How to Talk Treatment Options With Your Presbyopic Patients

With the oldest millennials (born in 1980) beginning to turn 40 and joining generation Xers in “Club Presbyopia,” the need for effective modalities for presbyopia correction continues to rise. In this article, I discuss strategies for improving our understanding of our patient’s needs in order to change our approach to treatment and consequently produce loyal and satisfied patients.

We need to pay specific attention to three areas when interacting with patients with emerging presbyopia: their mindsets, their accommodative demands, and their care plans.

GET INTO YOUR PATIENT’S MIND

There’s no denying the stigma around getting older, which is why it’s important to know your patient before you dive into your spiel on presbyopia. The discussion will likely go much easier with an emerging presbyope who has already been using progressive addition lenses (PALs) or another form of vision correction, but you may have to take a more delicate approach when having this conversation with an emmetrope. I have found that being sensitive to this age-related change and using language such as “changes in near demand” and “growing wiser” work well with these patients. You may even get a chuckle or two, which can make having this conversation even easier and more enjoyable.

Your wording determines whether you arrive at the appropriate next step. In my experience, patients who are engaged in shared decision-making are more open to correction and tend be happy with their correction, compared with patients who are told they are getting older and need to accept the change. I’ve had patients tell me they didn’t give their previous optometrist a chance because they didn’t want to accept that they were getting older.

LEARN ABOUT YOUR PATIENT’S ACCOMMODATIVE DEMANDS

Once you have gained your patient’s trust, the next step is learning more about his or her accommodative demands. This can be accomplished by asking the following questions.

What do you do for work?

The answer to this question will help determine how precise the patient’s vision correction must be. For example, is depth perception important in his or her line of work?

Do you experience eyestrain or headaches?

If the answer is yes, find out when these symptoms occur.

How many hours a day do you spend on a computer?

Find out if the patient goes back and forth from standing to sitting.

Do you use a laptop, a desktop, or a tablet?

The intermediate reading distance is different for each type of screen.

How many screens do you use at one time? What are the working distances?

In other words, how far away is the furthest screen compared with the nearest screen?

What is your priority: optimal distance of intermediate or near vision, or a combination of both?

This will be especially important for patients interested in contact lenses.

IMPLEMENT A CARE PLAN

Once you have all of that necessary information you can create a care plan. There are four main treatment options for presbyopia: multifocal IOLs, pharmaceuticals, spectacle correction, and contact lenses.

Multifocal IOLs

Multifocal IOLs are typically an option only if your patient plans to have cataract surgery in the near future; however, this is something worth discussing with patients who have cataracts, as they are likely not aware of this IOL option.

We should also address how successful the multifocal option is, based on where we think the technology will be by the time this particular patient needs the surgery. Postoperative recovery time should also be discussed, and we should recommend that patients discuss all their options with their surgeon.

Pharmaceuticals

Presbyopia-correcting drops are getting a lot of attention right now, but none have been FDA approved. These will not likely be your first mode of treatment for some time to come, but we should continue to stay current on this modality as it evolves.

If you have a patient who may be a good candidate for this modality, you can mention that the first of these drops could become available this year. In my experience, patients are more likely to be open to new modalities if they have heard about them beforehand.

Spectacle Correction

The simplest option that isn’t always addressed is a hyperopic shift that can occur as near demand changes over time. This is especially the case in high myopes who have been over-minused. Sometimes addressing this with a single-vision spectacle prescription can solve the issue of blur, discomfort, and eyestrain at near. If this change is made to a patient’s prescription, it is important to discuss it with him or her and explain how it will affect vision.

It’s also important to note your patient’s working distance. PALs are the easiest way to correct distance, intermediate, and near prescription concerns all at once; however, these lenses may not adequately address your patient’s concerns at the computer screen. It is vital to point this out to patients. Using an analogy can help the patient to understand why this is the case and why it may be necessary to integrate multiple pairs of spectacles to address different working distances appropriately. For example, running sneakers and dress shoes both allow you to be mobile, but each is better suited for a particular activity.

Many patients now use multiple screens at different distances, and new presbyopes may require spectacles to address this situation. PALs may work for some, but for those who work on desktops, laptops, and multiple screen combinations they may limit the field of view.

One helpful modality to address specific working distances is the dedicated computer multifocal—a lens that addresses the specific intermediate working distance of your patient, as opposed to single-vision reading glasses set at a distance of 16 cm. For people who may be interested in this option, it can be helpful to draw a diagram or to explain that you are in essence taking the bottom two-thirds of a PAL and enlarging it to take up the whole lens. This can create a better visual image for the patient. Then, setting up a trial frame using those working distances can help you to perfect the prescription. Trial frames also allow the patient to get excited about seeing well at the distances where he or she may have struggled previously, so I use them often in my practice.

Contact Lenses

Explaining contact lens designs to patients is trickier because they often assume that contacts work like spectacles. Make sure to create an adequate visual image of the design and limitations of multifocal and monovision contact lens options.

Even when we renew a prescription for someone already wearing multifocal or monovision contact lenses, we should investigate whether an improvement can be made. Which domain is more important to this patient, near or distance? Whichever is more important, we can try to improve that domain, while also making sure that vision in the other domain is still acceptable. Discussing the choice in this way can help set the foundation for the patient’s expectations and boost his or her satisfaction with this treatment modality.

BE DIRECT AND HONEST

In implementing any treatment modality, be sure to explain to the patient how to adjust to the modality and what to expect from this new mode of correction. In our world that has become highly technology-dependent, it is essential to establish clear communication and open dialogue to achieve success in correcting and improving our presbyopic patients’ near vision. Taking the time to accomplish these goals can be rewarding and can lead to better-informed and more gratified patients.