Presbyopia is an undeniable sign of aging. Therefore, patients experience a host of physical, emotional and psychological responses to its onset. Simply put, the need for a separate reading prescription makes people feel “old.”
Recent population reports estimate there are 154.9 million people over age 40 living in the United States. That is almost one half (47.6%) of the total estimated population of 325.7 million. As presbyopia is a naturally occurring process within the eye of those in this age group, population estimates can paint a picture of the prevalence of presbyopia.
By explaining the nature of the condition and then outlining the available treatment options, we can reduce the negative impact this developmental milestone has on patients.
EXPLAIN THE NATURE OF PRESBYOPIA
Improving the understanding a patient has of their condition(s) will increase their acceptance of your treatment plans and improve their outcomes. (Encourage your patients to complain about their vision concerns. The more problems the patient expresses, the more solutions you can offer and, in doing so, satisfy the patient.)
For example, “Presbyopia is a natural part of the aging process of the eye; it occurs when the crystalline lens of the eye loses flexibility, which can make it difficult to focus on close objects.”
The ultimate goal of treatment is to provide the patient with clear and comfortable vision. To do so, we must understand and communicate the multiple options for correction; no single option will provide the best visual performance for all tasks in all environments. Furthermore, we must recognize that different treatment plans may work better for different patients in the same environment or visual demand circumstances.
One analogy I use with presbyopic patients is that once they have distinctly different distance and near prescriptions, treatment options are very similar to shoe styles. You don’t wear your hiking boots dancing and you don’t wear your bedroom slippers to church. It seems to make sense to most people that you don’t wear your reading glasses to drive and (unless you’re Corey Hart) you don’t wear your sunglasses at night.
OUTLINE TREATMENT OPTIONS
Although refractive patients often present telling us exactly what they want, keep in mind that the presbyopic patient is likely unaware of all their treatment choices. Therefore, it is good clinical practice to review all the available options with them, while educating patients that no single option will provide the best visual performance for all tasks in all environments. Consider the following treatment categories comparable to an all-you-can-eat buffet. Allow your patients to choose multiple solutions from the smorgasbord of options to meet the visual needs of their lifestyles. The treatment alternatives for presbyopia currently fall into three major categories: spectacle lenses, contact lenses and ocular surgeries. (See, “Are Eye Drops a Treatment for Presbyopia?” below.)
Here is a brief review of the treatment alternatives in each category. These descriptions can be the basis for how you educate patients.
- Single vision near. These lenses provide clear vision of close objects, but need to be removed or replaced to see distance objects.
- Lined bifocal/trifocal. These lenses have dividing lines that segment the prescriptions for different focal distances.
- Progressive addition lenses. These lenses gradually transition from distance vision in the top of the lens down through intermediate vision to the near prescription toward the bottom of the lens.
- Near variable lenses. These lenses gradually transition from intermediate vision in the top of the lens down to the near prescription toward the bottom. This design is clear and comfortable for visual demands out to about six feet.
Are Eye Drops a Treatment for Presbyopia?
TWO DROPS IN THE PIPELINE aim to increase accommodation. One, EVO6 (Novartis) is designed to break bonds in the crystalline lens structure to restore flexibility. The other, FOV Tears, is designed to affect the ciliary muscle.
Meanwhile, other drops — specifically, LiquidVision (Presbyopia Therapies) and CSF-1 (Orasis Pharmaceuticals) — seek to improve both distance and near vision using the pinhole effect to increase depth of focus.
Contact lens-based options
Each of the following options are available in soft lenses, corneal and scleral RGP lenses and with orthokeratology lenses:
- Multifocal contact lenses. These contain both distance and near prescriptions, so each lens focuses near and far images on the retina simultaneously. The brain automatically focuses on what the wearer wants to see.
- Monovision contact lenses. These lenses correct for distance vision in one eye (usually the dominant eye) and near vision in the other eye.
- Modified monovision. These correct for distance vision in one eye (usually the dominant eye) and utilize a multifocal contact lens for intermediate and near vision in the other eye.
- Translating GP contact lenses. These have distinct distance, intermediate and near zones, which align with the pupil as the patient changes their point of fixation in space.
- Distance single-vision contact lenses. These lenses combine distance lenses with near variable spectacle lenses, as needed.
Lens implantation is the most common form of surgical correction for presbyopia chosen by patients in our office. Also, be aware that it is the most invasive and the least reversible surgical alternative. That said, this is my favorite option for any presbyopic patient who has a significant degree of cataract.
Four approaches for correcting presbyopia are available with lens implants:
- Accommodating implants. These implants change position or shape within the eye, but still require some degree of monovision.
- Multifocal implants. These implants contain both distance and near prescriptions, so each implant focuses near and far images on the retina simultaneously. The brain automatically focuses on what the wearer wants to see.
- Extended depth of focus implants. These implants create one elongated focal point to provide an extended, continuous range of functional vision across all distances.
- Monovision implants. These implants correct for distance vision in one eye (usually the dominant eye) and near vision in the other eye.
Additionally, a variety of surgical alternatives are directed to the cornea:
- Conductive keratoplasty. This procedure uses radiofrequency energy to shrink collagen fibers, resulting in an increase of central corneal curvature. Treatment is variable in both effect and duration via the amount of hyperopic correction induced, and a steady rate of regression is inevitable in all cases.
- LASIK/LASEK/PRK. These procedures use a laser to permanently reshape the cornea. The laser corrects for distance vision in one eye (usually the dominant eye) and near vision in the other eye.
- PresbyLASIK. This procedure uses a laser to reshape the cornea of both eyes into different zones for distance, intermediate and near vision. Like multifocal contact lenses, the brain automatically focuses on what the wearer wants to see.
- Corneal inlays. Also called keratophakia, these are implants placed in the corneal stroma. The inlays available work by different optical principles: increased depth of focus by a pinhole effect; plano center surrounded by rings of different add powers and diffraction. (The latter is still in development.) Inlays are typically implanted in the non-dominant eye.
- Scleral expansion bands. These have been redesigned to be more stable, resulting in a more predictable and sustained accommodation. The implants are placed into the sclera, between the ocular muscles, avoiding surgery in the visual axis.
Create a list of eye surgeons in your area, and contact them to find out who performs the procedures you are comfortable offering to your patients. Then, schedule a meeting with those you might want to work with to arrange the details of co-management in advance. Remember to discuss each doctor’s role in the provision of care, when the patient will be released to your care, what post-op complications would necessitate returning the patient to the surgeon, the specific exam notes to share, as well as billing and reimbursement protocols.
When you discover you have a medical condition, you will have to go through the remainder of your life with, don’t you want to know all your options for treatment? Presbyopia is no different. Thus, discuss the risks and benefits of each solution. Provide comprehensive treatment plans for each patient that include multiple prescriptions. Write one prescription for general use and one for occupational needs, such as computer work. Further, include a sun prescription for outdoor activities, and offer daily disposable contact lenses as event wear for every patient who has a primary spectacle prescription.
A frequent comment from our new patients is, “So, you’re saying I need more than one prescription?” To which we reply, “Well, you told us you had more than one problem.” Our clinic has proven, time and again, that the more treatment options we offer these patients, the more treatment options they accept. OM