Prescribing for Presbyopia

Things I Wonder About

By Craig W. Norman, FCLSA

For many of us, this time of year is a time of reflection, both personally and professionally. I'm no different. At this stage of my career—almost 35 years associated with one multi-specialty practice—I've been spending quite of bit of time contemplating contact lens-related challenges for our patients with presbyopia. Unfortunately, despite all my experience, I still have as many or more questions than answers.

Here are some of the questions I've been pondering (and worrying) about.

Why aren't more presbyopic patients interested in contact lenses?

Are eyeglasses really a better option than contact lenses for presbyopia? Is vision with spectacle lenses that much more superior, or do these patients just view contact lenses as an annoying hassle at their age? Would continuous wear negate the hassle factor? Or maybe it's our own fault, and we aren't presenting contact lenses as an alternative mode of correction often enough to these patients.

Why are there still so many presbyopic contact lens dropouts?

For the most part, silicone hydrogel materials have solved our concerns with corneal oxygenation. Single-use soft lenses alleviate lens care-related concerns. So, is lens-related ocular dryness the culprit? How big a role does a patient's daily environment play? Or is it simply that presbyopic patients want better vision than we can provide today?

As an industry, we need to determine the etiology of the high dropout rate and fix this as soon as possible.

In our technology-driven world, why haven't there been any dramatic changes in contact lens designs for presbyopia?

Spectacle lens manufacturers outinely market new lens designs that offer definite advantages over previous products for presbyopia. We're even seeing breakthroughs with computer chip-managed add power enhancements. Yet, our soft and GP lens offerings for presbyopic patients are fundamentally the same as they've been over the past two decades.

Is there a significant advancement in presbyopic contact lenses being developed today, or will it be more of the same for the foreseeable future?

Why aren't there more alternating-vision, rotationally asymmetrical bifocal soft lens designs?

There are excellent silicone hydrogel materials today. Why can't they be married to a ballasted, segmented progressive lens to provide crisper vision and better contrast sensitivity than we now provide with our multifocal designs? This has the potential of overcoming the inherent limitation of centernear designs that depend on pupil size and dynamics and proper alignment with the line of sight for various visual tasks.

Why aren't more young eyecare practitioners recommending and prescribing GP multifocals and bifocals?

GP wearers in our clinic routinely greet me with, “You're not going to retire soon are you?” I've never heard this from a routine soft lens wearer. GP wearers realize they need skilled practitioners to take care of them, and they place value on those skills. This is a niche that has served me well during my career. Is it a lack of interest in specialty contact lens fitting or is it inadequate training that keeps young practitioners from recommending and prescribing GPs? It seems to me there's a significant opportunity to differentiate one's practice by offering GPs to presbyopes.

Am I alone in these wonderments? Let me know by e-mail if you agree or disagree, and I'll discuss these issues again in a future column. CLS

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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 an advisor to the GP Lens Institute. He is also a consultant to B+L. You can reach him at craignorm@aol.com.