Framed by the Evidence

Noah (name changed to protect the guilty) is a bright nine year-old child who was referred to me six months ago due to the obvious disparity between his intellect and the way he struggled to “look inside”, a term common in the parlance of Yeshiva students who must sustain visual attention to a visually crowded text page for extended periods of time while learning what can at times appear on the surface to be relatively arcane details.

His mother, who accompanied him to his visit yesterday, reported that Noah had been doing much better with reading and learning shortly after beginning to wear the glasses I prescribed for him. The prescription was -2.50 sphere in the distance for both eyes with a +1.00 add and one prism diopter bases in OU. For the uninitiated, an “O” surrounding a “U” inside is a symbol used to designate kosher food super-vision (the acronym for “Orthodox Union”). Here however we use it ophthalmically for its Latin designation of Ocluus Uterque to indicate that his prescription was the same in both eyes. Yet something was decidedly not kosher about the situation.

Noah was rough on his glasses, and he presented to his visit with the temple missing from the right side of his frame. As he sat in the examination chair, his mother elaborated that the original concerns about Noah’s inability to “look inside” were recurring, and he acknowledged that he had recently become less comfortable looking through his glasses when learning and preferred to read without his glasses. He had the right amount of uncompensated myopia to be perfectly conjugate at near, and evidently felt better without the prism. Because his frame was broken, I conducted the remainder of Noah’s progress evaluation through a trial frame. Everything seemed to point to the same powers at distance and near as before, as well as the same prism power and direction. Clearly more detective work was needed.

The -2.50 OU in his Rx was enough power that just a little bit of torque from the way the frame sat on his face might explain some induced prismatic imbalance that was making Noah uncomfortable. But the right temple had only recently broken, and his regression seemed to start before that. I took another look at his glasses and, because his round bifocal was nearly invisible I had missed something the first time I glanced at them. Can you see it now?

That’s Noah’s right lens your looking at, and the bifocal is displaced temporally instead of nasally. The same was true of his right lens. I asked his mother if the lenses might have fallen out of his glasses at some point, and she said that indeed they had but was proud that Noah had been able to put them back in. Because he had unintentionally reversed the lenses in his round frame, his base-in prism became base-out prism and the bifocal position made reading through them untenable. Noah took his frame back, quickly popped the lenses out and snapped them back into their proper orientation. The mystery had been solved.

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