Article Date: 10/1/2011

Arming Your Practice for Presbyopia

Arming Your Practice for Presbyopia

Use these six steps to manage patients who have “long-arm syndrome.”

Robert Murphy
Contributing Editor

NO DEGREE OF PRESCIENCE SHORT OF THE DIVINE could have allowed Benjamin Franklin to imagine the long-range consequences for vision correction he sparked when he invented the first bifocal spectacles in 1784. Imagine if you will, the statesman sitting with an optometrist today and learning of a dizzying array of methods to correct for an aging eye's evolving range of focus. He might be as impressed with these latter-day options as his contemporaries presumably were with his own stunning innovation.

And for good reason. Today's presbyopes can avail themselves of a range of effective multifocal vision corrections to meet their specific visual needs—from the simple, such as monovision contact lenses or reading glasses, to sophisticated progressive-addition spectacles and multifocal contact lenses, to innovative surgical solutions.

It stands to reason that aging Baby Boomers—those born between 1946 and 1964—are now stepping up in droves for presbyopic vision correction.

“Presbyopia is sort of the golden ring of eye care today,” says David I. Geffen, O.D., director of refractive and optometric services at Gordon & Weiss Vision Institute in La Jolla, Calif. “It's something everyone's trying to fix, whether it's a surgical correction, contact lens correction or spectacles.

As leaders in vision correction, “we need to make sure we're giving our patients the best types of corrections possible,” he says.

Those interviewed for this article agree: As aging Americans remain more active into their senior years, including working later in life, it's critical to match the mode of vision correction to the individual needs of the patient.

In this article, leading optometrists explain six steps to help you stay at the top of your game.

1 Provide a foundation for patient understanding.

The first step in managing presbyopia is to provide patients with a concise, easy-to-understand explanation of the condition, say those interviewed. In fact, you should discuss presbyopia with patients before they've experienced any near vision loss, so that they aren't alarmed by “long-arm syndrome” when it occurs.

“We tell the patient, you know, presbyopia is something that happens to everyone,” Dr. Geffen says. “It's just a question of when. And we explain that it's the loss of the lens's ability to focus up close.”

Sometimes, you might have to dispel a patient's notion that he has “farsightedness” when in fact it's presbyopia. In these instances, assure the patient that there's nothing wrong with their eyes, say those interviewed. Like gray hair, it's a part of the aging process, and can be readily remedied.

2 Gather information about the patient's lifestyle, complaint and goals.

When patients present with a complaint of presbyopia, it's helpful to begin by asking them: What is the purpose of your visit today? Or: What would you like to accomplish during your visit? The answers to these questions will allow you to address patient-specific needs, say those interviewed. And at best, it's an effective way to arrive at the right solution. For example:

“They may express frustration with multiple pairs of glasses, such as several pairs of readers lying at work and around the house,” offers Dianne Anderson, O.D., of DuPage Medical Group Eye Specialists in Naperville, Ill. “Or, having to be on and off with glasses throughout the day or difficulty reading with their current glasses or contact lenses.”

Continue the information-gathering process with a thorough and accurate exchange of information between you and your patient. Here, the key to an effective remedy begins with an accurate assessment of the patient's lifestyle and visual needs, say those interviewed. Using a patient questionnaire or interview, determine the level of difficulty the patient is experiencing. Consider these questions:

► Do the patient's job or hobbies involve near work or a significant amount of reading?
► Is intermediate distance a factor, as with a computer user?
► Does the patient drive or enjoy playing or viewing outdoor sports, in which case distance becomes the critical factor?
► What's the patient's current vision correction, and how is that working for him/her?
► Are there any additional lifestyle issues that would make demands on the patient's vision?

3 Perform a thorough near-vision work-up.

It stands to reason that the refraction and near-point work-up provide the critical diagnostic data needed for an optimal presbyopic vision correction.

“Probably the most important (diagnostic test) is the refraction,” Dr. Geffen says. “We are actually using some of the newer high-tech refracting capabilities.”

Dr. Geffen says his practice uses an advanced phoropter that measures refractive error down to 0.01D. This precise endpoint is crucial to provide presbyopic patients with the most accurate vision correction, he says.

“Your starting point has to be pretty good, otherwise everything from there is messed up,” says Dr. Geffen.

Dr. Geffen's practice then moves on to near-vision testing. Here, you might pivot from today's high-tech refracting devices to good old trial lenses, which go back at least to 1900 when optometric pioneer Charles Prentice developed a set for American Optical.

“I still use a fair amount of trial frames with patients,” Dr. Geffen says. “I find that if you put a trial frame on a patient and show him or her how their vision is going to be, they tend to get a pretty good understanding of what they're dealing with. . .”

4 Present the various options for correction.

Now, it's time to sit with the patient, and discuss the range of presbyopic vision-correction options, and offer recommendations. Your optician or a technician may also reinforce and explain the recommendations.

Several of the doctors interviewed note that while the patient should understand all forms of correction available—spectacles, contact lenses and surgery—if you burden the patient with the dozens of options across all the categories, you may inadvertently devise a recipe for confusion. A better approach, they say, is to narrow your suggestions to just a handful, based on the results of your refraction and the patient's lifestyle questionnaire. And don't be reluctant to use your expertise to make a recommendation.

A brief summary of the modes of presbyopic vision correction follows.

Spectacles. Clinicians widely find that today's progressive-addition lenses offer the best vision at all distances, says David H. Hettler, O.D., a partner in a seven-location private practice in Alexandria, Va. In his practice, those presbyopes who don't wear progressive correction are those “who specifically opt out of it,” he says.

To keep confusion at bay, Dr. Hettler and his staff stick to just three presbyopic spectacle offerings—known simply as good, better and best, and priced accordingly. For him, the best is a state-of-the-art lens.

“One of the biggest changes in the progressive market is the advent of digitally surfaced lenses,” Dr. Hettler says.

In describing one manufacturer's lens, he says, “This is a lens surface that is cut using a diamond tool and a lathe that is spinning very quickly. It cuts a spot at a time, and it's doing it very accurately and with such small dots, that the surface when the lens is finished is smoother than a lens that's been sanded or polished.”

The benefit of this advanced manufacturing process is that it produces “more complex designs of progressives that have less distortion,” Dr. Hettler says.

For example, a custom dualadd lens, in which part of the presbyopic correction is on the front of the lens and part on the back, cuts down on distortion. Several companies, such as Essilor of America, Kodak Lens and Carl Zeiss Vision, each offer their version of these high-definition spectacle lenses.

Many doctors also advocate add-ons, such as anti-glare coatings and photochromic lenses, says Michael Lange, O.D., of Lange Eye Care & Associates in Gainesville, Fla.

“Almost anyone today will want the AR coating once the doctor and staff mention the benefits. Who wants glare?” Dr. Lange says. “Photochromic lenses are also very important to help prevent UV damage.” Dr. Lange says he also recommends an impact-resistant lens for patients vulnerable to projectiles while on the job or playing sports.

Of course, the simplest presbyopic spectacle correction is reading glasses for those otherwise emmetropic, say those interviewed. Many practices recommend “drug store readers,” for this patient group, some even offer readers in their own practice. Regardless of your approach, educate patients as to the lenses' benefits (low price, off-the-shelf wear) and drawbacks (no correction for astigmatism, the lens is not customized, etc.).

Contact lenses. There are those patients whose lifestyle or personal preference leans more toward a presbyopic contact lens correction. Others may wish to obtain both spectacles and contact lenses (for part-time wear say, when participating in sports).

But perhaps the bigger challenge lies in educating patients on all the contact lens options available to them. Let patients know that in addition to monovision, modified monovision and multifocal contact lens options, manufacturers offer lenses in a variety of materials, designs and wear schedules. In short, give patients confidence that there are options that will atch their specific needs.

Those patients who have tried contact lenses years ago may be surprised to learn that today's multifocal contact lenses offer clearer vision than previous generations. What steps should you take if a patient isn't delighted with one particular brand of lenses? Don't give up, advises Dr. Hettler.

“Sometimes, doctors get frustrated with failures and don't keep trying,” he says. “The manufacturer guidelines improve success along with setting patient expectations.”

Dr. Hettler says his patients have experienced successful wear with a number of manufacturer's multifocal contact lens offerings. Yet, for those who do not require exacting visual demands at near, intermediate, or distance—or those who are not good candidates for multifocal contact lenses—a recommendation for monovision or modified monovision may provide a satisfactory solution.

Dr. Hettler says he likes the idea of prescribing multifocal contact lenses along with spectacles as a back up. This provides benefits for the practice and the patient, as he/she can maintain the best possible acuity throughout the day.

“Contact lenses shouldn't be worn 24/7,” he says. “So you're going to need glasses for some amount of your wear time.”

Surgical correction. Cataract patients aren't the only ones who can obtain surgical presbyopic correction, in this case a multifocal intraocular lens. Surgeons in recent years have developed multiple surgical means of correcting presbyopia. If your goal is to present to your patient all the options, be ready to describe these in a concise summary fashion, say those interviewed. Here are just a few.

Monovision LASIK—correcting one eye for near and leaving the other alone for distance—is commonly performed in the United States, according to the American Academy of Ophthalmology (AAO). Attracting greater investigational attention is presbyopic LASIK, involving a multifocal ablation that steepens the central zone for near, and targets the peripheral area for distance. The procedure has produced some good early results—especially for those who have moderate hyperopia but still requires refinement, according to the AAO.

“For presbyopes who consider laser vision correction, I think it's important for them to try contact lenses first to see whether they're going to like what they get,” Dr. Hettler says. “If they like what they get, and they just don't like contact lenses, then laser surgery is a good solution for the presbyope. The laser is for keeps. Contact lenses we can modify.”

Also attracting attention are corneal inlays, in which a special polymer is inserted in the midcornea under a flap, according to the AAO. The inlay's numerous tiny holes allow for oxygen permeability. This investigational procedure is now scheduled for clinical trials.

Then there's conductive keratoplasty (CK), which, in 2004, was the first FDA-approved procedure for treating presbyopia, according the AAO. It's a thermal technique that uses radio frequency to shrink peripheral corneal collagen and thereby steepen the central cornea. CK initially produced sporadic and sometimes disappointing results, but refinements have improved outcomes in some cases, mostly for mild presbyopes.

Stay tuned for further surgical advances designed to correct presbyopia as well as other visual disorders. It's a hot area of investigative ophthalmology.

5 Train your staff as a “presbyopia team.”

The mutual education of patient and doctor is pivotal in the case of presbyopia. In fact, it's a team effort, say those interviewed for this article.

“It is extremely important that the entire staff be experts on the options for presbyopia, whether they are glasses, contact lenses or surgery, and make sure everyone is on the same page,” Dr. Lange says.

Also, take advantage of lens representatives who offer to come to your office and train your staff. No one knows their lenses better than they do, says Dr. Lange. And besides, “you can't have enough training,” he says.

A knowledgeable staff not only helps improve patient education and the chances for successful vision correction solutions, it also enhances the bottom line.

“When an optical staff comes across as being very knowledgeable regarding specific products, the patient is much more likely to purchase,” Dr. Lange says.

Also, do not let the patient leave until your staff has trained the patient on how to use his/her new eyewear, he says.

6 Manage expectations and patient satisfaction.

Clinicians emphasize: Let patients know, in very clear terms, what to expect visually from their vision correction solution. Overpromising “perfect” clarity or the “vision of youth” will set expectations too high, thus leading to dissatisfied patients. To forestall or eliminate early complaints, explain that any presbyopic vision correction requires an adaptation period.

Beyond that, do whatever it takes to make the patient happy. Go as far as to let patients know they can return to your office anytime they're not satisfied with their vision, say those interviewed. This will go a long way in reducing complaints. The last thing you want is someone grumbling to a friend about a new pair of glasses that don't work as you promised. It will alert you to problems, giving you the opportunity to solve them quickly.

“My favorite way to check all alignment issues [with progressive lenses] is to cover each eye and see whether the reading card is in focus at the same point for each eye,” Dr. Hettler says. “We also recheck the prescription each time. This avoids correcting one problem when it turns out that there was more than one issue.”

Franklin comes to fruition

Benjamin Franklin's 1784 invention of bifocal spectacles was all the more remarkable when you realize that no one in his day understood what causes age-related near vision loss. That didn't come until 1855 when the German scientist Hermann von Helmholtz described how accommodation works. Franklin thereby came up with a solution to a problem no one even understood.

The fruits of his dazzling invention expand with each passing year. The spectacle, contact lens and surgical means of correcting presbyopia continue to improve and better serve a wide scope of patient needs. Presbyopia has always been part of the life cycle. Don't break out the banners and balloons and marching bands, but perhaps there's never been a better time to be a presbyope. OM

Mr. Murphy is a freelance editor/writer based in the Philadelphia area. Send comments to

Optometric Management, Issue: October 2011