Article Date: 6/1/2002

Lessons Learned
Rx for Presbyopes
Here are some pearls to help you understand presbyopic patients.
By Jack Runniger, O.D.

"My grandfather lived 90 years and never used glasses," a patient once told me.

You and I know that either the old gentleman wasn't seeing as well as he should, or else what my patient meant was that his grandfather drank straight from the bottle. No one escapes eye and vision problems as he gets older.

"Poetic justice"

My friend, Ben Milder, M.D., is co-author of the definitive text on refraction for ophthalmology, The Fine Art of Prescribing Glasses Without Making a Spectacle of Yourself, which received the American Medical Writers Association AMMY award for best new book of the year in medical and allied health -- the so-called "Pulitzer Prize" for medical texts.

He's also a delightful humorous poet and weaves poetry into the text of the book. The preface to his chapter on presbyopia consists of the following poem.

How will multifocals work
For the average groc'ry clerk?
Do you fear to recommend
Trifocals to a life-long friend?
Will you tend to be obsessive
About the use of a progressive?
No doubt you'll know just how to cope
By the time that YOU'RE a presbyope.

There aren't many advantages to old age, but being able to better understand the vision problems of presbyopes is one advantage.


Helpful tips

Younger O.D.s must work harder to appreciate these difficulties to best care for their older patients. A few "pearls" that might be helpful include:

There's no rule limiting the near add to +2.50. A few years ago, I prescribed a +4.00 add for the lady who shares my home so she could do fine needlepoint at a 10-inch distance.

Now that she has eye problems that cause somewhat lowered acuity, I note that she often uses the +4.00 add prescription for reading.

There's no standard best seg height. I had to prescribe an executive-style bifocal for an attorney at above pupil height, even though he wore them all the time. Conversely, a bank president couldn't tolerate a seg height of more than 10 mm, even though he did a great deal of desk work in determining which mortgages to foreclose.

Patients aren't symmetrical. In personal correspondence, Dr. Milder says that a pet subject of his is "the often (no, usually) missed vertical facial/orbital asymmetry, so that the pupillary centers are vertically misaligned -- but the bifocals aren't!" It's not a good feeling to see the cattywompous alignment of such patients' new glasses when you adjust them for proper bifocal seg position.

Master and prescribe progressive addition lenses. Another Dr. Milder poem on this subject:

For all those patients who are vocal
Regarding wearing a bifocal
Which they're intent upon fore stalling
Just try to stop their caterwauling!
You'll ease the problem of cosmesis
By reading through this exegesis
And use progressives for the client
Who's presbyopic and defiant.

There's been a reluctance in the past to prescribe progressives because they're more trouble to fit and some patients have trouble adapting to them. But I found that mastering the techniques usually resulted in delighted patients.

Be careful with the myopic early presbyope. More often than not, myopes of less than 2.00D will balk at wearing any type of multifocal lens during early presbyopia. They prefer to remove their glasses for close seeing.



Optometric Management, Issue: June 2002