objects at all distances without
moving their heads forward and
 No image jump back.
 Improved appearance  They only need one pair of
 Thinner and lighter than many spectacles.
multifocals  They simulate a person’s normal
vision.
 They are light, comfortable and
attractive.
24
Disadvantages of progressives
 Peripheral aberration
 More expensive
25
Progressive Lens Design
1. History of Progressives
1950s Varilux from Essel (now Essilor)
 Hard Design, symmetric lens
1970s Varilux II
 Hard Design, asymmetric
1980s Families of lenses (hard, soft and in-between)
 Lenses for different patient types or uses
1990s New soft lenses (multi-design)
 Lenses for all uses and adapted to all prescriptions.
As worn lens design
26
1. History of Progressives
1950s Varilux from Essel (now Essilor)
 Hard Design, symmetric lens
1970s Varilux II
 Hard Design, asymmetric
1980s Families of lenses (hard, soft and in-between)
 Lenses for different patient types or uses
1990s New soft lenses (multi-design)
 Lenses for all uses and adapted to all prescriptions.
As worn lens design
27
2. Hard Vs Soft Lens Design
Hard Soft
28
Hard Lens Design
Hard Design
 Wide distance and near zones
 Narrow intermediate zone
 Rapid increase in unwanted
astigmatism
 Shorter progression
29
Soft Lens Design
Soft Design
 Narrower distance and near zones
 Wider intermediate zone
 Gradual increase in unwanted
astigmatism
 Longer progression (except in latest
designs)
30
3. Symmetrical Vs Asymmetrical
Symmetrical Design
 Lenses are rotated for near centration
Asymmetrical Design
 Lenses are designed with
pre-determined inset
A B
31
Symmetrical
PAL - same
lens design is
rotated to fit
the other eye
Asymmetrical
PAL - each
eye has a
different lens
32
The same lens Symmetrical
progressive
design is rotated
lens
anti-clockwise for
the right lens and
clockwise for the
left lens. The
patient's binocular
vision is
unbalanced when
looking to the
sides.
Asymmetrical
Each eye has a progressive
different lens. The lens
optical
characteristics are
similar on either
side of the
progression zone
so the patient’s
binocular vision is
balanced. 33
3. Mono Vs Multi Lens Design
Multi Design
•Lens characteristics change with
prescription
•Lens performs appropriately over
full prescription range
34
Recent changes
Hard Design Early Soft Design New Soft Design
35
Occupational Lenses
36
Extended focus lenses
37
Progressive Lens Design - Optics
Lens Radius Changes Along Umbilical
Line
Distance
Umbilical line Zone
Near
Intermediate Zone
Zone
38
1. Conical Curves
Gradual Increasing Power from Distance to Near
Conical Sections
 Parabolic Curves
 Hyperbolic Curves
 Elliptical Curves
39
2. Manufacturing Methods
•Producing the Progressive Surface

•Prism Thinning
Lens
New back surface
Prism thinning
40
Tools For Comparing
Progressive Lenses
1. Cylinder Contour Plots
(Isocyl Charts)
 Define the shape and width of the various zones
 Show areas of equal cylindrical power on the front
surface
 Or areas of equal cylindrical power in a given range
41
Tools For Comparing
Progressive Lenses
1. Cylinder Contour Plots
(Isocyl charts)
 Hard and soft design contour plots
Soft Hard
42
Tools For Comparing
Progressive Lenses
Usefulness of Contour Plots
 They can give useful information about the design type
 They can allow some comparisons with other designs
Problems with Contour Plots
 They only describes the shape of the front surface
 They cannot predict actual performance accurately
 They do not consider other aberrations
43
Tools For Comparing
Progressive Lenses
Contour Plots and Useable Zone Width

The first isocyl line is not a true indicator of zone
width
44
Tools For Comparing
Progressive Lenses
2. Spherical Contour Plots
 Define the length of the
progression
 Show areas of equal spherical
 power on the front surface
45
Tools For Comparing
Progressive Lenses
3. Isoacuity Plots
 Define the useful zones of the lens
 Show areas of equal visual acuity
46
Determining Patient Suitability
1. Occupation
Relative need for

 Distance/intermediate/near
 Field of view requirements
 Direction of gaze requirement
47
1. Occupation
Relative need for

 distance/intermediate/near
48
1. Occupation
Field of view requirements
49
1. Occupation
Direction of gaze
requirements
DISTANCE VISION
T E
DIA
E
M N
ER
INT VISIO AR
E N
N SI O
VI
50
2. Prescription
Emmetropic Presbyope
 1st pair
 Bifocal wearer
 Progressive wearer
Myope
Hyperope
51
2. Prescription
 1st pair
 Bifocal wearer
 Progressive wearer
Myope
Hyperope
52
2. Prescription
1st pair
Bifocal wearer
Progressive wearer
Myope
Hyperope
53
3. Contraindications
1.Occupation
 Field of view
 Direction of gaze
 Mobility/head
movement
2.Prescription
54
Field of view
55
Direction of gaze
56
Mobility/head movement
57
2.Prescription
 Anisometropia
 Antimetropia
 High Cyls for certain axes
58
Fitting and Dispensing Progressive
Lenses
59
Progressive Lens Marking
Permanent Markings
Horizontal locators (circles positioned nasal and temporal)
Lens logo and material code (below locator on nasal side)
Add power (below locator on temporal side)
Micro-etching
Micro-etching
Temporal 2.0
6 Nasal
Material
Add Power
Logo
RE Lens
60
Progressive Lens Marking
Ink Stamped Markings
 Distance reference circle  Horizontal meridian markers
 Fittings cross  Near reference circle
 Prism reference point Prism
Reference Point
Distance Reference Circle
Fitting Cross
Micro-etching
Micro-etching
Temporal Nasal
6
2.0
Add Power Material

Near
Reference Circle Logo
RE Lens 61
Re-locating Progressive
Lens Markings
 1. Find micro-engraved permanent markings

 2. Mark the position of the horizontal locators
 3. Select manufacturer’s layout chart for the
correct lens type
62
Re-locating Progressive
Lens Markings
 4. Lay the lens on the chart with the marked locators in the
correct position
 5. Trace the distance and near reference circles, the fitting
cross and the prism reference point
63
Dispensing Progressive Lenses
1. Frame Selection
Frame shape
Frame depth Frame size
Good Shape Good Depth Good Size
Bad Shape Insufficient Depth Too Large

64
1. Frame Selection
 Back vertex
distance
 Pantoscopic tilt
 Facial wrap
65
2. Frame Adjustment
When to Adjust
 Before taking the facial
measurements
 When delivering the
spectacles
66
2. Frame Adjustment
Special Considerations
 Back vertex distance
 Pantoscopic tilt
 Facial wrap
Reduced BVD gives Increase Pantoscopic Tilt

wider field of view increases near field of view
67
3. Facial Measurements
Methods
 Distance method 1
 Distance method 2
 Near method 1 (the
mirror method)
 Near method 2
68
Distance Method 1
 Step 1: Adjust the frame
 Step 2: Measure the monocular
PDs with the pupillometer
61
Monocular PD Monocular PD
29
29 32
32
69
Distance Method 1
 Step 3: Mark the HCL & PD on the dummy lenses
70
Distance Method 1
 Step 4: Check the pupil height
 Step 5: Check the height while talking to the
patient
71
Distance Method 1
 Step 6: Order the PD as per the
pupillometer reading &height as per step 5
72
Distance Method 2
 Step 2: Measure the
monocular PDs with the

pupillometer
73
Distance Method 2
 Step 3: Place the frame on the patient and dot the
pupil centre
 Step 4: Check the height while taking to the patient
Dotting the pupil centre 74

Distance Method 2
 Step 5: Order the PD as per the
pupillometer reading & height as per step 4
75
Near Method 1
 Steps 1 - 5: as per Distance Method 1
 Step 6: Mark the distance and near visual point circles
76
Near Method 1
 Step 7: Place a mirror between the patient and you and
observe through the mirror the patient’s eyes when looking at
the mirror
 Step 8: Adjust the near visual circles if necessary to
correspond with the patient’s lines of sight
77
Near Method 1
 Step 9: Place the adjusted near visual circles on the
layout chart to determine the final position of the

fitting crosses.
78
Near Method 2
 Step 2: Measure the monocular near CDs with the
pupillometer
61
Monocular PD Monocular PD
29 32
79
Near Method 2
 Step 3: Mark the HCL & PD on the dummy lenses
80
Near Method 2
 Step 4: Check the pupil height
 Step 5: Check the height while talking to the
patient
81
Near Method 2

Step 6: Order the PD as per the pupillometer near CD
reading plus 2.5 mm each eye & height as per step 5
82
Comparing the Methods

 Distance Vs Near methods
 Mirror method Vs Near
Method 2
83
Comparing the Methods
 Pre-marking the dummy lenses Vs dotting the lenses
 Pupillometer vs PD rule or dots
84
4. Lens Ordering
PDs
Heights
 From the horizontal centre line (Datum)
 From the frame bottom
85
4. Lens Ordering
Checking the cut-out
86
Delivery
1. Pre-delivery Verification
 Checking the markings

 Checking the frame details
 Checking the distance power and prism
87
Delivery
Checking the addition
88
Delivery
Checking the fitting cross heights and monocular PDs
89
Delivery
2. Sources of Manufacturing Error
1.Heights
2.Monocular PDs
3.Lenses swapped
4.Wrong power
5.Axis error
90
Delivery
3. Remedies for Manufacturing Errors
1.Heights
2.Monocular PDs
3.Lenses swapped
4.Wrong power
5.Axis error
91
Delivery
4. On Eye Assessment
1. Check frame fit
2. Check the position of the fitting crosses
3. Check distance vision
4. Check near vision
5. Remove the ink markings
92
Patient Management
1. Instruction
How to use the lenses

Positive language
93
Patient Management
2. Troubleshooting
General Problem Areas

 Poor frame adjustment or frame choice
 Errors in heights or PDs
94
Patient Management
2. Troubleshooting
General Problem Areas

 Poor frame adjustment or frame choice
 Errors in heights or PDs
 Change in lens type or base curve
 Unsuitable lens type
 Errors in prescription
95
Patient Management
2. Troubleshooting
The steps for solving progressive problems
 1. Question the patient
 2. Re-mark the lenses and check the powers
96
Patient Management
2. Troubleshooting
The steps for solving progressive problems

 1. Question the patient
 2. Re-mark the lenses and check the powers
 3. Check the frame fit and fitting cross
positions
 4. Watch the patient using the lenses
97
Patient Management
3. Patient Complaints & Remedies
1. Visual Problem
 Blurry distance vision
98
Patient Management
1. Visual Problems
 Blurry reading vision
99
Patient Management
1. Visual Problems
 Swim sensation
100
Patient Management
1. Visual Problems
 Reading area too small
101
Patient Management
2. Posture Problems
 Having to look to the side to read
102
Patient Management
2. Posture Problems
 Having to tilt their head too far back to read
103
Patient Management
2. Posture Problems
 Having to tilt their head back for distance
104
Patient Management
2. Posture Problems
 Having to tilt their head forward to read
105
Patient Management
2. Posture Problems
 Having to tilt their head forward for distance
106
Case Studies
Case 1
 46 year old first time wearer of progressives
complains of small reading area
107
Case Studies
Case 2
 48 year old first time wearer of progressives
complains of not being able to read binocularly
108
Case Studies
Case 3
 56 year old wearer of progressives complains of
having to tilt his head forward to see in the distance
109
Case Studies
Case 4
 57 year old wearer of progressives complains of a
narrow reading area
110
Case Studies
Case 5
 55 year old wearer of progressives complains
of having to tilt his head back too far to read
111
Case Studies
Case 6
 A 52 year old patient
who uses the computer
screen a lot complains
of eye strain, ocular
discomfort, and has
chronic neck and back
pain
112
Summary
Progressives - the future for presbyopes

 Improved designs lead to easier adaptation and easier
dispensing
 Progressives mimic normal visual function
 Progressives are the most attractive lenses for presbyopes
113
REFERERENCES
 Australian Optometry. (1999) Ophthalmic Lenses 1999 (supplement). Optometrists Association of Australia
 Jalie M (1999). Ophthalmic Lenses and Dispensing Butterworth- Heinemann, Oxford
 Jalie M (1988). The Principles of Ophthalmic Lenses. 4th ed. The Association of British Dispensing Opticians, London..

Wilson D (1999). Practical Optical Dispensing. Open Training & Education Network, Sydney.
NOTES
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Published in Australia by

The International Centre for Eyecare Education

First Edition 2002

The International Centre for Eyecare Education

The International Centre for Eyecare Education

The optics of progressive lenses 7

PALs and visual physiology 12

Why use progressive lenses? 19

Progressive lens design 26

Determining patient suitability 46

Progressive lens marking 59

Dispensing progressive lenses 63

Case studies 107

The course of study includes:

Module 1 Ocular Anatomy and Refractive Errors

EDITORIAL CONTRIBUTORS PRODUCTION

2 International Association of Contact Lens Educators (IACLE ) Sydney, Australia

3 International Centre for Eyecare Education (ICEE) Sydney, Australia

4 School of Optometry University of Waterloo Waterloo, Canada

5 Documentation Consultant Sydney, Australia

What are progressive addition lenses?

power gradually increasing from the

Even surface power of

Discrete power change

Spherical plot Cylindrical plot

Progressive lenses enable the presbyopic eye to see objects clearly in a

The usable field of

As the patient’s gaze is lowered

(a) Bifocal (b) PAL

Bifocal lens Progressive lens

Bifocal lens with noticeable segment Progressives: the transitions between

 Narrow intermediate zone

 Rapid increase in unwanted

 Wider intermediate zone

 Gradual increase in unwanted

Hard Design Early Soft Design New Soft Design

•Producing the Progressive Surface

New back surface

 power on the front surface

 Show areas of equal visual acuity

Relative need for

 Field of view requirements

 Direction of gaze requirement

Relative need for

Field of view requirements

Add Power Material

 1. Find micro-engraved permanent markings

Good Shape Good Depth Good Size

Bad Shape Insufficient Depth Too Large

Reduced BVD gives Increase Pantoscopic Tilt

 Near method 1 (the

 Step 2: Measure the monocular

PDs with the pupillometer

 Step 5: Check the height while talking to the

pupillometer reading &height as per step 5

 Step 2: Measure the

monocular PDs with the

Dotting the pupil centre 74

pupillometer reading & height as per step 4

 Step 6: Mark the distance and near visual point circles