prescribing for presbyopia
Recapturing a Presbyopic Contact Lens Drop Out
BY MARY JO STIEGEMEIER, OD, FAAO

We often lose presbyopic contact lens patients because of discomfort, poor visual performance and hassle. Many of these problems we can fix or improve -- as I did for the following patient.

Longing for Lens Wear

A 63-year-old caucasian female recently presented to try contact lenses. She'd worn monovision soft contact lenses 20 years prior. As she became increasingly presbyopic, soft lenses no longer served her visual needs. She then wore GP lenses for a number of years, but subsequently dropped out of lens wear because of increasing discomfort. She hadn't worn contact lenses for approximately 15 years.

This patient was highly motivated to try contact lenses again. She'd worn eyeglasses since the age of four and wanted to reduce her dependency on her current trifocal eyeglasses.

Examining the Patient

This full-time bookkeeper exhibited mild refractive amblyopia OS and was taking Zyrtec for seasonal allergies.

Slit lamp examination revealed clear corneas, a reasonable tear film in each eye and a trace of nuclear sclerotic changes in each eye. Subjective manifest refraction was +2.50 ­1.00 x 044 20/20 +2.50 Jaeger 1 OD and +4.25 ­2.50 x 025 20/25^­2 +2.50 Jaeger 1 OS. K readings were 47.12 @ 032/47.87 @ 122 OD and 47.12 @ 026/47.12 @ 116 OS.

Options for this patient were:

• Distance soft toric contact lenses with reading glasses
• GP distance contact lenses with reading glasses
• GP monovision
• GP multifocal lenses
• Soft toric multifocals
• Modified monovision soft toric lenses with readers and/or distance glasses to augment vision

Choosing a Corrective Option

After a long discussion regarding this patient's visual needs, I opted for a modified monovision approach. She wanted to eliminate glasses for the majority of her day. She was also slightly amblyopic, so a true monovision approach probably wouldn't give her the near acuity she needed for bookkeeping, but a modified approach may give her excellent distance and midrange vision. GP lenses may give her the best acuity, but she was reluctant to try again after her previous failure.

Because of the fairly steep nature of her corneas and her seasonal allergies, I opted to fit her with Bausch and Lomb's SofLens 66 Toric lenses. Her final prescription was +3.00 ­0.75 x 050 OD and +6.00 ­1.25 x 020 OS. These lenses rotate five degrees temporally OU, but they're stable and move well. The patient finds them extremely comfortable, and she achieves 20/20 distance vision with the right eye and Jaeger 3­ near acuity with the left eye. I also prescribed reading glasses for near that she uses part time to augment her vision at work.

Making a Difference

Following is the feedback that I received from this patient:

• She's so happy that she pursued contact lenses and loves how she looks
• Friends continue to rave that she looks younger or that they "notice something different"
• She can go out to dinner and see the food on her plate
• She loves the freedom for sports
• She has more self esteem

From this case, I learned the importance of listening to our patients' needs and then providing lens options to meet those needs. Communicate and educate patients about current technologies. The extra few minutes you invest increases patient satisfaction and will grow this market. What may seem like a "presbyopic nightmare" can actually be a happy return into lens wear.

Dr. Stiegemeier is in private practice in Beachwood, OH. She lectures throughout the country on the subject of contact lenses and performs clinical research.