C L I N I C A L A N D E X P E R I M E N T A L
OPTOMETRY
cxo_441 37..38
Progressive addition lens design and the short of stature
Clin Exp Optom 2010; 93: 1: 37–38
Santos Shan-Yu Tseng OD
James I-Chih Chan BOptom
Department of Optometry, Chung Shan
Medical University, Taichung, Taiwan
E-mail: santos_tseng@hotmail.com
Submitted: 25 June 2009
Revised: 15 September 2009
Accepted for publication: 21 October
2009
Traditional progressive addition lens
(PAL) design, which places the distance
vision correction in the upper half of the
lens,1,2 may pose a specific challenge for
the short of stature. Given that PALs are
used by those who have presbyopia, which
occurs in middle-to-old age, and that
persons become shorter as they become
older,3 it is reasonable that this fitting chal-
lenge be recognised.
CASE DESCRIPTION
A 150 cm tall, 51-year-old Chinese female
with low myopia presented with a desire
to wear PALs. Her current eight-year-old
single vision spectacle prescription was R
-1.25 DS and L -1.50 DS. She habitually
read unaided but was interested in PALs
because she no longer wanted the trouble
of removing her spectacles to read. Mani-
fest refraction was R -1.50 DS (6/6) and L
-1.75 DS (6/6) with an addition of +1.75 at
40 cm. PALs were prescribed and she was
instructed in their use.
© 2009 The Authors
Journal compilation © 2009 Optometrists Association Australia
CLINICAL COMMUNICATION
One week later, the patient returned
complaining of blur at distance. Although
she suspected the prescription in her new
spectacles was wrong, a refraction pro-
duced the same manifest result as on her
previous visit. It was determined that the
patient’s blur was associated with her
shortness of stature. Her lack of height
had fostered in her the lifelong habit of
elevating her face to look at people,
objects and the world around her. This
caused her line-of-sight to fall into the
plus-addition progressive corridor of her
new lenses, resulting in unclear distance
vision.
The patient was told she would have to
modify her habitual head position, if she
was to view clearly at distance with her
new glasses. The patient said she would
attempt the adjustment to her head
posture.
DISCUSSION
The patient’s habitual head position was
not a problem with her old single-vision
lenses because they did not depend on the
position of her line-of-sight. Her chin
elevation4 effectively raised the position of
the lenses relative to her eyes, making her
new PALs ‘too high’ for her visual axes
and causing her line-of-sight to fall into
the lenses’ progressive addition corridors.
This head tilt is often done purposefully
by PAL-wearing computer users who re-
quire use of their additions to see their
video-display terminals clearly.5
Clinical and Experimental Optometry 93.1 January 2010
DOI:10.1111/j.1444-0938.2009.00441.x
A basic trigonometric construction
(centre of rotation 13.1 mm posterior to
the corneal apex,6 14.0 mm back vertex
distance, 10-degree pantoscopic tilt)
shows that a short-statured individual
who habitually views the world with an
8.5 degree face elevation above primary
position (this would allow a 150 cm tall
person to view the eyes of someone
180 cm tall standing at a distance of two
metres) would have her line-of-sight fall
by 4.0 mm at the spectacle plane, if a full
vestibular-ocular reflex were to occur.7
This distance would be sufficient to
cause a wearer to view through the
intermediate-Rx portion of her PALs,
given that modern designs with min-
imum fitting heights of 15 mm and cor-
ridor lengths of 11 mm are widely
commercially available. Assuming a linear
increase in addition power from the dis-
tance reference point to the near refer-
ence point, a 4.0 mm movement into the
progressive addition corridor would
result in +0.63 D of blur for a +1.75 D
addition lens, coinciding with approxi-
mately two lines of loss in visual acuity.8
Given that the addition power of typical
PAL designs is non-linear,1 it is likely this
amount of blur is an underestimation.
For an otherwise properly-fitted PAL
wearer, the following five factors would be
expected to increase the likelihood of this
distance-blur condition occurring:
1. an increase in addition power
2. a decrease in corridor length
3. an increase in chin elevation
37
Progressive addition lenses Tseng and Chan

4. a lack of training on how to use PALs
5. a patient’s particular sensitivity to blur.8
Unsatisfactory techniques that would
allow a patient to view clearly at distance
given a chin elevation include:
1. over-minusing the distance prescrip-
tion (this would result in unclear vision
at all other distances)
2. significantly increasing the pantoscopic
tilt (this would induce considerable
astigmatism9 and aberrations at all
other distances)
3. lowering the lens in the frame or low-
ering the frame on the face (either of
these techniques would lower the near
reference points out of useable reach).
When dealing with patients who are
short, it is important that the clinician
make note of any compensatory chin
elevation as described in this report. If
one exists, additional counselling on PAL
usage may be indicated to help the patient
with adaptation.
Proper use of PALs is important not
only for visual acuity but also for patient
safety. A wearer who is driving a vehicle
and who encounters an emergent situa-
tion must avoid reverting to their habitual
viewing posture during such stress.
Although our case discusses an indi-
vidual who is short, those who are very tall
may also require particular care in PAL
training, as they too may adopt unconven-
tional head or viewing positions10 that
may interfere with proper PAL distance
viewing to compensate for the relatively
‘short’ world around them.
6. Bron AJ, Tripathi RC, Tripathi BJ. Wolff’s
Anatomy of the Eye and Orbit, 8th ed.
London, UK: Chapman & Hall Medical,
1997.
7. Griffin JR, Grisham JD, Ciuffreda KJ. Bin-
ocular Anomalies Diagnosis and Vision
Therapy. Woburn, MA: Butterworth-
Heinemann, 1995.
8. Hirsch MJ. Relation of visual acuity to
myopia. Arch Ophthalmol 1945; 34: 418–421.
9. Illueca C, Hernández C, Domenech B. Foci-
meter measurement of the astigmatism
arising from oblique central refraction.
Ophthalmic Physiol Opt 1992; 12: 52–57.
10. Lichota M. Spine shape in sagittal and
frontal planes in short- and tall-statured
children aged 13 years. Physical Educat Sport
2008; 52: 92–95.
Corresponding author:
Dr Santos Tseng
Department of Optometry
Chung Shan Medical University
No 100, Sec 2, Da-Cing Street
Taichung, 402
TAIWAN
E-mail: santos_tseng@hotmail.com

REFERENCES
1. Sheedy JE, Buri M, Bailey IL, Azus J, Borish
IM. Optics of progressive addition lenses.
Am J Optom Physiol Opt 1987; 64: 90–99.
2. Meister DJ, Fisher SW. Progress in the
spectacle correction of presbyopia. Part 1:
Design and development of progressive
lenses. Clin Exp Optom 2008; 91: 240–250.
3. Chandler PJ, Bock RD. Age changes in
adult stature: trend estimation from mixed
longitudinal data. Ann Hum Biol 1991; 18:
433–440.
4. Williams CR, O’Flynn E, Clarke NM, Morris
RJ. Torticollis secondary to ocular pathol-
ogy. J Bone Joint Surg Br 1996; 78: 620–624.
5. Good GW, Daum KM. The use of progres-
sive addition multifocals with video display
terminals. J Am Optom Assoc 1986; 57: 664–
671.

Clinical and Experimental Optometry 93.1 January 2010 © 2009 The Authors
38 Journal compilation © 2009 Optometrists Association Australia
Copyright of Clinical & Experimental Optometry is the property of Blackwell Publishing Limited and its
content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual use.