Photograph by Ned Matura; Vintage 1 from Norman Childs Eyewear
By Palmer R. Cook, OD
Your special-needs prescribing and eyewear design should not be limited to using impact resistant materials, safety eyewear and sport frames. Today, eyecare providers have more tools at hand than ever before to meet the challenges of many sorts of special-needs patients such as machinists, surgeons, dentists, artists, coin and stamp collectors, and a multitude of other vocations and avocations.
There is probably no category among these special needs that offers more diverse challenges than those presented by professional musicians. They spend long hours practicing, read music at typically longer distances than a normal reading distance, need to monitor the conductor’s motions ranging from a few feet to optical infinity, and they sometimes must switch from one instrument to another with different visual demands (especially for presbyopes) during a performance.
Fortunately non-presbyopic musicians have little need for multifocals or PAL lens designs, but prolonged practice sessions may make an accommodative lag or a minor reduction in vertical or lateral fusional ranges more troublesome than one would expect. Either lenses, orthoptic care or a combination of both is sometimes used for these problems.
Concert halls often have a low humidity environment, and the stress of performance may lower the blink rate. This combination can cause an otherwise marginal dry eye diagnosis to become problematic. Depending upon the performance situation, illumination can simultaneously be too low for reading the score, yet high enough to cause glare and photophobia.
Violinists tilt their head to their left to the extent that there is a medical condition commonly called “fiddler’s neck.” One might expect that this tilt would have visual implications, especially if the violinist is presbyopic. Orchestral performances require musicians to see the conductor, so there are demands for distance as well as “near,” which for reading a score could range from approximately 30 inches to 50 or 60 inches. Even worse, there may be glare issues from stage lighting as well as possible reduced lighting on the score if the musician is performing in the “pit.”
Michael Skelly, who teaches piano at Columbia University and also performs, says, “When teaching, I sometimes follow the student’s score, or I use a duplicate score while sitting at a second piano.” From a visual standpoint, these two approaches may represent two different intermediate distances, and it is the ECP’s challenge to determine what solution will best serve.
Tips for Dispensing to Musicians
- A PAL designed for computer or office use should be considered if a wide near field is needed. Using a D-45 or an executive design might also be considered.
- If the near field requirement is not too wide, simply using a reduced add power and possibly a short corridor, depending on the distance vision requirements, may do the job.
- Lined multifocals can eliminate peripheral distortions for a wider field at both near and distance, but if the musician is using PALs for his common-use and sunglasses needs, the adaptation may require some time.
- For presbyopic patients who find difficulty performing in multifocal contacts, consider prescribing single-vision distance lenses for performing by using a spectacle over-correction with an appropriately powered add combined with single-vision contacts.
- Although ordering a roll and polish finish for the edges of high minus lenses gives the lenses a thinner appearance from the side, they can cause annoying reflections to appear to the wearer under some lighting conditions. This seems to occur more often with rimless mountings or drill mounts.
- Don’t overlook the consulting resources of your lab if you are searching for ideas and options for special vision requirements.
Prior to prescribing or designing eyewear, you need to know your patient’s challenges and expectations. For musicians, never assume that they only play a single instrument. Ask about the amount of time they spend practicing and the typical level of illumination when they perform. Asthenopia related to performing and practicing can help in determining special needs, and knowing the actual distance to the score can allow you to avoid prescribing for a 40-cm distance, when a 60-cm distance is the actual demand.
Working distances for musicians can vary greatly. For example, a trumpet player reported a 30-inch (about 76 cm) distance for reading music, and a viola player reported a need to read music at 5 feet. In the case of the trumpet player, a wider and higher seg is likely to be needed, and a lower seg might be much more comfortable for the viola player.
YOUR BIGGEST CHALLENGE
As with most special needs prescribing, your biggest challenge may lie in helping the patient understand that it is not possible to fully meet his needs with common-use glasses and sunglasses. The easiest way to do this is with trial lenses. These should include PALs and bifocals in various powers. Although the reading area of standard PALs may be not be wide enough for some instruments such as the xylophone or piano. A design such as the Office by Shamir might make a good trial lens demonstrator in addition to having at least one pair of conventional-use PALs. All trial lenses for demonstrating near or intermediate performance should be on a relatively flat base curve and should have a plano power for distance. Mark the PALs with a lens-marking pen for ease of use, and always place trial lenses with adds in the posterior cells of the trial frame for the most accurate demo purposes.
IT’S NOT ALL ABOUT PRESBYOPIA
Pre-presbyopic musicians are faced with some easily missed difficulties. Even though a 30-year-old pianist may have plenty of accommodative reserve for normal tasks, an accommodative lag can develop during hours of intense practice. Single-vision “music glasses” with a little more plus or a little less minus might be a perfect solution. Whenever you design task-specific eyewear, be sure to adjust the PD for the needed working distance rather than using the distance PD (even though the patient is not yet presbyopic) or a near PD that is appropriate for a conventional 16-inch reading distance.
Musicians who complain of discomfort only while performing may actually have a dry eye problem. The low humidity of many concert halls coupled with a steady concentration on the score can reduce your patient’s blink rate. Prescription or OTC drops may help, and hydrating with plenty of water in the days before a performance can be helpful for both dry eye patients and contact lens wearers.
Performers on a concert stage are often looking into intense stage lighting. Asthenopia, tearing and interference with clear vision can result. On the other hand, performing for theatrical productions or the opera puts the musicians in an orchestra pit with intentionally (and necessarily) lowered illumination. A tint, which could help in the former case, would probably be contraindicated in the latter. One alternative could be to use a gradient tint. Your lab can adjust both the positioning and density of gradient tints. Careful measurements and discussion with the patient should be a part of fitting this kind of tint.
One way to make the best use of ambient illumination is to use good quality AR lenses for increased transmission and reduced internal lens reflections. Because increased illumination, as well as increased lens transmission tends to increase the depth-of-field, don’t overlook the possibility of using higher wattage bulbs in the existing music illuminators, or possibly enhancing the illumination on the score with one of the many clip-on book illuminating gadgets available should be considered. Coupling a light overall tint or a gradient tint with AR lenses can boost lens performance by reducing veiling glare more than simply using AR alone.
Presbyopia presents some unique and potentially complicated challenges for anyone designing eyewear for professional musicians. Ideally, the examining doctor knows and has prescribed for the needed sheet music distance and has prepared the patient for the need for task-specific eyewear.
If you are fitting spectacle lenses with more than a single focal length, you must consider the musician’s head position when performing, as well as determining the requirements for distance(s) and width of field. It can be appropriate to ask the musician to bring a music stand and their instrument to your office for accurate measurements, even though this may not always be practical. In most cases, the intermediate corridor of a PAL will not be adequate for reading sheet music, and wide instruments such as xylophones, marimbas and pianos may require very wide fields for near.
In the movie “Roadhouse,” musicians played behind a chicken wire screen for their own protection. In their case, Trivex or polycarbonate would probably be the material of choice. Reflectance and weight, however, are probably more important for most performing musicians. Trivex, at a density of 1.11, is the lightest of ophthalmic lens materials. Using a lighter material could be a blessing, especially if the player performs in a head-down position as with the cimbalom or marimba.
Significant reflectance from the back surface of performers’ lenses would be uncommon. However, ambient lighting, overhead auditorium lighting and spotlighting may become more annoying and distracting if the reflectance of the lens material is higher rather than lower. This is caused by light from in front of the wearer passing into the lens and reflecting from its back surface to the front surface and subsequently into the eye. This is the same light pathway that causes ghost images of oncoming headlights at night and creates a veiling effect in brighter illumination. The brightness of ghost images and the intensity of the veiling effect increase proportionately as the index is increased. For example, compared to standard plastic, using Trivex causes an increase in brightness of about 19 percent, polycarbonate about 64 percent, 1.60 about 75 percent and 1.70 about 169 percent for both ghost images and the veiling effects. The use of a good quality AR effectively reduces these ghost images and veiling effects.
Key Questions for Professional Musicians
Here are some questions to ask your professional musician patients:
- What instruments do you usually play?
- How many hours do you practice per day or week?
- Do you read music when practicing or performing?
- What is the typical distance from the bridge of your nose to your score when performing or practicing? Is the distance the same for each instrument?
- Do you experience eye tiredness or eye discomfort when practicing or performing?
- Do you experience blurred vision for reading the score or seeing at any needed distance when practicing or performing?
- Would you like to know about special contacts or glasses or other ways that might make your vision clearer and more comfortable?
Donnie Nossov, a veteran rock ’n’ roll bass guitarist suggests, “Performers may be particularly sensitive to the issue of wearing glasses while performing for reasons of appearance as well as function.” Speakers, talk show hosts and many top-level performers including musicians sometimes sidestep this issue by removing their eyewear when they perform (if they can). If not, you might suggest a totally rimless mounting with AR lenses. From a distance of 15 feet or so, the eyewear would be nearly invisible.
Occasionally, people in the public eye who need a refractive correction select an iconic, distinctive frame style and make it their trademark. Elton John might be the preeminent example of a musician who has made his need for corrective lenses a part of his public image. A special color, size or eyewire shape may give a desired “dramatic” or “iconic” appearance, but it’s important not to forget functionality. Another pro, bass guitarist Mark Polott, who has recorded and performed with various rock bands comments, “Sometimes I just push my glasses up on my forehead and try to get along without them.”
If your patient is a recording artist, ask about whether he or she must use headsets that could dislodge the frame. Problems of the headsets interfering with the frame may be resolved by attaching thin, wire cable temples to eyewear for use in the studio.
Musicians present a wide variety of challenges to ECPs. Most of them may not even be aware of the tools you can use to make the professional road they are traveling much easier. The first step, as with all clinical problems, is to achieve a diagnosis. For successful treatment, you then need to understand their special-need challenges and the options the ophthalmic industry makes available to you.
Special thanks to the Columbus, Ohio Symphony Orchestra; the Columbus, Georgia Symphony Orchestra and their members as well as the professional musicians who contributed information for this article.
L&T contributing editor Palmer R. Cook, OD, is director of professional education at Diversified Ophthalmics, Cincinnati, Ohio.