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Fitting the almost bridge-less nose.

A tutorial on the right frame selections and fitting techniques for the Asian, African-American and kid's noses.

By Maryann Santos

Release Date: November 1, 2013

Expiration Date: March 18, 2016

Learning Objectives:
Upon completion of this program, the participant should be able to:

  1. Become familiar with population growth trends in the U.S. and how that relates to your frame inventory
  2. Understand the relationship of bridge fit and optical clarity
  3. Understanding of adjustments and frame modifications to create a well fitting bridge on the wearer

Faculty/Editorial Board:
Maryann SantosMaryann Santos is a Licensed Optician at Madison Optical in Madison, CT and owner of Optical Concepts an Optical Dispensary Training Service throughout Connecticut. She is ABO-M and NCLE certified.






Credit Statement:
This course is approved for one (1) hour of CE credit by the American Board of Opticianry (ABO). Course #SWJHI507



SERVING ALL FACES
Our job in the optical dispensary is to serve each patient that crosses the threshold. We do this by being knowledgeable, on the cutting-edge of technology and up-to-date on frame styles. We need to have frames to fit youth, teens and adults in a variety of eye and bridge sizes. However, many of the frames I see in the offices I consult, are challenged to fit the low and wide bridge.  In a population of diversity include frames that fit high cheekbones and/or a low nose bridge.

img1POPULATION TRENDS
There are over 314 million people in the United States of America according to the U.S. Census Bureau's U.S. & World Population Clock which is consistent with the Census 2010 data. And, within that population, there are various groups in which the need is more apparent. For example, the Asian population increased more than four times faster than the total U.S. population. The U.S. 2010 Census Brief states in The Asian Population 2010: "The total U.S. population grew by 9.7 percent, from 281.4 million in 2000 to 308.7 million in 2010. In comparison, the Asian alone population increased more than four times faster than the total U.S. population, growing by 43 percent from 10.2 million to 14.7 million."

Asian Americans are reported to have the highest education levels among all the populous in the country. That can translate to a clientele that would understand eyewear options but also demand more from products to meet their exact needs. As a result, we must have the inventory to properly serve our clientele. With the right products, this can also translate to increased patient satisfaction and an opportunity for multiple pair sales. With the right fitting frames, an optician or paraoptometric, knowledgable about face contours and fit, can create the trust and confidence that results in recommendations for a pair of progressvies, perscription sunglasses, a pair of computer glasses and readers for reading in bed. So, what's the problem?

WHY IS FIT SO IMPORTANT?

Low Nose Bridge and High Cheek Bones
In the dispensary, there are challenges when selecting eyewear for a patient with a low bridge and high cheek bones. Those with high cheekbones coupled with a low and narrow, or a low and wide bridge, tend to wear their eyeglass frames resting on the cheekbones. They slip continuously. When the frame doesn't fit the nose, the temples bow out.

Accommodating the bridgeless typically requires decreasing the pantoscopic tilt (from about 8° to less when viewing the frame from the side), or by flattening the frame front. These changes affect the aesthetics of the frame as well as the viewing area of the lens. Not only does an improperly fitted frame leave marks on the bridge and cheekbones, the patient ends up not viewing out of the proper area of the frame.

Optical Centers/Lens Positioning
Glasses are both a fashion accessory and function to correct a patient's vision. When a frame fits poorly and sits low on the nose, the patient is not looking through the originally intended fitting point. The best and most accurate vision is when one looks through the optical centers of the lens. The result is the patient may be viewing through unprescribed vertical prism. If the Rx is minus and the glasses sit too low, the patient will be viewing above the optical centers with unwanted Base Up Prism. If the Rx is plus, the unwanted prism would be Base Down.

Progressive Lens Success and Satisfaction
Progressive lenses are marked and set at the pupil center after pre-adjusting the frame to the patient's face. If the bridge of the frame does not match the bridge of the patient, the eyeglasses will end up slipping on the nose. A patient with a low and wide or low and narrow bridge would be affected. The wearer will not utilize the intermediate and the reading portion of the lens correctly because they are too low to be used effectively. The wearer will have to continually push up their eyeglasses to obtain adequate vision and to fully use the lenses.

Comfort and Good Looks
Glasses that fit well on the bridge of the nose are the most comfortable. They leave fewer marks. We all see people with eyewear that is so low on the bridge of the nose that we are tempted to go over to them and push them up. A well fitting frame looks better on the face.

BUILDING A NEW CUSTOMER BASE 

Every office looses patients each year and attracting new patients can be done in a variety of ways. Consider lines of frames that fit unique facial characteristics. Work with your frame reps for those products to best serve a variety of your "bridgeless" clientele. Here are two categories where frame selection purchases can add to an office's appeal.

img2Plano and Rx Sunwear - An Untapped Market
Sunglasses present their own challenges. They tend to be larger and can contain heavier and thicker lenses than a smaller clear pair of eyeglasses. Protecting our patient's eyes from harmful UVA and UVB rays from the sun is an important part of serving patients. Some Asian contact lens wearers may choose not to wear sunglasses as the large frames tend to slip and become bulky and uncomfortable. By providing patients with a line of sun wear that are designed for their features, they would be able to wear sunglasses comfortably and protect their eyes from the harmful effects of ultraviolet rays. Many patients have activities in their lives which would also lend itself to having a pair of sun wear.

Children
Children are another segment of the population that would benefit from frames that fit the low bridge. Take a look around an amusement park, or the local schoolyard, and see the many children who are either looking over their eyeglass frames or wearing a poorly fit frame. In some cases, it merely means that the child needs a good old fashioned frame adjustment more frequently. In others, it is just a poorly chosen frame that will never fit well.

The bridge, eye size or temple length may not be correct for the child's face. Young children have low bridges and, therefore, a frame with nose pads would fit better, or even plastic frames with a modified bridge. Nose pads help when there are long eyelashes which so many kids have. The pads need to be adjusted for a larger splay angle which is easy with most of the pad arm configurations. Larger nose pads can be substituted to better distribute the weight of the frame more evenly. Of course, the best yet would be a frame specifically designed for the low bridge of a child.

Clear Vision Optical's dilli dalli line
featuring Munchkin

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Vendor Selection
According to Alexandra Charton, designer of TC Charton eyewear, "Experienced opticians appreciate and have been waiting for a line of eyewear that fits the low bridge customer." Alexandra added, "time is saved in the dispensary with less time spent in adjusting and fitting of frames. There is 'no tweaking required' with the Asian Fit, TC Charton ophthalmic and sunglass frames. It isn't just the Asian population that has low bridges. African-Americans and Latinos can benefit by wearing frames that fit those with low bridges and higher cheekbones." 

Oakley's Asian Fit line has sun and ophthalmic frames that were modified to better fit the Asian population. One key factor to keep in mind is the incidence of high myopia in the Asian population. Oakley lifestyle frames allow the optician to keep the eye size on the small side, modify the nose bridge, temples and face wrap. By doing this, the overall lens thickness can be minimized by size and the use of higher index materials. If the eye size was increased, the result would be thicker and heavier lenses. According to Warren Modlin, Oakley's Rx Frames, Global Division, "Oakley's goal is for frames not to dig, have no pressure, and fit at the right height so the optical centers are more in line with the eyes. This ensures a stable and comfortable fit."

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Demonstrate to each patient the differences in bridge design. The word will spread. Customers who spent years dealing with ill-fitting frames that are now provided with variety and well-fitting frames will tell their friends. This is a natural byproduct of a satisfied customer. If you stock your store with frames to fit all shapes and sizes, that are now designed for varying facial features, you will increase your sales and the number of visually and cosmetically satisfied patients.

Do you know your customer as well as you think you do?
Look at who walks through your door each week, and reassess your frame boards. Do you have a mix of bridge sizes? Use frame manufacturers that provide frame choices with varying eye, bridge and temple lengths. To succeed in providing your patients with optimum vision, comfort and fit, your frame boards must reflect variety and include frames that fit the low and narrow and the low and wide bridges.

FRAME SELECTION

Bridge Selection
Asian and African Americans and some Latinos have nose bridges that are low and narrow or low and wide. Selecting a frame that fits their bridge is of critical importance for optimal vision and comfort. Metal frames with guard arms that can be adjusted tend to work best for patients with little or no bridge. For patients who want to wear plastic frames, choices are limited. Plastic frames with adjustable nose pads are not available in abundance. There are companies that can add a guard arm nose pad to the frame. You can also, with a kit, modify the frame yourself from parts and tool from suppliers like Hilco. Collections that cater to the lower and narrow bridges, with hand crafted and highly polished pad arms, reduce the need to send frames out to "add " nose pads to acetate frames.

Wearability
How does the patient plan to wear his/her eyewear? Is it for a progressive addition lens? Readers? Will they be on and off throughout the day? Do they have allergies or a sensitive bridge where a light weight frame would be in order? Investigate whether a more rugged frame would better suit them. We can determine the answers to these questions during the conversation while selecting the frame and by visual observations of their current pair of eyeglasses. Once the intended frame usage is identified, we need to find a frame with the proper width.

Overall Frame Width
Select frames to match the width of the patient's face. We need to look for good balance and symmetry. An ophthalmic frame that is too narrow between the temples causes pressure on the side of the head and the eyewear will slide down constantly. A frame that is too wide looks unnatural and will not fit well and, most likely, will have longer temples and not be comfortable. Many patients with a minimal bridge, and high cheekbones, need a frame that fits well on the bridge to alleviate the frame from resting on the cheeks.

img5Pad/Pad Arm Choices
Take a close look at the guard arm on metal ophthalmic frames. The guard arms that allow you to adjust the frontal, vertical and splay angles are preferred.

There are more options with this type of guard arm. The arm can be lengthened or shortened to increase or decrease the vertex distance. Changing the nose pad size or shape often helps redistribute the weight more evenly on the nose. A larger, oval shaped pad is not the solution for everyone, but usually results in a balanced, more comfortable fit.

Temple Length
When fitting a patient for a pair of eyeglasses consider temple length like any other frame fit. Take a peek behind the ears at the pre-fitting stage. With frame on the patient's face, have them turn to the left and the right; look to see if the temples are resting comfortably both over the back of the ears and along the side of the head. Use the warm air blower to get the temple pliable for pre adjustment.

If a patient has a wide face, this does not necessarily mean that they need a long temple length. A temple that is too short will constantly lift up and the frame will not fit securely. A temple that is too long can be aesthetically unappealing and need a bend so far back in the temple that the structure can be compromised. Children, especially those with a low bridge, would benefit from comfort cable temples (hook behind the ear). The comfort cable temple is effective at pulling the lenses back toward the face comfortably.

According to Mark Zyskowski, Licensed Optician and co-owner of Eyeworks a full service pediatric optical shop in Farmington and Glastonbury, CT, his "top choice" is Marchon's Flexon Kids 90 and the 92 as they work well with his young cliental and have the comfort cable option. Mark also uses comfort cable kits available to modify frames for kids.

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Fitting techniques
If your optical dispensary does not have a line of frames devoted to the specific needs of patients with low bridge and high cheekbones use metal frames with adjustable pad arms or ones with modified bridges.  However, your adjusting and frame modification skills must be polished.

Adapting a Frame
Either you can learn how to modify a zyl (plastic) frame by adding nose pads to the bridge or you can use a service that specializes in it. One word of caution is to modify first, then measure. Make sure you take multifocal heights or vertical measurements after you've altered the frame.

FINAL FITTING OF EYEWEAR
Always work from front to back, and that's especially important for the low bridge patient.  Beginning with the bridge and ending with the temple adjustments, properly align the frame to ensure the frame is straight on patient's face and have proper face form and pantoscopic angle. Due to the natural curve to the facial structure, it is best to have some positive face-form though for some with a low bridge or high cheekbones, flat or near flat may be best. Remember face-form improves the width of the visual field and can reduce reflections from the back of the lens. A tilt angle of 8-10° can improve access to the reading area of a progressive and provide the patient the opportunity to read without looking under the frame. Be sure to decrease the pantoscopic tilt if the frame is resting on the cheekbones. 

CONCLUSION
Patients have unique needs and wants.  Be ready and able to provide them with a bridge inventory that fits their faces and their lifestyles. If you personally are not able to add to your ophthalmic frame inventory, you can develop your skills in the dispensary by mastering the art of frame adjusting and by being resourceful in how to modify frames to fit your patient.