prescribing for presbyopia

Rethink Some of Your Prescribing Habits

BY JOHN MARK JACKSON, OD, MS, FAAO

Can you teach an old dog new tricks? How about an old clinician? Even with advances in technology, it's been observed that many clinicians tend to keep some prescribing habits they learned as a student or resident. I freely admit to being an old dog in this way, and some old habits are tough to break when you learn them the hard way by early mistakes.

Case in Point

One of the first contact lens patients I saw as a resident complained that her eyes were tired at the end of the work day. She was 41 years old and had early presbyopia. She could read small print clearly, even at the end of the day, but it was wearing her eyes out. I decided she could benefit from some plus for near, but less than what over-the-counter reading glasses would provide.

She was not quite ready for the idea of wearing reading glasses anyway, so we discussed further options and I encouraged her to try monovision with +0.50D plus for the near eye. I felt this would provide enough plus to relieve her symptoms but not blur her distance vision too much.

It was a disaster. She complained that her headaches were worse, her eyes were fighting each other for dominance, and I was perhaps the worst eyecare practitioner she had ever seen. She went back to distance-only contact lenses with occasional use of +0.75D reading glasses. We decided it would be best to delay presbyopic contact lens options until she felt that she needed to rely on the reading glasses for most of the work day.

The lesson I took from this experience was: don't try presbyopic contact lens correction until the patient is dependent on near help for most of the day. I've followed this "nugget" ever since and have taught it to my students. But is it true?

Consider More Current Options

I still think that my strategy was wrong by not prescribing enough plus power; the central suppression necessary for monovision to work is too difficult to obtain with such a small power difference. But as multifocal contact lens technology has improved, I have found that early presbyopes can do very well with them, and early on is really the best time to get such patients "trained" to use multifocal lenses. I would give someone interested in progressive addition spectacles the same advice: get used to them now while the add is low and they'll be easier to use with increasing adds when you really need them.

For these early presbyopes, a low-add distance-center design is a good choice because they can get the small amount of add they need without compromising distance acuity. The Biomedics EP lens and the Proclear Multifocal D lens (both CooperVision) are two such available designs. Of course, most simultaneous vision GP designs are distance-center and would also work well.

Learn Some New Tricks

Can you think of any common habits in your prescribing routines that you should rethink? The next time you try the same old thing you've been doing forever, stop and question your assumptions. Maybe there's a better option for your patient that you have resisted, and it's time to learn some new tricks. CLS

Dr. Jackson is an associate professor at Southern College of Optometry where he works in the Advanced Contact Lens Service, teaches courses in contact lenses and performs clinical research.