Article Date: 12/1/2010

Fit Elderly Patients
contact lens

Fit Elderly Patients

By overcoming the hurdles elderly patients pose to wear, you can successfully fit this overlooked population.

Susan Kovacich, O.D., F.A.A.O., Bloomington, Ind.

Betty White is having a remarkable career resurgence. At age 88, the actress, best known for her roles in the ’70’s classic Mary Tyler Moore and the ’80’s hit The Golden Girls, recently won an Emmy Award for hosting a 2010 episode of Saturday Night Live. She appears healthy, mobile and still possesses her trademark comedic timing.

All of us have patients, family members and friends who, like Betty White, seem to defy the aging process. In fact, a colleague told me about an 80-year-old female patient who recently presented to see whether she could wear contact lenses. Her vision was 20/20, her eye health within normal limits, and she could see well with the soft bifocal contact lenses. Further, she had no problems with contact lens insertion and removal (I&R). If anything, the biggest problem posed by this patient was her schedule: She was so busy socializing, seeing her grandchildren and performing community service, that scheduling a follow-up visit was a challenge, my colleague explained.

Although elderly individuals like Betty White and the patient mentioned above are unique to their age group, they do, indeed, exist. Further, many septuagenarian and octogenarian patients who are experiencing the normal aging process have lifestyles (e.g. gardening, golfing, etc.) that could benefit from lens wear. To enable elderly patients to achieve successful wear, we must overcome this population's inherent hurdles to wear.

Here, I discuss the primary hurdles of this group and how to overcome them. (See “Correcting Complications,” below.)

The “too old” assumption

Both elderly patients and some eyecare practitioners are guilty of this mind-set. Many elderly patients automatically assume they're too old for this vision correction device because (1) contact lens advertisements for the elderly are virtually nonexistent, and (2) their eyecare practitioner hasn't offered them the option.

As practitioners, some of us tend to automatically assume elderly patients wouldn't want to get involved with contact lenses due to their age, or that they're on a fixed income that doesn't allow for the costs of wear. And, so because our chair time is valuable, some of us simply don't bother to broach the subject with these patients. (This, despite the fact that a thorough and realistic assessment of the patient's ocular and systemic health has revealed lens wear as an option.) Yet, as with my colleague's 80-year-old patient, this isn't always the case. And because it isn't always the case, many patients and practices are missing out on the benefits of contact lens wear.

Awareness of this possible assumption in you, the practitioner, as well as a commitment to consistently offer contact lens wear to those elderly patients whom you think could benefit from wear will overcome this hurdle. Specifically, we must explain to elderly contact lens candidates how, specifically, they could benefit from wear, and, why, specifically, we think they could handle the responsibility of wear. Doing so dispels their assumption that they're “too old” for wear. Further, explaining the benefits, while outlining your perception of the patient's abilities goes a long way in not only dispensing lenses, but also in instilling compliance to your prescribed wear and care schedule. The reason: You've given the patient a vote of confidence, and he wants to maintain that confidence.

Dexterity/mental health deterioration

A 75-year-old male patient recently presented for a contact lens evaluation because spectacles failed to improve his left eye's vision after sustaining a corneal scar from trauma. The irregular cornea proved difficult to fit, requiring a large diameter specialty lens, which greatly improved his vision. Unfortunately, the patient was unable to successfully manipulate and perform I&R of the contact lens — even after returning to the clinic for several lessons. He lived alone, and no one was available to help him. Since a corneal transplant wasn't an option, the patient had no choice but to live with the vision from his spectacles.

Manual dexterity and hand-eye coordination are critical to successful contact lens wear. Because both decrease with age, elderly patients who could benefit from contact lens wear often struggle with I&R. In addition, arthritis of the fingers and hands can affect a patient's ability to handle contact lenses satisfactorily. You can overcome this dexterity hurdle in some of these patients, however, by prescribing GP lenses.

GP lenses are often easier for elderly patients to handle, as they're comprised of rigid and durable material. Soft contact lenses, on the other hand, can fold and drape over the fingers, making lens manipulation difficult for this patient population. Something else to keep in mind: GP lenses are known to have strong protein and lipid deposit resistance, as they don't contain water. This facilitates the lens cleaning process for this dexterity-challenged population.

Arthritis of the neck and hand/body tremors can also hamper I&R. To overcome these dexterity hurdles, prescribe insertion/removal aids to these patients, such as a hard contact lens plunger, and evaluate alternative techniques, such as using different fingers, or even different parts of the hand, such as the knuckles.

Because elderly individuals often experience changes in their mental status, be aware of signs that contact lens wear, I&R and maintenance are becoming too complex for the patient to manage cognitively. Specifically, if the patient has difficulty answering routine questions, is unable to follow simple instructions during the exam or doesn't appear oriented to person, place or time, he may be unable to wear contact lenses without the assistance of a caregiver.

If the patient decides to employ a caregiver, however, have the caregiver present to your office so you can educate him on the disinfection and storage of contact lenses, I&R and the signs and symptoms of contact lens complications. After all, it's imperative the caregiver “buy-in” to the importance of contact lens wear and care if the patient is to remain satisfied and healthy in his lenses.

Anatomical lid changes

Sagging and redundant eyelid tissue can affect GP contact lens removal. If lax lids prevent the patient from using the “Blink Method” to remove lenses (e.g. opening the eyes widely and then pulling on the outer [lateral] corner of the eyelid to pop out the lens), the patient may have to hold the inferior lid in place with one finger and push down on the upper eyelid to pop the GP lens out. If, however, the lids are too lax for either method, a hard contact lens plunger may be employed. If this is unsuccessful, refit the patient in a soft contact lens — if, that is, he has the dexterity to handle these lenses, or a caregiver to assist him. If none of these solutions work, the patient will have to return to spectacle wear.

Keep in mind that senile ectropion may exclude a transitional bifocal GP lens, as this design depends on lower lid position for translation. Also, you may need to repair senile entropion before contact lens fitting, although soft contact lenses are sometimes utilized in these cases to act as a shield for the cornea from the inturned lid or trichiasis. If the patient's lid/contact lens dynamics change as a result of blepharoplasty, overcome this hurdle by refitting the GP lens. For example, a lens that was “lid-attached” before surgery might now sit intrapalpebrally, and the fit may require adjusting.

Correcting Complications
Contact lens wear can also correct specific complications associated with aging. Here are three examples:
1. CONTRAST SENSITIVITY. Age-related macular degeneration (AMD) (especially in Caucasians) not only impairs vision in the elderly, but also reduces contrast sensitivity. Multifocals, which further reduce contrast, may not be the best choice, as compared with single vision contact lenses and readers.
2. UNEXPECTED REFRACTIVE CHANGE. Although cataract surgery has been improved through the years, patients may still have post-surgical complications, such as unexpected refractive changes. Contact lens wear can often correct these complications. For instance, contact lenses can help correct the symptoms of post-surgical anisometropia, such as anisokonia and/or the need for slab-off prism in the bifocals.
3. AGING CORNEA. The transparent cornea, with its exposed location, can really take a beating during the aging process. As a result, our elderly patients tend to present with epithelial basement membrane dystrophy, among other insults to the epithelium. To treat these patients, you can employ a bandage contact lens to control corneal erosions.
In addition, elderly patients are more likely to present with corneal insults, such as irregular astigmatism, pellucid marginal degeneration and herpes simplex and zoster. In these cases, a GP lens for visual rehabilitation is ideal, with its rigid optical surface and tear lens. Finally, because irregular corneas are often difficult to fit, large diameter and sclera contact lenses are available for these patients. (Keep in mind, however, that these products do make I&R more challenging.)

Blepharitis

Elderly patients are particularly prone to blepharitis. In fact, when I did my residency at the John Cochran Veteran's Administration Medical Center in St. Louis, Mo., I was amazed by how many of my elderly patients had posterior blepharitis/meibomian gland dysfunction (MGD). This observation was corroborated by a study that revealed men older than age 65 are most likely to present with posterior blepharitis/MGD.1 This condition has been implicated in contact lens (particularly soft contact lens) complications, such as infiltrative keratitis and contact lens-related peripheral ulcers. To overcome this hurdle to wear, the treatment of blepharitis includes, but is not limited to the use of warm compresses and lid scrubs b.i.d., Omega 3-supplements (2 gm/day) and, if needed, oral medication, such as oral doxycycline (20mg to 50mg/day).

Dry eye syndrome

Blepharitis, aging of the lacrimal and accessory tear glands, changes in sex hormones and an increase in medication use (e.g. beta blockers, antihypertensives, anticholinergics, antihistamines, etc.) contribute to one of the greatest hurdles in contact lens wear in the elderly patient: dry eye syndrome (DES).

If the tear film is insufficient, the contact lens-wearing patient will report intermittent blurred vision, discomfort, decreased wearing time and possibly discontinue contact lens wear altogether. Mild symptoms of DES, such as slight discomfort or reduced wearing time, may be managed with artificial tears b.i.d. to q.i.d. If the patient's DES is due to inflammation, prescribe topical cyclosporine 0.05% (Restasis, Allergan). If you utilize punctal plugs, it is recommended that any inflammation also be managed to keep the eye from being continually bathed in inflammatory tears.

Silicone hydrogel (SiHy) lenses have been successfully employed in these patients, and daily disposable lenses can also provide comfortable contact lens wear to these patients. SiHy lenses generally have a higher modulus than hydrogel lenses, including the new SiHy daily disposable lenses, allowing patients with dexterity issues to better manipulate these stiffer, soft contact lenses.

Lens care may also play a role in the management of the DES patient. As a result, you may want to prescribe a peroxide system to reduce the amount of disinfection/preservative reactions. Good contact lens hygiene is always an issue in contact lens wear, and should, therefore, be assessed at each visit.

Finding a lens that will work in a DES patient isn't always possible, but it's worth a try, given both the patient and practice benefits of contact lens wear.

By taking the time to overcome the elderly population's hurdles to wear, you'll not only improve many of these often-overlooked contact lens candidates’ quality of life, but your bottom line as well. As Betty White's Rose Nylund of The Golden Girls once said, “the older you get, the better you get, unless you're a banana.” OM

1. Campbell Alliance Group. Patterns of Practice and Prevalence Rates for Lid Margin Disease. July-August 2008.

Dr. Kovacich is an associate clinical professor in the Cornea and Contact Lens Clinic at the Indiana University School of Optometry. She is a Fellow in the American Academy of Optometry and has been active in the Association of Optometric Contact Lens Educators. E-mail her at skovach@indiana.edu. Or, send comments to optometricmanagement@gmail.com.


Optometric Management, Issue: December 2010