Article

PRESCRIBING FOR PRESBYOPIA

CONTACT LENSES AND EMMETROPIC PRESBYOPES

We’ve all been in situations in which we have patients who have been correction-free for their entire lives and are now frustrated with their new demand for reading glasses. Because they’ve always been correction-free, contact lenses are usually more appealing compared to the on-and-off of reading glasses.

But this is a challenging group of patients to manage with contact lenses; their tolerance for blur or aberrations is pretty low, which can make monovision and multifocal contact lenses a difficult transition. Hopefully, some of the following tips can improve outcomes in these cases for both you and your patients.

Set Goals and Expectations

Like all new multifocal lens wearers, these patients need to understand how multifocal lenses work and the adaptation process that needs to occur to best function in their new contact lenses. Be straightforward about expectations, the time commitment, and potential lens adjustments. I also mention that reading glasses are going to be a part of their vision toolbox, even with contact lenses, and we’re going to try to decrease the need for them as much as we can.

It’s also just as important for prescribers to listen to patients’ needs and to identify their main vision demands so that these can be simulated during testing.

Selecting Initial Lenses

Emmetropic presbyopes are used to having great distance vision, so I like to start with maintaining that clear distance vision and taking steps to improve near vision. Start with a low or medium add power, depending on the age of the patient and the lens brand selected for both eyes. The goal is to minimize the effect on the distance vision quality and to make an improvement at near. Most of the time, this gives patients enough near improvement to demonstrate that multifocal lenses can work without resulting in too much impact on their distance vision. I’ll then push plus binocularly with loose lenses and apply one more pair with more plus in the sphere power or a higher add to further increase the reading with minimal impact in the distance. By now, patients should definitely notice an improvement in their near vision and feel comfortable with how they see at distance.

Adjustments

On the first visit, I try to maintain equal acuities between eyes at distance and near, rather than pushing plus in the nondominant eye. Decreasing their binocularity is like trying to introduce both multifocal and monovision optics at the same time; it’s too much change in one visit. I may try a small amount of modified monovision at a second visit, but certainly not at the first.

To prepare for the follow-up visit, I make sure that my fitting set has the lenses that I might need, and I place them in a tray for the next visit. During follow-up visits, keep the changes small and simple, such as gaining one line of acuity at near or decreasing distance blur. Keep in mind that this group has a low tolerance for blur, so make small changes and sometimes in just one eye.

Finalize

More than any other new multifocal patient, emmetropes need education and time. Give them adequate time for adaptation between visits, but advise them to come back sooner if it’s just not working. Lastly, don’t forget to ensure that they are comfortable with lens handling, replacement schedule, and cleaning regimen, as these seemingly simple things can be a deterrent for someone who hasn’t previously needed to use eyewear on a daily basis. CLS