A 40-year-old female came into our office for the first time. Her chief complaint was trouble seeing up close, and she felt that she really needed to adjust the distance of what she was looking at to make it come into focus. She also felt that her vision problems were creating eye strain and headaches because she felt that her eyes had to work so hard to focus on what she was reading. Her manifest refraction was plano in the distance OD and OS, with a +1.25D add. All ocular health findings, including dilated exam, were normal.

At the conclusion of the exam, the patient was educated about options for glasses. We discussed reading glasses and, as an alternative, we offered her a progressive addition lens. We did not discuss contact lenses. We saw this patient 16 years ago. Although she was put into our recall system, we have not seen her since.

Presbyopia is a predictable and unavoidable loss of accommodation that occurs starting around age 40. There is no other age category in which everyone requires refractive correction that has such a low percentage of patients wearing contact lenses. With the number of contact lens options available, we have a lot to discuss with presbyopes.

Contact Lenses for Presbyopes

Multifocal Contact Lenses Multifocals have been the mainstay for providing presbyopes both distance and near vision. Soft multifocals are available in every replacement schedule, and some available designs can correct astigmatism.

Multifocals are also available in GP lens designs. Most of these have the distance power in the center of the lens and progress to the near optics in the peripheral portion of the lens. This provides exceptional distance vision and, through translation of the lens when looking down, optimal near vision as well.

Monovision Certain individuals have a difficult time adapting to simultaneous vision multifocal designs. In these instances, a monovision strategy that corrects the dominant eye for distance and the nondominant for near may be appropriate. Depending on the patient, we can potentially incorporate a modified monovision fit in which the dominant eye is corrected for distance and the nondominant eye is fit with a multifocal contact lens.

Orthokeratology While much of the recent attention that orthokeratology has received is in the area of myopia management, it can also provide off-label options for presbyopes. As with monovision, myopic presbyopes can be fully corrected for distance vision in the dominant eye and for optimal near vision in the nondominant eye. Additionally, there is a hyperopic orthokeratology design that can provide a monovision strategy to emmetropic presbyopes by inducing myopia in the nondominant eye.

Specialty Lens Designs As scleral lenses become more commonplace, their designs are becoming increasingly sophisticated. Several scleral lens designs now incorporate multifocal optics.

Hybrid lenses can also correct presbyopia. They are available in both center-near and center-distance designs. The GP center portion can also correct corneal astigmatism through the tear lens that is created between the lens and the cornea.

The Verdict

Numerous options can help our presbyopic patients become more independent of glasses for near vision. If the patient described initially had been offered contact lenses, the opportunity to be less dependent on glasses may have prompted her to return. If prescribing only glasses for presbyopes is still the norm, we don’t want to be normal. CLS

Mile Brujic, OD, FAAO is a partner of Premier Vision Group, a three-location optometric practice in northwest Ohio. He has received honoraria for speaking, writing, participating in an advisory capacity, or research from Akorn, Alcon Laboratories, Allergan, Art Optical, BlephEx, Contamac, Eyevance, Oculus, Optovue, Paragon, RPS, Shire, SpecialEyes, Sun Pharma, Tangible Science, TelScreen, TearScience, TruForm Optics, Valeant, Valley Contax, VMax Vision, and ZeaVision.

  

DAVID L. KADING, OD, FAAO owns the Specialty Dry Eye and Contact Lens Center in Seattle. He is the co-owner of Optometric Insights with Dr. Mile Brujic. He has received honoraria for consulting, performing research, speaking, and/or writing from Alcon, Allergan, Bausch + Lomb, BioTissue, CooperVision, EyeVance, EyeEco, Novartis, Oculaphire, Oculus, OptoVue, RPS, Shire, Solution Reach, Sun Pharma, TearScience, Valeant Pharmaceuticals, Valley Contax, Vistakon, VSP, Weave, Zeiss, and ZeaVision. He is also a stock shareholder of Ocularis Pharma. Follow him on Twitter @davekading.