For practitioners, understanding the advancement of a patient’s presbyopia is helpful in determining when and if to intervene surgically, and with what technology or procedure. In this conversation, Dr. Ralph Chu, MD, and Dr. Selina McGee, OD, discuss their go-to treatments and approaches for their presbyopic patients.
1. What’s your most-prescribed presbyopia treatment, and how do you make the decision?
Ralph Chu, MD: Clinically in our practice, we use the patient’s age and their near vision values as the two main criteria to assess the degree of a patient’s presbyopia. We know that the loss of accommodative amplitude differs in every patient and have found that correlating age with near vision loss can help us in our conversations about presbyopia and the treatment options for our patients. We have all experienced patients who have come into the clinic needing to wear reading glasses in their late 30s and early 40s; and on the other end of the spectrum hear stories and have seen patients with a near plano lens prescription who can still read without reading glasses well into their late 50s and early 60s without have any previous surgical intervention.
Patients contemplating laser vision correction may also consider a monovision solution which can be simulated prior to surgery with a contact lens trial.
Selina McGee, OD: In my practice, it depends on the patient and their motivation. As Dr. Chu pointed out age does not necessarily correlate with amplitude of accommodation. An in-depth and pointed conversation about how the patient uses their vision every day and what gaps they experience will dictate what my go-to treatment is. For many patients, it is customized spectacles designed for their need’s. I also have a lot of patients who choose to wear contact lenses in addition to their spectacles. Emerging emmetropic presbyopes will typically fall into this category of spectacles and contact lenses (albeit sometimes kicking and screaming).
I do have patients who are moderate presbyopes that are highly motivated to pursue the least dependence on glasses and contact lenses possible and my emmetropic presbyopes are very interested in more options. With these patients, we discuss surgery, such as clear lens exchange, but surgery is difficult to contemplate when distance vision is 20/20. Through these conversations, it is obvious that patients are demanding alternatives to our traditional treatments.
2. What factors go into referring a patient to an MD for further treatment for presbyopia?
Dr. Chu: Many patients present to our practice with presbyopic symptoms in their early 50s and have had previous laser vision correction who now don’t want to wear reading glasses. Their distance vision may be 20/20 to 20/25 and they may have a slight myopic refraction of -0.5D vision. The near vision in this situation is very helpful in guiding the conversation about treatment options for these patients. Helping these patients understand dysfunctional lens syndrome and the aging process makes them more comfortable understanding why there may be a period of “presbyopic limbo,” in which a nonsurgical option may be their best choice before seeking surgical solutions.
Dr. McGee: When a patient desires the least amount of spectacle dependence, it’s time to make a referral. (Emmetropic presbyopes are the exception here and warrant further discussion.) Again, this varies widely from patient to patient, so it’s important that you don’t assume that a patient won’t want to know all of their options. Even if they don’t choose a particular course today, for me, it’s critical to educate my patient about all of their options today and in the future. Patients are also greatly relieved to know there could be new therapeutic and surgical treatment options for them in the future. I want every patient empowered to know all of treatments available, and we choose and customize what will work best for them today and for the rest of their life.
Dr. Chu: We are excited about having more treatment solutions for our presbyopic patients. As new treatment options—both medical and surgical—become available, understanding the patient’s visual and lifestyle needs will continue to be critical to matching the right patient to the right treatment.