Article Date: 9/1/2010

Prescribing for Presbyopia

Prescribing for Presbyopia

Consider this proven method of educating patients on the many options for correcting presbyopia.

Loren Azevedo, O.D., F.A.A.O., Arcata, Calif.

With the declining usage of the Ben Franklin bifocals, how can we efficiently educate our patients on the many options for correcting presbyopia, from monovision contact lens (CL) wear to progressive eyeglass lenses? In other words, what words best communicate the value of the CLs and eyeglasses we prescribe — the "bread and butter" of optometry?

The emergence of the Internet and high definition videos may someday render paper-based education and instructions obsolete, but at our practice, I've found that a summary handout is very effective for presenting all the presbyopic and accommodative insufficiency (AI) options to patients. Our staff does this with an informative page, titled Near Vision Options (see below). In this presentation, wording is crucial, and as our staff speaks to the patient, we often draw on the handout to emphasize the points we make. For example, the staff might circle the intermediate zones of both the indoor (or computer) lens and the progressive lens to illustrate the difference in the size of each zone.

Here is an example of how we may begin the conversation with a presbyopic patient:

"We have found a normal change in your near vision that can easily be corrected with glasses, CLs or LASIK. Since this condition does not improve with time, we recommend you select one of these options for correction now."

Begin with spectacles

We start with "Spectacles" (point number 4) on the Near Vision Options handout and work our way up the page, making educational points in the following order:

► "We recommend both progressive glasses and indoor computer glasses. Learning to use them takes a few weeks [patients are thrilled when it takes less time], but once you learn, you will be comfortable wearing progressive lenses throughout your life, even though your prescription may change. Seventh- and eighth-generation progressive lenses provide excellent distance vision with an infinite number of powers descending to near vision in the downgaze portion of the lenses. We also recommend progressive sunglasses — the best are polarized — to provide you with the best vision outdoors and while driving."

Note: We all have "progressive non-adapts," but I'd venture to guess that most of these are patients who tried progressive lenses several years ago. In these cases, we explain: "Mrs. Jones, the new lenses are much better than earlier versions, and our certified opticians measure the lenses more accurately than ever, including vertex distance — the distance between the back of the lens and your eye — which may have caused your dissatisfaction in the past. With the new technology, we can create infinite prescriptions for all distances that are so much better than bifocal lenses, that I strongly recommend them." (Consider explaining to patients that progressive technology has replaced bifocal technology, which is more than 300 years old.)

► "We recommend indoor lenses to relieve the neck strain associated with computer, art, music and other sit-down tasks. The straight ahead — primary gaze — portion of the lens provides excellent vision at about two feet. The lower zone of the lens improves close vision, and the upper zone is used for seeing distances. Since they are designed for specific indoor tasks, most people do not walk, watch television or drive in theses lenses."

If appropriate, we will discuss reading glasses at this point in the presentation. We do not recommend readers, except as a fourth pair of eyeglasses, used specifically for the activities described here:

► "Single-powered readers provide clear vision at only one distance, but we can recommend them for three situations: Reading aloud to children — while holding the book to face the audience — extended overhead tasks and close-up upward gaze reading while laying down."

Two contact lens options

A wide variety of contact lens options are available today. We recommend one of two "tracks" of vision correction: monovision for those considering LASIK and multifocal contact lenses for everyone else. Here's what we say:

► "We recommend multifocal contact lenses, as each lens provides clear vision at both distance and near."

► "Monovision is the second ‘track’ one can use with contact lenses — an option not available with glasses. With monovision, one lens is adjusted for distance vision and the other for near vision. In patients who wear lenses designed for monovision, the visual system integrates vision at all distances very well."

Note: An effective way to relay this message to patients is to lift both your hands, face the palms toward you, and turn both wrists until your hands are pointing toward one another, when you say "integrate." With this simple gesture, people get it.

In our practice, we offer both gas permeable and soft disposable multifocal contact lenses. We recommend the lens option we feel is best for the patient. We explain, "These high-tech lenses are super breathable for comfort, and they usually provide the best vision at all distances. They are also the safest and the most costeffective long-term solution." The result: We have a 90% rate of successful fits with patients who follow our recommendation.

The LASIK recommendation

We also describe laser vision correction options to patients (number 2 on the Near Vision Options sheet).

Recent innovations in LASIK allow surgeons to correct each eye for either distance or near vision, so we recommend monovision correction, as explained below.

► "LASIK eye surgery is also an excellent option in a monovision fashion. You can trial monovision contact lenses prior to the LASIK procedure to determine visual comfort and the proper add power."

We include multifocal intraocular lenses on our Near Vision Options sheet (point 1) as well, so that our patients are educated in all available options for vision correction. But, we would rarely recommend it to correct presbyopia, as presbyopes typically find excellent results with the other less-invasive options we've described.

Beyond presbyopia

For patients who have AI (the same symptoms as presbyopia, but for the younger than 40 crowd), use the same treatment options described in this article, and also note the following:

► Anti-fatigue spectacle lenses — lenses with a variation in power for computer use and other close-range tasks — are a new and successful option for AI patients, as these patients are typically in need of low adds such as +0.75D or +1.00D.

► Consider corneal refractive therapy (CRT) gas permeable non-disposable monovision contact lens fittings for those AI patients younger than age 21. LASIK is not yet an option for this age group, and CRT allows these patients to enjoy freedom from daytime contact lens wear.

► LASIK monovision is an option for those patients 21 years old and older.

Proven results

Since we have begun using the steps I've described in this article, our practice has improved patient satisfaction and increased practice revenues. Our presentation of the Near Vision Options sheet ensures that our patients learn all presbyopic and AI vision correction options through our practice — not another competing (or worse, less reliable) source.

With many of us living more than half our lives with presbyopic vision changes, it is exciting to have so many options for clear vision. I'm confident that if you clearly present all appropriate options to your patients, you will enjoy a more rewarding and successful practice. OM

Dr. Azevedo is a partner in A to Z Eyecare, a private practice in Arcata on the Northcoast of Calif. E-mail him at

Optometric Management, Issue: September 2010