prescribing for presbyopia
Managing Early or Emerging Presbyopes
BY CRAIG W. NORMAN, FCLSA

Pre-presbyopia is the earliest stage at which patients begin to describe symptoms of (or when clinical findings demonstrate a decline in) accommodative amplitude. At this life stage, readinging small print requires extra effort and the patient history suggests that a reading addition would prove helpful. Unfortunately, when we give patients the option of optical correction for near work, they usually decline it. I call this the "initial denial stage," where patients refuse to believe that they may need bifocals to improve their reading vision.

What should we do for patients who are currently wearing contact lenses when they first describe presbyopic symptoms?

Will Reading Glasses Work?

Obviously, for some patients a low-power spectacle reading prescription works just fine depending on their vocation, avocation and willingness to wear an auxiliary correction. The key for some patients is to have more than one pair of reading glasses "strategically placed" where they use them most often. Generally speaking though, most lens wearers would prefer not to wear reading glasses if possible.

Undercorrect Distance Vision

Another strategy is to slightly undercorrect the contact lens distance power in both eyes. This is especially effective for mid- to higher-range myopic patients where full contact lens distance correction may stimulate accommodative effort and result in increased presbyopic symptoms. If acceptable to the patient, this is a very effective short-term solution, given that you create only subtle decreases in distance acuity. Beware, though, of patient symptoms regarding vision while driving, especially at night.

Monovision

Monovision, in which you (generally) correct the dominant eye for distance viewing and the fellow eye for near, can also prove effective for emerging or early presbyopes. Decreases in contrast sensitivity and stereopsis tend to be minimal at this stage because the undercorrection of the reading eye is usually only 0.50D to 1.00D. Even so, patients may describe some difficulty driving, especially at night, or for other vision-sensitive tasks.

Offer Multifocal CLs Early

For the past few years, we've become more aggressive in offering multifocal soft or GP lenses to early presbyopes. These lenses can provide excellent vision for this demographic at the three key levels of distance, near and intermediate.

The Bausch & Lomb Multifocal Low Add design is a center-near aspheric lens that may work well in these cases. CooperVision also offers the Frequency 55 Multifocal, Proclear Multifocal or Ultravue Multifocal, all available in either a distance "D" or near "N" design. Generally, using the D design with a +1.00D add power in both eyes corrects emerging presbyopes quite well. CIBA Vision's Focus Progressives lens is also effective for this patient type.

Aspheric lenses are also an excellent option for current GP wearers who are demonstrating signs of early presbyopia. It's important to note that you should use only low add correction in these cases. Parameters for many of these designs are available on the www.GPLI.org Web site.

Final Word

Consider correcting contact lens wearers with multifocal soft and GP designs when they first describe presbyopic symptoms. You might find this strategy very effective in helping patients deal with their initial denial stage of presbyopia.

Craig Norman is director of the Contact Lens Section at the South Bend Clinic in South Bend, Indiana. He is a fellow of the Contact Lens
Society of America and is an advisor to the GP Lens Institute. He is also a consultant to B&L.