Contact Lens Practice Pearls

Managing the Needs of Emerging Presbyopes

BY GREGORY J. NIXON, OD, FAAO

It is common to find that the longer you are in practice, the more your patient base ages with you. As a result, many of my longstanding patients are in their 40s, battling with the visual challenges that ensue with the onset of presbyopia. Because my toes are dangling over the edge of the presbyopia cliff, I am sensitive to the impact that blurred vision can have on the daily tasks of our busy lifestyles. With the proliferation of smartphones, tablets, e-readers, laptops, and other handheld devices, the near visual demand for busy professionals is on the rise. In fact, patients’ inability to quickly and accurately recognize images on handheld devices is becoming my most frequent chief complaint.

However, a recent patient encounter reminded me of the various other ways in which presbyopia can influence a patient’s visual function.

Isn’t Presbyopia Supposed to Cause Blurred Near Vision?

A longstanding patient presented for a comprehensive contact lens exam. He is a 41-year-old white male who was wearing –1.00DS monthly silicone hydrogel lenses on both eyes. He is a regional retail manager who drives to multiple office locations daily and has meetings that involve focusing on a laptop and on images projected on a screen. The remainder of the day is spent working on his smartphone. He stated that he “needed stronger contacts” because he was having difficulty focusing on distance objects on the screen and while driving. Despite stating that the letters were blurry, his entering distance acuity was 20/20 OD and OS, with a clear 20/20 OU at near. Examination revealed a plano over-refraction in each eye and a manifest refraction of –1.00 OD and –0.75 –0.25 × 125 OS. His positive relative accommodation measured +0.25D, and although he did not complain of problems with near visual comfort or clarity, he did appreciate improvement with the demonstration of a +0.75D add.

Multifocals to the Rescue

As a result, I refit the patient into a monthly silicone hydrogel aspheric multifocal lens with powers of –1.00D with a low add in each eye. He initially responded quite well, reporting good comfort and vision with in-office visual acuity remaining at 20/20 OD and OS at distance and 20/20 OU at near. At the two-week contact lens check, he was ecstatic and reported great comfort and vision at all distances including complete resolution of blurred vision while driving or during meetings. He even wore his multifocal lenses on a hunting trip and reported the best distance clarity he has ever experienced while hunting.

Multifocal Lenses Aren’t Just for Near Vision

This case illustrates that presbyopia can present in a variety of ways. My patient’s distance vision complaints were likely secondary to some accommodative infacility and an inability to relax accommodation from the increased focusing strain of early presbyopia. An aspheric multifocal lens provided some accommodative relief and allowed greater facility in transitioning from near to distance targets.

While many practitioners are often hesitant to fit multifocal lenses due to a degradation of distance vision, this case shows that multifocals can maintain and sometimes improve distance clarity. Multifocal lenses can provide a tremendous benefit to your presbyopic patients, even those who may not even be complaining yet of near vision issues. CLS

Dr. Nixon is a professor of clinical optometry and director of extern programs at The Ohio State University College of Optometry. He is also in a group private practice in Westerville, Ohio. He is on the Allergan Academic Advisory Board, the B+L Advisory Board, the Alcon Glaucoma Advisory Board, and the Alcon Speakers Bureau. You can reach him at gnixon@optometry.osu.edu.