Finding the Best Lenses For Presbyopic Patients

By Cristina M. Schnider, OD, MSc, MBA, FAAO

See perfectly near and far, and everywhere in between.� We�ve all been promised Nirvana in the presbyopic contact lens arena, and although several options are available, no one has delivered the entire package to date. While the brightest minds in the optical industry are working on the next best design, we can take steps as practitioners to keep the promise alive for our patients who want to wear contact lenses into their presbyopic years.

The following tips, collected from successful fitters through the years, are worth sharing as a way to bridge the gap between today�s realities and tomorrow�s hopes. The Contract � Control The Controllables Any attorney will tell you this: Never enter into an agreement without a clear understanding of expectations from both parties. This advice also can apply to fitting contact lenses for presbyopia. In other words, ask your patient for a very specific definition of success before you start.

You might ask, �What is the one activity that, if you could do it more easily with these lenses, would make you consider the lenses successful?� Then concentrate your efforts on the requirements of the patient�s stated task or situation, and focus the patient on her own definition of success when she leaves your office for the real-world test. For example, if a patient defines success as being able to read a menu more easily with the new lenses, then having perfect vision at the computer is outside the scope of the contract.

We also need to resist the urge to impose our somewhat arbitrary 20/20 rule on the definition of success. Very little in life really requires 20/20 vision, and people can be successful with less. And on the flip side, 20/20 acuity does not ensure visual satisfaction. By asking patients to define task- or situationspecific criteria for success at the beginning of the process, you will probably find they are indeed successful. Of course, the list may have grown when they return, but this is a good start and leads to the second tip.

Match the Tool to the Task

Most of us wear different shoes for different activities, such as work, working out, running, tennis, golf, lounging around the house, working in the garden and so on. The same goes for sporting equipment and tools for the workshop, the kitchen or the exam lane. In a pinch, we may use one tool for several purposes, but we often sacrifice quality or convenience to do so.

It�s worth remembering and, more important, reminding our patients, that while one solution may be possible, it�s not likely to be optimal for varied visual needs, given that we no longer have the full power of our built-in �power assist� or accommodation. So if you�re successful for most of your patient�s lifestyle situations but the last adjustment triggers a critical comment, consider offering another of our tremendous array of options to fill the gap, such as over-spectacles for driving, reading glasses for cross-stitching, PALs at tax time and the like.

Think of this as enhancing success versus admitting defeat. I don�t know about you, but taking the time to change from my business suit and dress shoes into my workout clothes and running shoes is generally worth the effort, and definitely enhances my workoutexperience. The same will hold true for changing eye �equipment� for the few tasks that don�t fit the bulk of day-to-day activities.

Life Beyond the Chair

As fascinating as our exam lanes might be to us, they fall well short of the richness of texture, contrast, lighting conditions and dynamic nature of the real world. For most of us, simulating even a standard office environment can be a challenge during lens fitting, let alone the real-world conditions of a competitive rifleman, a figure-skating judge or an auto mechanic.

Two mistakes that can limit your success with multifocals are:
1) making too many changes too soon or all at once without allowing patients time to experience the real world in all its wonders; and
2) assuming that everyone�s world is the same and is represented by our office environment.

My policy is to rely on my own best refraction (I push plus in all monocular testing and am very stingy with minus in binocular testing), follow the manufacturer�s fitting guide for the first pair of lenses, and let the patient leave for at least 3 to 5 days, armed with her self-determined criteria for success.

Unless a patient is unable to drive safely from an acuity standpoint or is nauseated in the chair, I try not to change anything until the patient has gone through a typical week. At follow-up visits, I make very small, discrete changes (0.25D steps on one eye), letting the patient answer the �worth it� question. That brings me to the final tip.

Know When to Say When

I have adopted a three-strike rule: Three strikes (usually visits and/or lens adjustments) and they�re out. A patient can come back next season and see if we�ve picked up any new hot prospects, but my experience has been that the more I adjust and change, the more likely I am to end up back where I started, but with a more frustrated patient and a significantly lower margin on my professional fees. Maybe you have more patience than I do, but making the call at three strikes is a good idea because it will save you and your office time, money and frustration.

I hope these tips have inspired you to look at your contact lens wearers, who are nearing presbyopia or are in their presbyopic years, in a new light.

One last comment: Don�t forget that despite all the focus on lens design and patient factors, material still matters. You can design all the optics you want into a lens, but if it doesn�t stay clean and wet throughout the blink cycle, wear cycle and replacement cycle, neither vision nor comfort will be optimal for the patient. Similarly, a thick hydrogel design that causes striae after a few hours of wear also can impact performance. Spectacles are revenue generators for most of our practices, so we should not ignore them as part of the eye fitness �equipment� package for our presbyopic patients. Even if you don�t sell spectacles, you are always selling �you� and your services. Happy patients make happy doctors!

If you have any tips you�d like to share, email them to me at cschnide@visus.jnj.com.

Contact Lens Spectrum, Issue: May 2007