Prescribing for Presbyopia

Where Do We Go From Here?

BY CRAIG W. NORMAN, FCLSA

Will 2013 finally be the year in which more patients are successfully fit with presbyopic contact lenses? Can we decrease the number of presbyopic patients dropping out of contact lenses because of dissatisfaction with visual acuity? Is there a way to get presbyopic soft lens wearers to continue in lenses after their initial purchase? Let’s look at some possible answers to these questions.

Patient Acquisition

As suggested by many experts, we can begin to present multifocals earlier than we currently do, maybe even during pre-presbyopia. We can also consider moving away from offering monovision. Maybe we should follow the 2010 recommendations of the American Society of Cataract & Refractive Surgery (ASCRS), which suggested that we rename presbyopia “Age-Related Focus Dysfunction” so that “presbyopes, upon hearing this terminology, would be able to understand it and intuit its applicability to their own condition.”

For me, it’s more simple than this. I suggest that we embrace educating patients about the inevitability of this condition and together start the process of determining which patients would be suitable for the contact lens options that are available.

Patient Selection

Not all presbyopic patients want (or need) their full correction in contact lenses. For many, either spectacles or contact lenses plus reading glasses are sufficient for their daily tasks.

For those who do, however, the first step is to verify that they are good candidates: ruling out dry eye, unusual prescriptions, or ocular conditions that contraindicate contact lens wear is vital for increased patient success.

Ensuring that we understand the environment in which lenses will be worn is also important during this selection process. The key is to avoid attempting to fit those who have small chance of success to begin with.

New Designs

Recently, the industry has introduced improvements in presbyopic soft lenses, GPs, torics, and hybrid presbyopic designs. Scleral presbyopic lenses for regular and irregular corneas are beginning to be fit more often. I’ve even seen tandem designs in which a bifocal GP is placed within a “pillow” cutout insert soft lens to enhance both multifocal vision and patient comfort. In addition, as I’ve mentioned in previous columns, I’m quite excited about some upcoming options in soft ballasted translating designs.

Improved Fitting Techniques

I think corneal topography is the best tool when prescribing lenses for presbyopia. The most basic measurements of surface curvature, corneal diameter, and pupil size should be performed by topography as part of the fitting process for all presbyopic lenses.

Plus, taking maps over the lenses during follow-up exams to determine where the optics are in relation to the line of sight can explain many visual complaints that patients describe.

Industry Support for Educating Young Practitioners

Today, eyecare practitioner graduates are focusing on the medical component of eye care to build their practices, mostly because of the focus in this area at their educational institution. The contact lens industry has recognized this and has implemented The Soft Toric and Presbyopic Lens Education (STAPLE) Program, a collaborative effort on behalf of Alcon, Bausch + Lomb, CooperVision, and Vistakon that provides hands-on soft toric and soft multifocal fitting workshops to optometry students in North America. This program gives young practitioners the fitting skills necessary to entice more of their patients into presbyopic contact lenses and should play a big role in increasing patient awareness and success in the future. CLS

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. You can reach him at craignorm@aol.com.