Article Date: 8/1/2012

CooperVision Launches Multifocal Daily Disposable
presbyopia

Keep Presbyopia at Arm's Length

By understanding the patient's visual needs and lifestyle, you can better identify the right solution.

Lindsey Getz, contributing editor

The age 40+ patients of today not only desire a youthful appearance, but they also lead active lifestyles. For many of them, these characteristics make standard reading glasses an unappealing option to correct their presbyopia.

Here, your colleagues provide a primer on the alternatives to standard reading glasses and the ideal candidates for each option, so you can satisfy this notoriously hard-to-please patient population.

Progressive lenses

Progressive ophthalmic lenses can fit in stylish frames, lack the “granny” line and also provide the crispest vision possible. These features make them an excellent alternative to standard reading glasses, says Kim Castleberry, O.D., of Plano Eye Associates in Plano, Texas.

“I counsel my presbyopic patients that the safest alternative to bifocals that provides the sharpest vision is absolutely progressive lenses,” he explains.

He adds that HD digital progressive lenses have satisfied his patients who present with complaints of visual disturbances despite 20/20 vision in their current standard progressive lenses.

“HD digital progressive lenses can be customized for the patient's lifestyle and frame selection,” he explains.

In addition, this alternative provides infinite prescriptions and, therefore, clear vision at all distances, says Loren Azevedo, O.D., of A to Z Eyecare, in Arcata, Calif.

“… Thanks to new, more customized digital designs and improved measuring systems for each frame, success in prescribing progressives has risen from about 50% to nearly 90% in my practice,” he says.

Adjustable focus lenses are also progressive lens options, say those interviewed.

The ideal candidate for progressive lenses: The ultimate fastidious presbyopic patient, Dr. Castleberry says. “This is the patient who is bothered by the slightest visual difference,” he explains.

When it comes to successfully dispensing this option, both doctors say a personal recommendation along with an explanation works best.

An example: “Mrs. Smith: I'm going to prescribe progressive lenses for you because they've been shown to provide the crispest vision. Our optician can show you the options we offer in our dispensary.”

Contact lenses

Monovision and multifocal contact lens wear can enable the presbyopic patient to maintain a youthful appearance, while also forgoing every-day spectacle wear. Both characteristics make them an attractive alternative to standard reading glasses, say those interviewed.

A monovision contact lens fit is comprised of one eye fit with a lens to provide distance vision while the other eye is fit to provide near vision. The result is that the distance vision eye becomes slightly blurred when viewing items up-close and vice versa for the near vision eye.1

Some monovision contact lens patients drop out of this correction because they aren't comfortable with the slight compromise in binocular vision, which can throw off their depth perception, the clarity compromise of their distance vision and/or their resulting near vision, which requires them to wear reading glasses anyhow.1 Add these down sides to the recent influx of vastly improved multifocal contact lens designs, and it appears monovision is no longer the first choice in presbyopic contact lens wear.

“Multifocal contact lenses provide distance and near vision without the large asymmetry between the two eyes found in monovision,” explains Brian Chou, O.D., F.A.A.O., of Eye-Lux Optometry in San Diego, Calif. “With multifocal vision, there is a better blend of vision between the two eyes, and there is evidence-based support that roughly three-quarters of patients tend to prefer multifocal vs. monovision when given the opportunity to compare between the two modalities.”2,3

In addition, today's multifocals are available in more comfortable materials, they're refined, in terms of providing acceptable vision, and they offer an increase in parameter availability vs. yesterday's offerings, says Jason R. Miller, O.D., M.B.A., F.A.A.O., of EyeCare Professionals, Inc., in Powell Ohio. (He's also editor of Contact Lens Spectrum, an OM sister publication.)

The ideal candidate for presbyopic contact lens wear: Regardless of whether you, the doctor, prescribe monovision or multifocal lenses, the patient must understand and be comfortable with the fact that there is a difference in the level of clarity between contact lenses and up-to-date progressive spectacle lenses, explains Dr. Chou.

(As a brief, yet related aside, he adds that you should educate the patient that ophthalmic lens wear and contact lens wear are not mutually exclusive. He suggests you explain to these patients that all contact lens wearers should have a good pair of glasses because, “there are instances in which it is impractical to wear contact lenses, such as when the eyes are red, itchy and irritated.”)

To assess whether you're dealing with the aforementioned patient, be sure to discuss the differences in vision between progressive lenses and contact lenses, using real-world examples of these differences. This will help ensure that the patient is satisfied with their vision solution, say those interviewed. The bottom line is that the patient must be motivated enough by the freedom from spectacles.

To successfully dispense contact lenses to this patient, let him know that contact lenses are a great alternative to full-time eyeglasses and can turn back the clock by many years, but of course not restore their vision to their childhood level, explains Dr. Chou.

Dr. Azevedo adds he educates his presbyopic contact lens candidates that contact lenses can outperform progressive lenses by often providing near vision laterally and superiorly and improved peripheral vision, in general.

Surgery

Because surgical intervention affords these patients the chance at being completely free of all refractive-correction products, not just standard reading glasses, many presbyopic patients express an interest in this alternative.

Monovision LASIK is the only FDA-approved surgical option for presbyopia, although refractive surgeons have been performing refractive lens exchanges (RLE) on presbyopic patients as well.

For the monivision LASIK procedure, the surgeon leaves the non-dominant eye slightly nearsighted, so the patient can see near sans spectacles.4

Non-FDA-Approved Surgeries
Currently, three non-FDA-approved surgeries for the correction of presbyopia are being evaluated for use in the United States:
Corneal inlay surgery. The surgeon inserts what looks like a tiny contact lens into the non-dominant eye's cornea via either a corneal flap similar to LASIK or by the creation of a pocket, both utilizing femtosecond laser to reshape its front surface.5 This is a two-step procedure for most patients, as the majority will need to have LASIK first to get the mild monovision they need to be the ideal candidate for receiving these implants, explains Dr. Black. The inlay's benefits: No cornea tissue is removed, the surgery occurs within the cornea, and it's reversible, should the patient be dissatisfied with the results. Also, there is no need to remove the inlay, should the patient develop cataracts in the future. The surgeon can implant a monofocal lens, and the patient will still have the near vision benefits, says Dr. Black.
The corneal inlays:
1. Flexivue Microlens (Presbia Coöperatief U.A., Amsterdam, The Netherlands): www.presbia.com
2. Kamra (AcuFocus, Inc., Irvine, Calif.): http://kamrainlay.com
3. PresbyLens (ReVision Optics, Inc., Lake Forest, Calif): http://revisionoptics.com
“If we're comparing surgical options, everything that is already out there is not only more of a compromise but is irreversible,” explains Dr. Black. “But with this, if the patient can't adapt, the surgeon can take it out. In this field, that's huge. If you mention to a patient that it's removable, doing so will alleviate a lot of pre-operative anxiety. It will make patients feel much more comfortable [undergoing such a procedure].”
Corneal reshaping sans surface breakage. The surgeon employs femtosecond laser energy pulses inside the non-dominant eye's cornea to alter its shape to provide presbyopic vision correction.6
“Some of the initial data, which was presented at ASCRS, shows good results with mild hyperopes,” explains Dr. Black. “I think that while it has promise, this will be limited to a small percentage of presbyopes that fit the proper pre-operative prescription range.”
Multifocal LASIK. The surgeon employs an excimer laser to reshape the patient's cornea into different zones for their near, intermediate and far vision. In each of these zones, the light entering the cornea refracts differently, enabling presbyopic patients to regain good vision at all distances.7 Refractive surgeons employ an array of approaches in this procedure, such as a central zone for distance vision, to achieve the best possible presbyopia correction.
“We were involved with some of the early clinical trials for multifocal laser correction in Canada. While no doubt, some of the patients were happy, patient selection was key,” explains Dr. Black. “ We found hyperopes got the best results as long as all dry eye issues were dealt with preoperatively. A large percentage of patients still required reading glasses in certain situations, such as when reading small print in dim lighting, so managing expectations was paramount. The biggest issue with creating a multifocal pattern on the cornea is that it is permanent. If the patient doesn't heal well, has night vision issues or is just not happy with the outcome, they are stuck.”

As is the case with monovision contact lens wear, not every presbyopic patient is able to adapt to this form of vision. For this reason, it's essential you have the patient test-drive it with monovision contact lens wear first, explains Justin Holt, O.D., of West Point Eye Center, in West Point, Utah.

“The neuro-adaptive period for a patient to fully adapt to monovision can vary from just a few minutes, to three months,” he explains. “It's my opinion that if a motivated patient has not fully adapted to monovision after three months, he never will. Luckily, that is not something that happens often.”

Dr. Chou adds that regardless of successful adaptation to monovision contact lenses, you must educate these patients that variability in their vision can still occur with surgery based on treatment response. In other words, the surgery, like all others, does not have a 100% success rate. Such an explanation helps set the patients expectations so that they are satisfied with the outcome of the procedure, he says.

RLE is the replacement of the eye's natural lens with an artificial, or intraocular lens (IOL). With the recent FDA-approval of several accommodating and multifocal IOLs shown to correct presbyopia in those patients who require cataract surgery, the procedure is becoming more popular, particularly with presbyopic patients who have the beginning signs of cataracts.4

The ideal candidate for surgery: With regard to monovision LASIK, the patient has a healthy cornea and the benefits of the procedure (e.g. leading an active lifestyle unencumbered by refractive correction products), outweigh the risks (e.g. the possibility of needing an enhancement in the non-dominant eye — the eye corrected for near — as the presbyopia progresses), says Dr. Holt. Further, this patient is one who you know, as their primary eyecare practitioner, will be satisfied with 20/happy, adds Sondra Black, O.D., of Crystal Clear Vision in Toronto, Ont. “They must understand that we are looking to reduce their dependency on glasses or contact lenses not necessarily eliminate them,” she explains. Dr. Azevedo says the main risk with this procedure is dry eye, so it's important to both evaluate patients for the condition prior to the surgery, and educate them about its possibility of occurring post-surgery.

As a brief, yet related aside, Dr. Holt says presbyopic patients who wear contact lenses or undergo surgery after wearing glasses for a majority of their life may feel a bit “naked” without them. In fact, he says, some patients rely on spectacles for cosmetic reasons:

“I certainly would not suggest a doctor ask the patient whether he will be bothered by the bags under their eyes being more conspicuous with contact lenses or after surgery,” he says, “however that is a real concern to some patients, so you should keep it in mind when discussing contact lens wear or surgical options.” Dr. Holt suggests you ask patients what they do and don't like about their glasses. “I've actually found that this question has yielded the answer, 'they hide the bags under my eyes,'” he explains.

In the case of RLE, patients who have hyperopia are the best candidates because “they can't see far and can't see near, so the refractive surgeon can do nothing but make their vision better,” explains Derek N. Cunningham, O.D., F.A.A.O., of Dell Laser Consultants in Austin, Texas. He adds that patients who have high myopia (greater than 4.00D, so they have no practical reading distance) are likely to be satisfied with the outcome as well because “they don't really have functional distance vision — they can only see things really close, so the surgeon is giving them freedom at both distance and near.”

Psychologically speaking, the ideal patient for surgery understands and is agreeable with the fact that their vision post-surgery may require additional refractive correction, such as re-treatments, spectacles and/or contact lenses.

“A type A hyper-critical patient is not going to do well with surgery. They will notice every single minute area of blur or visual artifact,” explains Dr. Cunningham. “While they may have gotten that [less-than-optimal vision] with glasses or contact lenses, when they're spending $10,000 or $15,000, their expectations can go through the roof.”

For this reason, you must talk to the potential candidate about their expectations vs. the reality of refractive surgery, says Dr. Black, O.D. (See “Non-FDA-Approved Surgeries,” page 26.)

“By thoroughly explaining the procedure, postoperative healing process and expected outcome as well as being honest about possible risks and complications, the patient will then have realistic expectations and be happy,” she explains. “Under promise, and over deliver. In doing so, the patient will then see you as the 'refractive-specialist.’ This, in-turn, makes you the person who the patient refers all his friends and family to as opposed to the surgical center. You are the one who helped them through the process, the trusted one and the one whose name will be remembered.”

Knowledge equals loyalty

Considering the U.S. population is aging, presbyopia will soon become a factor that either makes or breaks one's practice. By being aware of the latest treatment options and the best candidates for these options, you have the power to create presbyopic patient loyalty. OM

1. All About Vision. Monovision With Contact Lenses. www.allaboutvision.com/contacts/monovision.htm (Accessed 7/16/12')
2. Situ P., Du Toit R, Fonn D, Simpson T. Successful monovision contact lens wearers refitted with bifocal contact lenses. Eye Contact Lens. 2003 Jul;29(3):181-4.
3. Richdale K, Mitchell GL, Zadnick K. Comparison of multifocal and monovision soft contact lens corrections in patients with low-astigmatic presbyopia. Optom Vis Sci. 2006 May;83(5): 266-73.
4. All About Vision. Surgery for Presbyopia. www.allaboutvision.com/visionsurgery/presbyopia_surgery.htm (Accessed 7/16/12')
5. All About Vision. Corneal Inlays and Corneal Onlays. www.allaboutvision.com/visionsurgery/corneal-inlaysonlays.htm (Accessed 7/16/12')
6. Technolas. Perfect Vision. Intracor: A new approach to vision correction. www.technolaspv.com/dasat/index.php?cid=100171. (Accessed 7/16/12')
7. All About Vision. PresbyLASIK (Multifocal LASIK, Bifocal LASIK or LASIK for Presbyopia). www.allaboutvision.com/visionsurgery/presby-lasik.htm. (Accessed 7/16/12')

Lindsey Getz is a Philadelphia-area-based freelance writer, who has written for several consumer and trade magazines. She is also a former editor of Eyecare Business magazine (a sister publication of Optometric Management). E-mail her at lindsey.getz@yahoo.com, or send comments to optometricmanagement@gmail.com.


Optometric Management, Volume: 47 , Issue: August 2012, page(s): 22 - 29