ODs: Rulers of the Land of Presbyopia

October 3, 2017

Article

We often perform cataract surgery with near vision correction, using monovision or presbyopia-correcting intraocular lenses (IOLs). These folks are typically happy despite having mild residual refractive error. Something magically happens between that patient getting glasses that she “just cannot wear, at all” and getting cataract surgery. Let’s follow that patient’s path.

The views expressed here belong to the author. They do not necessarily represent the views of Optometry Times or UBM Medica.

You may have noticed that surgical correction of presbyopia is a hot topic.

This is not surprising because there are a lot a demanding presbyopes. U.S. Census Bureau figures suggest that 112 million Americans had presbyopia in 2006, with increasing prevalence over the last decade.¹

I practice in a contact lens world 50 percent of the time and in a surgery world 50 percent of the time. We often perform cataract surgery with near vision correction, using monovision or presbyopia-correcting intraocular lenses (IOLs). These folks are typically happy despite having mild residual refractive error.

Yes, I just said these patients are happy with residual refractive error. Something magically happens between that patient getting glasses that she “just cannot wear, at all” and getting cataract surgery.

Let’s follow that patient’s path.

A patient’s journey

This is the same patient who decided to try progressive lenses at age 47 after you told her at age 43 she would benefit from progressive lenses. She had second, third, and fourth thoughts when she was presented with the price (that is so much lower than presbyopia-correcting IOLs).

She had to talk to her spouse and her friends and return twice to the office to see the frame and make sure you can’t see the bifocal line when they are made. And the logo on the frame? That will be gone? Yes, that will be gone, and no, you can’t see the lines.

Then we have to go over her vision and medical benefits before she committed to the progressive spectacles. She spent 20 minutes on whether or not to get an antireflection coating (always) or a separate pair of computer glasses (required if you are an engineer) or sunglasses (required if you are not a hermit).

She calls daily for 10 days to see if her glasses are ready. When you send her a text and an email, then make two phone calls to tell her the glasses are ready, she shows up three days later when it finally stops raining to pick them up.

She makes the face that says, “I do not like these glasses.”

We adjust them. We mark them up and adjust them again. We clean them. We show the patient how to read with them, how to drop her eyes, how to point with her nose. She says she does not want to point with her nose, and we explain she must to do this to avoid the distortion on the edges. Then she spends 20 minutes complaining about the distortion on the edges. We spend 10 minutes explaining why the small amount of distortion is negligible when she looks through the lenses properly.

She leaves. The optician lays his head on the table and thanks the Lord. Any patients in the dispensary with a sense of humor clap, and close friends of the staff will give high fives.

The patient returns with her progressives 10 days later and says she can’t wear them at the computer. After drawing several pictures of a channel, we attempt to explain intermediate vision. We discuss computer glasses, including single vision, office lenses, and modified bifocals. We educate the patient on lens coating and the evils of blue light. She leaves without computer glasses, but with a cranky disposition.

Moving to surgery

Years later, she proceeds with cataract surgery. We are well informed of the options at her disposal because we spend 20 minutes explaining standard, “government issue” surgery, toric, and presbyopic options.

She return to the office the next day after surgery. And she is happy with her 20/25 vision.

Me: “How are you doing?”

Patient: “Pretty good”

Excellent.

At one month, she returns, reporting she can drive without glasses. Her visual acuities are 20/25 OU at distance, and she is wearing over-the-counter (OTC) readers. She has two pairs, one for reading and one for the computer. She finally got computer glasses.

I offer refraction because how can anyone be happy with OTC readers? Her eyes are not balanced. The prism induced by the line of sight not traveling through the lens center causes asthenopia. Her lenses do not have anti-reflection coating. She has severe lens aberrations, so everything looks distorted.

You can’t walk in these lenses, and distance is horribly blurry. The glasses can’t be found because they are left in the car/bedroom/living room/desk/by the pool/in a coat pocket. The right lens keeps falling out. The frames never stay adjusted, and after two adjustments, they break. But the patient reports, “They are fine.”

Where was this attitude when the same patient got progressives?

Maybe the new IOL increases the brightness, and images are clearer. The patient compares it directly to the “old eye” after the first eye is done, and the impression is remarkable. I have had multiple patients say the surgery “turned up the volume” on their vision. Loudness trumps clarity, apparently.

And if the patient complains? The surgeon says, “Your surgery is perfect. Go see your optometrist.” Lucky me.

Or it may be that patients paid so much money, they do not want to admit they did not get their money’s worth.

Maybe the twilight anesthesia has a long-acting, diazepam effect.

Maybe the evil-spirited crystalline lens being removed takes the evil-spirited, “I hate my glasses” personality with it.

Maybe the female patients are so busy cleaning their homes, they don’t have time to complain.

Maybe the males are too busy worrying about their spouses seeing them now that their vision is corrected.

Optical perfection

Whatever the reason, I will continue to strive for the perfect optical correction.

When patients come to the office with minor refractive errors, I offer to change their spectacles and contact lenses, one tiny step at a time if necessary. I hold loose lenses over their eyes and ask, “Which is better, one or two?”, over and over and over and over.

Ever see that happen in a surgeon’s office?

If you did, an OD did it.

Reference

1. American Optometric Association. Care of the Patient with Presbyopia. Available at: http://www.aoa/org/documents/optometrists/CPG-17.pdf. Accessed 6/6/17.