It’s no secret that satisfying patients who have presbyopia can be challenging. The good news: I have found that preparing patients for this eventual change in vision, and explaining the many options they have to achieve satisfactory vision has enabled me to overcome this challenge. Here, I discuss these two action steps.

Preparing patients

Change is hard to accept, but it’s even more difficult to accept when it’s unexpected. Therefore, I have found that preparing patients for the onset of presbyopia makes them more amenable to accepting this change and the vision-correcting options available.

I am a firm believer that the conversation should begin with patients in their late 30s; sooner, if they perform a job that involves heavy device/computer use. Letting our patient know what lies ahead in a way that is not presented as a catastrophe, is ideal. I let my patients know before they are experiencing symptoms exactly what to look out for as their eyes age.

When addressing this, I use the following patient script: “Though your vision is changing, you don’t need to give up certain hobbies or tasks just because your eyes are no longer able to focus as they once did. While your vision will never be exactly like it was in your teens, 20s, and 30s, we have modern, convenient, and cost-effective solutions to help with your sight.”

Because this may be a jagged pill for most patients to swallow, I usually follow up with this script: “While there are options that allow us to approximate a natural visual experience, factors like the aging of the ocular tissues, the use of lenses that are designed to address all levels of vision, and the numerous, complex ways in which we use our eyes make achieving ‘perfect’ vision difficult. Our goal isn’t to achieve perfection, but to provide highly functional vision that can give you a great quality of life.”

Explaining the options

• Spectacles. Any emerging plano presbyope sitting in my exam chair is always given some vision correction eyewear options at the conclusion of their eye examination. These options are presented in a way that allows the patient to make an educated choice on which will most likely fit their lifestyle.

First, I review the use of what I call “occasional use glasses.” These are spectacles patients often use on certain occasions when using a screen for a long time or when they need the flexibility of seeing well at certain working distances. Many spectacle lens styles can be lumped in this category: computer variable focus, single-vision computer, single-vision near, or a bifocal/trifocal/PAL. Based on when a patient is most likely to experience visual challenges, I prescribe an appropriate lens and let the patient know that these glasses are to be worn when needed and are likely their “gateway” glasses.

As the years go by and they reach for them more often, the constant “on and off” may become a nuisance. At that time, we can work on a full-time option that will more conveniently fit their lifestyle. A script for this type of patient would go something like this: “We have many options for spectacles you can choose from, and we’re going to start with a category called ‘occasional use glasses’ that you can use for specific tasks such as using a screen or doing tasks at working distance. You might find you need to use them more as time goes on, and if that happens we can talk about changing the type of glasses, or starting non-glasses options, in order to fit your lifestyle.”

• Contact lenses. I also present contact lens options to every plano presbyope. Any patient in my exam chair with a healthy anterior segment, no signs of dry eye disease (DED), and who is motivated by the idea of not wearing spectacles, is a candidate. I present single-day soft multifocal contact lenses as my first choice for this population. I explain to patients that monovision is still an option should they struggle with multifocals. However, I prefer to keep patients binocular at all distances if at all possible. After all, this is how our visual system is wired to work most optimally.

Discussing realistic expectations and presenting these contact lens options with enthusiasm and in a positive light have allowed me to grow my contact lens practice. For a patient script, I would recommend: “If you’re not interested in wearing spectacles, we can try these single-day, multifocal contact lenses. While there are other contact lens options, such as monovision I advise multifocal lenses. They allow us to remain binocular and maintain depth perception; exactly how our visual systems are designed to work.”

• Surgical options. The advances in IOL (intraocular lens) technology have gained momentum in recent years, so much so that offering patients a surgical correction has become a great option for folks motivated to be mostly spectacle and contact lens free. These patients are offered IOL technologies, including extended depth of focus, multifocal, multifocal toric options, and light-adjustable lenses.

While a clear lens extraction surgery may not be for everyone, there are patients who find that the cost of such a procedure is worth every penny given the anticipated improvements in their quality of life. Understanding the IOL options your surgical team utilizes and their comfort level with performing a clear lens extraction surgery is critical for success; be sure to have open dialogues with your surgeons to know what surgical options they are most experienced and comfortable with. The use of laser-assisted lens removal and interoperative aberrometry has allowed our surgeons to be very successful attaining the refractive goals that our patients desire. For a patient script, try: “If your goal is to be largely free of spectacle or contact lens wear in most situations, there are several surgical options to consider. One option, the use of intraocular lenses, or IOLs, typically requires our surgeon to perform a laser-assisted lens extraction surgery. The natural lens, which can no longer focus efficiently, is replaced with an artificial lens implant. These implants can be designed to work from distance to near, or can be optimized for other visual distances (in the case of monovision).” (As a rule, any patient undergoing a clear lens extraction surgery, or cataract surgery for that matter, are cleared for surgery only after we determine that they are not suffering from a corneal or retinal pathology that could impact the visual quality after surgery.)

• Pharmaceutical Options. The creation of a presbyopia-treating eye drops added a new dimension to eye care, and several such drops are now being developed. Emerging and emmetropic presbyopes are perfect candidates for these therapies. The first presbyopia correcting eyedrop approved by the FDA was introduced in late 2021. Relying on the “pinhole effect” and utilizing pilocarpine as the active ingredient, patients in our practice were able to attain functional near vision for several hours. The eyedrop is safe and effective for the plano presbyope population, but we must take into consideration the retinal health of folks who may be plano presbyopes AND post-refractive surgery. Many of these patients were highly myopic prior to refractive surgery, and the use of pilocarpine could pose an increased risk for retinal complications. There are several novel presbyopia-correcting eyedrops in clinical trials. We are surely just starting to see how pharmaceutical agents can impact presbyopia correction. When introducing this option to patients, I typically say; “If spectacles or contact lenses are not a great fit for your lifestyle, there are now eyedrops that can deliver on the promise of improved near vision. They are also a great ‘part-time’ solution for those occasions when other eyewear options are not convenient. I have found that the drops give me about 4 to 5 hours of functional near vision. If you are interested, I’d be happy to write you a prescription so you can try them out.”

Keeping up with presbyopia

As illustrated above, I have had success in addressing the needs of my presbyopes by preparing them for the inevitable onset of the condition and explaining the latest related treatment options. I invite you to try these two action steps in your practice. OM

DR. EARLEY is the co-owner, vice-president and human resource manager at Medina Vision Centre, Inc. in Medina, Ohio. He is the clinic director of Bright Eyedeas Vision Clinic, a local free clinic serving the uninsured. He has lectured nationally on the topics of dry eye disease, AMD, contact lenses and practice management. He is a member of the Ohio Optometric Association and the AOA. He is on speakers alliance and advisory boards for Alcon, Maculogix and MacuHealth. He can be reached at drearley@medinavisionandlaser.com.