Prescribing for Presbyopia

Solving the Dry Eye Dilemma for Presbyopes

BY CRAIG W. NORMAN, FCLSA

Presbyopic contact lens wearers face many challenges to success. First, there’s the cosmetic competitor: eyeglasses. The popularity of presbyopic spectacles continues to expand as patients own multiple pairs to meet their fashion, occupational, and recreational needs.

There’s the vision issue, of course—in particular, the ability (or inability) to meet all of their visual demands for their smartphone, desktop/tablet, and for driving.

Next is lens awareness, which falls into the category of either discomfort or dryness—or both, as they can be inter-related; and, for most wearers, it can be difficult to discern between the two unless there is a significant amount of discomfort involved.

The Culprits

The Tear Film and Ocular Surface Society’s (TFOS) International Workshop on Contact Lens Discomfort (CLD) and other projects carried out by TFOS have attempted to gain clarity on this frustrating challenge. As stated in The TFOS International Workshop on CLD: Executive Summary, “Contact lens discomfort is a condition characterized by episodic or persistent adverse ocular sensations related to lens wear, either with or without visual disturbance, resulting from reduced compatibility between the contact lens and the ocular environment, which can lead to decreased wearing time and discontinuation of contact lens wear,” (Nichols et al, 2013).

They go on to describe the main culprits for CLD, which include the lens and the environment, further breaking this down into eight subcategories. Interestingly, of the eight categories, six can lead to contact lens dryness: lens material, lens care, patient factors (age, gender, ocular/systemic disease), medication and compliance, lipid/tear stability, and blinking, along with external environmental factors such as humidity and air quality.

What I Recommend

So how can we resolve this clinically? My vote is to prescribe daily disposable (DD) multifocal lenses. Here’s why:

• DD manufacturers are making their materials more wettable and even adding wetting agents such as polyethylene glycol (PEG) and hydroxypropyl methylcellulose (HPMC) to the packaging solution. The theory: better wetting equals less dryness.

• DDs remove potential care solution reactions by eliminating their use, in particular for storage and disinfection.

• Compliance is easier because lenses are simply discarded at the end of their use.

• Lens deposits are minimized by not having enough time for formation. Again, less deposits equals better tear stability and less dryness.

• While this doesn’t directly impact dryness symptoms, part-time wear is not an issue with DDs. Patients can still wear their glasses when they want, while enjoying the convenience of contact lens wear on an on-demand basis.

One last item regarding dryness symptoms: patients don’t mind using in-eye lubricants. We performed an IRB-approved presbyopic contact lens wearer pilot study at our university comparing patients who were satisfied versus unsatisfied with their lens wear. Of the satisfied wearers, 80% used lubricating drops occasionally/frequently, whereas in the unsatisfied group, 66% used them only occasionally/rarely. This indicates that not only do the drops help, but that wearers don’t mind using them when needed. CLS

For references, please visit www.clspectrum.com/references and click on document #248.

Craig Norman is Director of Research, Michigan College of Optometry at Ferris State University. He is a fellow of the Contact Lens Society of America and is an advisor to the GP Lens Institute. He receives honoraria from Bausch + Lomb and Truform Optics. You can reach him at CraigNorman@ferris.edu.