EYECARE: Eye Health Presbyopia: The Art and Science of Matching Patients With Solutions With a multitude of vision correction options now available for presbyopes, personalized approaches to treatment are more important than ever. By Andrew Karp Wednesday, June 22, 2022 1:30 AM RELATED CONTENT The Power of Presbyopia Drops MEASURING THE MARKET: A Roundup of Presbyopia Statistics Presbyopia Snapshots Download a PDF of Presbyopia: The Art and Science of Matching Patients with SolutionsAlong with receding hairlines, crow’s feet and sagging skin, presbyopia is one of the least welcome physical changes we experience as we age. The gradual loss of our eyes’ ability to focus on nearby objects, a result of the stiffening of the crystalline lens, is an inevitable condition for most of us who are middle aged and older. In fact, you could even add presbyopia to the familiar litany of death and taxes. And it only gets worse with time. Resourceful inventors throughout the centuries have developed a multitude of ways to combat this age-old, age-related problem. Vision correction for presbyopia has ranged from hand-ground, glass magnifiers to Franklin bifocals to Kryptoks, an ”invisible” bifocal that was popular 100 years ago. Modern solutions range from simple non-prescription reading glasses to the latest generations of progressive addition lenses (PALs), multifocal spectacle lenses, multifocal contact lenses and implants. The newest treatment for presbyopia, pilocarpine hydrochloride eye drops that give short-term relief to emerging presbyopes, recently became available, and other, longer-term eye drops are being developed. When totaled up, the combined value of these treatments makes presbyopia correction one of the most lucrative categories in the vision industry. Considering the wide variety of vision correction treatments that are currently available, presbyopes today are living in a golden age. Yet finding the best solution for an individual patient, or a combination of solutions, can be challenging for eyecare professionals. There is no one-size-fits-all approach. Many factors influence presbyopes’ choice of vision correction, starting with their visual needs and including lifestyle, aesthetics and budget. The fact that presbyopia is not a static condition is also an important variable when considering vision correction options. Our vision changes as we age. Experienced eyecare professionals know that matching presbyopes with age-appropriate treatments and products requires knowledge and skill, and may even require ongoing training. To better understand the often-complex decision-making process involved in treating presbyopia, VM asked 11 eyecare experts, including opticians and optometrists, how to assess the needs of presbyopes and create personalized treatments for them. We also asked the ECPs which vision correction solutions they recommend to patients, and why. Collectively, their comments and observations provide a window into how presbyopia vision correction, one of the fastest growing, most dynamic categories within the ophthalmic market, is being managed today. Our VM report also includes the latest market data plus a special section on the newest vision correction solution for presbyopia, eye drops. Assessing Patient Needs It usually starts like this. A 40-ish patient walks into an optical shop or eyecare practice and says they’ve been having eye strain or headaches after reading or doing close-up work. They need to hold reading material farther away to see the letters clearly. And their vision is blurry at normal reading distance. These are the classic, early signs of presbyopia, and they’re familiar to virtually all optometrists and opticians. What typically follows is an assessment of the patient’s needs, starting with their visual requirements. While the protocol is similar in most cases, each of the opticians and ODs we spoke with have developed their own ways of evaluating those needs. “Questioning your patient is the first and foremost thing we do,” said Sandra Schainkin-Scott, LDO, optician and owner of Seacrest Optical in Delray Beach, Fla. “We ask if they use a computer, and if so, is it a laptop or a desktop computer? Then we’ll recommend a particular computer lens. If they’re an older person who hasn’t worn glasses and they’re nearsighted, and they don’t need glasses for anything but distance, but they also want to read, then I ask, ‘Do you want to take your glasses off every time you want to read? “If you notice, nearsighted people, a lot of times they’ll look over their glasses to read something, they’ll hold it above their head. It’s the most ridiculous thing I’ve ever seen. So I’ll say ‘Why would you want to strain the muscles of your eyes instead of using a lens that can give everything. It’s important to explain the situation in detail, and make sure that people understand that even though there’s oodles of lenses on the market, not every lens is good for everyone.” Schainkin-Scott often fits her presbyopic patients with Younger Optics’ Camber progressive lenses, which have “wider fields with very little if no swim or distortion.” As she explained, “the transition from distance to near is a very easy, which is great for all wearers, especially new presbyopes. Most working people need more than one focal length corrected, so rather than struggling with separate pairs, Camber has made progressive lenses easy to wear.” A patient’s career often provides clues about their vision needs, observed Alex Feldman, co-owner of Alexander Daas Opticians, a chain of three boutique stores in San Francisco, Los Angeles and Del Mar, Calif. “Certain types of jobs, such as being an attorney, programmer, financial advisor or writer, are flags for a lot intermediate and near vision use. I work with a lot of Hollywood film editors and have done customized lenses measured in their office for their multiple screens at different heights and distances to optimize their use. “Of course, we also find out what the intention is for the glasses we are making,” Feldman continued. “This may not be the pair used for work, and they just need something more casual focused on distance but a nice intermediate and reading bump for reading a menu at a restaurant, etc. We also factor in anatomical factors such as the wearer’s height.” Feldman said he often recommends Shamir Autograph Intelligence progressives, which give them “the biggest wow factor” of any progressive he and his staff have dispensed. For Timothy Earley, OD, taking a thorough patient history and a knowledge of their hobbies and visual tasks is critical for making a strong and meaningful visual correction recommendation. “As a rule, I will give every patient a summary of their refractive status, describe how it likely will affect their daily living, and give them any and all options for their visual correction,” said Dr. Earley, who practices at Northeast Ohio Eye Surgeons, which operates multiple locations throughout the state. “It must be noted that presbyopia is not only a visual issue. The changes that presbyopic patients are going through come with some emotions and feelings that we also need to address. Presbyopia is associated with feelings of anxiety, frustration, and denial. Patients often report that needing to wear a reading correction makes them ‘feel old.’ “Having vision correction options that give patients back their visual freedom is important. Soft multifocal contact lenses do a great job of checking all the boxes. They provide clear, comfortable, functional vision. Single-day use lenses also offer a very convenient option given the fact that no cleaning, solutions, or storing is required. There is never a single option that addresses the needs of all patients, but I will always recommend Alcon Dailies Total1 multifocal contact lenses to any patient in my exam chair who is a good candidate.” Starting the Conversation With Patients As patients in their late 30s or early 40s start to experience the effects of presbyopia, many turn first to the least expensive and often most readily available option—premade, over-the-counter reading glasses. Although this option satisfies some patients, at least in the short term, many eventually seek the advice of an eyecare professional as their near vision gets worse. “Often the first thing people choose is an over-the-counter reading glass, but they don’t feel very good about it,” said Carla Mack, OD, Alcon’s global head, professional affairs. “They’ll often say it makes them look 10 years older than they really are. The more we can help eyecare professionals talk to the patients earlier, even prior to them having symptoms of presbyopia, then they’ll know what’s coming because that’s often the first time patients start to feel old. “The first symptom may be a feeling that they don’t like it. It brings up all types of emotions. If we can be talking to them about that, and then when it happens, they know and they’re aware, and then they know what the options are.” Although all the practitioners we spoke with said that progressive lenses and multifocal contacts are their preferred vision correction solutions for presbyopia, some said that over-the-counter reading glasses can be a serviceable, though less than ideal solution. “Sometimes I’ll make that recommendation,” said Jim Winnick, OD, FAAO, a contact lens specialist who owns Family Vision Care Optometry in Oakdale, Calif., which is located in the Central Valley. “I’m in a rural farming agricultural community and I’ll get farmer men. The only reason they’re here is because I saw their wife and they made them come in. They’ve got 20/20, or 20/15 vision at distance and they don’t even own a computer. “I will always give a person an option of over-the-counter readers, if it’s appropriate. It’s not the best option, but I want you to know that you can use those as a backup and it’s a disposable thing. So especially with farmers and automotive workers, even if they get good glasses I’ll say ‘Don’t wear these at work, go to the Dollar Store and get yourself something that you can break and lose and it won’t matter, and keep your good pair for when you really need them and want them.’” Dr. Winnick said he’s been successful with recommending VSP’s Unity Via Mobile lens for presbyopes. “It’s not designed for mid-range computer use, but when you’re sitting there looking at a phone or a menu, that’s where that Mobile design really shines,” he said. “It works above and beyond a general-purpose progressive. Regarding his own vision needs, Dr. Winnick said, “I wear the Unity Via progressive as an everyday lens, then switch into an Unity OfficePro at work, and then the Unity Via Mobile lens.” When talking with patients who are starting to experience the symptoms of presbyopia, some practitioners said they avoid using the word itself. “Presbyopia is more of a jargon type term. So patients who really understand that but at the same time we just try to break it down to them in terms of understanding the meaning,” said Robert Chu, OD, managing director of EyeWorks, which operates three locations in the Fort Worth, Texas area. I don’t really use the word presbyopia unless it’s a science-oriented person, or a physician.” Just as some patients are reluctant to get professional help for their presbyopia, some ECPs avoid having a conversation with patients about their changing vision needs. “We know that in the past, some practitioners have kind of let it slide. They don’t want to talk about presbyopia with the patient,” said Jeff Harrell, Essilor’s vice president of product marketing. “So they end up telling the patient to go to CVS for a couple pairs of readers. I think that happens more out of discomfort or fear on the practitioner side about the price jump or having to explain to the patient that they’re getting a little older, and this is what happens. “You know, I always say that death, taxes and presbyopia are the certainties in life. But I would argue that over-the-counter readers are not a complete solution, depending upon the patient’s needs, especially if they’re already an emmetrope.” Harrell added, “You can definitely turn a negative into a positive, because it’s about what kind of quality of life do you want your patients to have as they get older.” When explaining vision correction solutions to an emerging presbyope who may feel anxious about their vision and their appearance, and may not be aware of the vision correction solutions available to them, word-of-mouth recommendations from friends and family can be reassuring and influential. “One of my most powerful tools to get them to engage with us is letting them know that I have solved the problem for other emerging presbyopes,” said Josh Rajasansi, OD, whose practice, Experts on Sight, has locations in Gilbert, Ariz. and Mesa, Ariz. “I suggest that they tell their friends and family that are of similar age that they don’t have to go through this. When someone mentions that ‘Wow, I got these incredible glasses that are working so well, or I got these contacts and I can play tennis and also look at myself and see more clearly,’ that tends to work.” Presbyopes Are Emerging Earlier Than Ever A major change in the diagnosis and treatment of presbyopia is that many patients are experiencing the onset of symptoms at earlier ages than ever before. This presents both a challenge and opportunity for ECPs. “We may have been taught in school that presbyopia begins at 40 or so, but I am seeing patients in clinic that are describing the symptoms of presbyopia at much younger ages,” reported Timothy Earley, OD of Northeast Ohio Eye Surgeons. “This is primarily due to the ways in which we use our eyes throughout the day. Screen time is often a major factor in a patient’s visual comfort. I am seeing patients in their early to mid-30s struggling with near and mid-tasks later in the day given the demand placed on their accommodation system. “I see college-aged adults and adults in their 20s describing the symptoms of digital eye strain due to their increased usage of cell phones and computers. While age is a consideration in patients who are of presbyopic age, I am discussing the symptoms and possible optical solutions with much younger patients than I did earlier in my career.” As Essilor’s Harrell remarked, “We may be living in the golden age of presbyopia solutions, but it’s also the golden age of presbyopia inducers, like the digital devices that we’re on all the time.” Yet he believes that the confluence of people reaching the age when presbyopia inevitably starts, along with their increased viewing of digital device screens, presents an opportunity for ECPs. “These things are coming together at the same time, and more people are realizing that they are struggling to view their device screens. But ECPs can turn the negative story of death, taxes and presbyopia into a positive story by saying, ‘Hey, do you want to keep living your life the way you want, playing with your devices and doing all the things that you need to do?’ If so, I have a solution for you.” Aleksandra Wianecka, OD, believes that patients should be treated before their full-blown symptoms of presbyopia emerge. For those patients, she recommends specially designed digital single vision lenses such as EyeZen from Essilor, which serve as a kind of gateway to progressives. “I get patients in early and put them in pre-presbyopic lenses even before their near vision gets fuzzy. Many patients in their mid to late 30s are using the computer and other electronics day and night, so they have eye strain. Their eye muscles are tired or exhausted, so I put them in an (Essilor) Eyezen lens,” said Dr. Wianecka, OD, who practices at Vision for Life in Babylon, N.Y. “For emerging presbyopes, we use Varilux Comfort Drx or Comfort Max because it’s the easiest transition from a single vision or Eyezen lens to a progressive. I try to use the strongest Eyezen first then go to the Comfort lens. It has a wide field of view and easy adaptability with virtually no non-adapts. For advanced presbyopes the Comfort is great too, but we use a lot of the Varilux X design due to its great optics and wide field of view. It’s also great for computer vision. “When patients purchase those glasses, they are so grateful because it changes their life,” Dr. Wianecka said. “It changes how they feel. From there, it’s an easy process to get into presbyopia. The conversation really doesn’t even need to continue for me because they’re already in a relaxing lens.” When recommending a lens for an emerging presbyope, optician Ed Marshall often relies on the Recruit, a private label lens produced by his wholesale lab, Laramy-K. “It’s part of their Integrity freeform line, and features Camber technology, which is a design developed by IOT combined with a lens blank from Younger Optics,” said Marshall, the co-owner of McNelly Optical, which operates two locations in Annapolis, Md. “It’s a soft design that’s supposed to make it a little easier for presbyopes to get into a first-time progressive. That’s the first choice. It’s as advanced a technology as anything else we’re working with. It really can’t be underestimated. I’ve never had a patient go back to their old lens after wearing Camber.” Dr. Chu said some of his newly presbyopic patients have an outdated idea about the treatment options available to them, and are eager to learn about new lens technologies. “There’s this whole misconception amongst the patient population where they think lined bifocals are the only way to treat it. When they don’t understand is that the new lenses are great. They look like normal glasses or that they do go through that but to let them know it’s not the end of the world. They’re not going to look like an old person.” For treating presbyopes and pre-presbyopes, Dr. Chu prefers Zeiss lenses, particularly the Smartlife line, which includes both digital single vision and progressive designs. “Our doctors provide custom solutions and recommendations based off the patient’s individual assessment and exact fitting measurements,” he explained. “We often recommend the Zeiss Smartlife digital portfolio. SmartLife lenses are optimized for patients in the 25-to-45 age range who frequently use their mobile phones and tablets. Zeiss Smartlife lenses include ‘age intelligence.’ Zeiss has researched the capabilities of adults of all ages to adapt each lens design according to changes in pupil size and accommodation depending on the patient’s age.” Dr. Chu and his colleagues use the Zeiss iProfiler, an instrument that measures aberration, to analyze and fine-tune a patient’s refraction. In the dispensary, they use the Zeiss iTerminal to ensure the patient’s glasses fit properly. They currently have Zeiss’s newest dispensing system, the Vizio 2000, on order. Although designers of progressive lens and contact lenses continue to refine and improve upon their existing designs, novel concepts emerge from time to time. A recent example is the OmniLux from QLDS, a Largo, Fla.-based lens design house headed by ophthalmic optics expert Michael Walach. The company describes OmniLux as a “natural accommodation multifocal lens,” as opposed to a bifocal, trifocal or PAL. Unlike those lenses, no fitting height measurement is required for OmniLux, and no adaptation period is needed, according to QLDS. “It’s the perfect lens if you’re selling multifocals online, because most online virtual try-on apps are not very good at measuring fitting height,” said John Bonizio, CEO of Metro Optics, a four-unit group in Bronx, N.Y. that also sells OmniLux. One Size Won’t Fit All “Sometimes there’s more than one solution. It’s not glasses or contacts. It can be both,” said Dr. Rajasansi, who prescribes Hoya progressives as well as CooperVision multifocals to presbyopic patients. “It’s not necessarily surgical intervention with a premium intraocular lens, multifocal lens. It can be that with a combined solution with contacts and glasses over that as well. So I would find that blending approach, depending on the task that’s involved. “I have some patients that are daily multifocal contact lens wearers, however, for them staring into a computer screen all day long, they prefer wearing glasses in those scenarios. But in the evenings, if they go to the gym or social events, they would put on contact lenses. So it even depends on the time of day or activity that would dictate which solution they choose.” “My preferred, broad purpose progressive is the Hoya iD MyStyle 2,” said Dr. Rajasansi. “The design is based on an algorithm that takes into account the wearer’s lifestyle. I’ll often ask my patients, ‘What is it that you look at the most?’ And it’s different for a pilot than, let’s say, an electrical engineer. This lens works for a wide range of patients.” When prescribing contact lenses, Dr. Rajasansi said he’s had “incredible success” with CooperVision’s MyDay multifocals. He also praised CooperVision’s Biofinity Toric Multifocal. “What I find absolutely astonishing about those lenses is the parameter range. There’s almost no one you cannot evaluate for that lens. In addition, they have a spherical version, and it’s the most customizable lens in terms of the amount of near correction. You can employ a dual design with both the distance center and near center. From an engineering standpoint, it blows my mind that they’re able to pull it off.” Dr. Earley of Northeast Ohio Eye Surgeons said he stopped prescribing “one size fits all” options for presbyopes many years ago. “Recommending PALs to all presbyopes is not a great policy. Doing so will make many patients uncomfortable when performing certain tasks (such as computer/screen use) that may occupy a large percentage of their day. Customizing the optical correction recommendation I make, based on a patient’s unique lifestyle, is very important. It is also much appreciated by my patients. Allowing our patients to have a voice in their vision correction choice is empowering for the patient and leads to fewer remakes, and a happier patient.” If spectacles, contact lenses, eyedrop therapy, and refractive surgery are all options for a presbyopic patient, Dr. Earley will describe the benefits and possible shortcomings of each. “Traditional progressive addition lenses are a great option for some, but may be cumbersome for a person looking at a computer screen several hours per day. Trying to find the PAL mid-range corridor, adjusting head/neck position, and head turning will likely cause strain and fatigue. It is ergonomically challenging as well.” Dr. Earley believes that refractive surgery, while a great choice for improving distance vision, may not yield near or midrange vision that is acceptable for most presbyopic adults. “Eye drop therapy for a presbyope may be an option as well. Because the currently available drops require the patient to be emmetropic or close to it, he advises many patients that eye drops will likely not replace contact lenses or eyeglasses as their primary vision correction solution. The drops’ duration of action, while great for part-time use, will not yield near vision for a full day,” he said. For contact lens wearers, Dr. Earley often recommends a soft multifocal made of a material designed to hold up to the demands of screen use would be a great option. It will provide the patient with highly functional vision from distance to near. “Utilizing a single-day use material such as a Dailies Total1 Multifocal with Water Gradient allows for all-day comfort and vision, in an extremely convenient modality,” he noted. For Warren Modlin, vice president of technical marketing at Hoya Vision Care, determining the best vision correction solution for a presbyope is a matter of optimizing their visual performance rather than choosing a particular product or modality. Modlin said many ECPs are quick to recommend a technology solution instead of first understanding the patient’s vision problem and then finding the best solution. “Before determining if the patient is going to be a contact lens wearer or a glasses wearer, it might be better to ask what are the patient’s needs? Having a patient-centric approach to finding a solution is the way that I would look at what is needed. The patient is not a contact lens patient. The patient requires contact lenses to solve the problem. “This isn’t about vision, it’s about performance,” Modlin asserted. “Can we make your work life less frustrating? Can we give you longer times to concentrate? Can we make you feel more comfortable during your work? That doesn’t mean I’m going to make you see better, it means I’m going to make you perform better. Presbyopia is not about visual clarity. It’s about visual performance. If we can focus on the human side of performance, I think we get to the next level. “We should be looking for the best solution for the patient’s needs, even if that requires two or three solutions,” Modlin added.