When I first entered private practice over 27 years ago now I thought that presbyopes were a rare breed. Most of the patients I was seeing at that time were in their late 20’s to early 30’s. Yes, of course, I saw older folks, however, it was more the exception than the rule. Well, low and behold as the years went on I started thinking that presbyopia was becoming an epidemic! So many more people I was seeing were in need of near vision correction. Those who wore contact lenses needed a solution that did not force them back into the regular use of glasses. A required expertise in presbyopic contact lens management was developed. The add powers then typically were between +1 and +1.50 – not highly challenging.
Move forward a few more years of practice and the add power requirements became +1.50 to +2.00. This was a bit more challenging but doable. Over the past few years, I feel like the average add requirement of my patients is +2.25 to +2.50! What is going on here? Well, simply my practice has aged with me. Most of the younger patients are being seen by my associates who more closely match their demographic. This happens to all of us in clinical practice. Fortunately my clinical acumen has developed along with the years. As such, we have been able to apply new lens technologies along with a better understanding of multifocal contact lens management that has allowed us to successfully treat even the more advanced presbyopes. However, along with the need for higher adds, other demands make the contact lens management of presbyopia quite challenging.
Let’s start with the ocular surface.
Regardless of age, we should always start here when we are considering vision correction with contact lenses. The ocular surface is the palate upon which contact lenses are placed. This palate must be optimized to increase the likelihood of success in contact lens wear. As such, every contact lens evaluation should include a detailed evaluation of the ocular surface. Careful attention should be given to the status of the eyelids, especially the condition of the Meibomian glands. If any evidence of anterior blepharitis, posterior blepharitis/MGD or lid wiper epitheliopathy is detected then appropriate treatments should be instituted. Similar attention should be given to the appearance of the tear film both in terms of volume and quality.
Finally and often overlooked, anatomical evaluation of the conjunctival surface and eyelid blink mechanics should be performed. Conjunctival chalasis and incomplete blink often can contribute to ocular surface problems. Surgical intervention for conjunctival chalasis repair has had dramatic impact on contact lens tolerance for numbers of our patients. Of course, we all realize that issues with the ocular surface are pervasive. They impact patients of all ages; however, these issues become more common and more severe with advancing age.
Ocular surface disease and contact lens wear
As such, it becomes critically important for us to consider ocular surface disease and its management when we are caring for the presbyopic contact lens wearer. An interesting question comes to mind in regard to the sequence of events when addressing ocular surface issues and contact lens wear. Do we insist on stabilizing the ocular surface prior to consideration of contact lens wear? Do we go forward with contact lenses and see if they exacerbate ocular surface symptoms and physical findings? Or do we consider simultaneously addressing both? I can tell you that there are those out there who strongly insist on addressing any ocular surface issues prior to placing a contact lens on the eye, while others are far more reactive and start with contact lens wear and then see what happens. For me, like most things, the truth lies somewhere in the middle. Each case should be considered individually. In the best of all worlds for sure we would want to address the ocular surface issues in advance of contact lens wear, however practicality and patient “buy in” also come into play.
Assuming that we have addressed any issues related to the ocular surface, presbyopic contact lens management is all about vision.
Understanding the interplay between distance and near vision demands as well as pupil size influences can be critically important. Today most of our multifocal contact lens designs function as some form of simultaneous multifocal where distance, intermediate and near power sections of the lenses all interact in contributing to overall visual function. The skilled multifocal contact lens practitioner will understand how to best select the most appropriate design and how to work with the various parameters of that design which will result in optimal visual performance.
In an effort to appeal to the “masses” most of the major contact lens manufacturers attempt to produce multifocal contact lenses with limited need for parameter modifications. Although that does result in “try once, try twice and if not successful we are done”, it does not allow for precision management of presbyopia with contact lenses. Those lens designs that allow the practitioner to modify and manipulate multiple parameters such as zone sizes, multiple add powers, near vs. distance center optics, etc. provide the tools that allow us to address a greater array of cases.
I would urge those who sincerely want to embrace presbyopic contact lens fitting to work with and gain experience with those lens designs that will enable you to address the needs of various presbyopic cases. Yes, managing presbyopia can be complex, yes it may involve fairly extensive chair time, however, the rewards are great. This is one of the most impactful ways to differentiate yourself and to establish a true specialty contact lens practice.