FOR YEARS NOW, I’VE BEEN embarrassed by my husband almost every time we go to a restaurant. He’s the guy holding the menu away from the table at arm’s length with one hand and the candle from the table in the other. Most of our friends joke and ask him, “Do you know a good eye doctor?”

Why does an intelligent, grown man resist a simple solution for his no longer emerging, but very annoying, presbyopia? He does it because presbyopia makes us feel old, and the mere thought of wearing progressive glasses commits us to accepting that we are one of the “old” people affected by age-related loss of near vision.

I personally have at least 5 solutions for my presbyopia: multifocal contacts for the OR, monovision contacts for every day, progressive glasses and sunglasses for home and backup, and removing my glasses completely. On occasion, I’ve been caught in a situation, like driving at high speed around a racetrack, with my monovision contacts in, wishing I had remembered to use my multifocal lenses. As a myope, one of my greatest fears is dealing with the day that I can no longer take my glasses off to see things up close. I spend a good deal of time wondering which solution I will choose when it’s my turn to have cataract surgery. Like most people older than 40, to say that I am looking for an ideal presbyopic solution is an understatement.

In fact, 1.8 billion people globally are affected by presbyopia, with 826 million of those having near vision loss because of no, or inadequate, vision correction.¹ In a study of nearly 13,000 US adults older than 50, 1 in 4 reported functional near-vision impairment, which was defined as at least “moderate-difficulty” with either reading newsprint or near-work.² At least 32.6 million Americans wear over-the-counter readers³; many choose bifocal or progressive spectacles or contact lenses, and some choose surgical options. The mere fact that there are so many choices demonstrates that we have yet to find the best solution. As eyecare providers, we are all looking for the Holy Grail of presbyopia treatment. Now is an exciting time in eye care, with improvements across the board in all of our existing therapies; however, for the first time in a long time, there are new medical and surgical options on the horizon.

We recently polled a group of ODs and MDs to gain insight into their personal choices for their own presbyopic solution, as well as their willingness to adopt new technology for treatment of presbyopia. Like many surveys, it left us with more questions than answers. Fortunately, the following experts have weighed in to give us their interpretation of the results:

• Alanna Nattis, DO, SightMD, Babylon, NY
• Denise Visco, MD, Eyes of York, York, PA
• Kenneth Beckman, MD, Comprehensive Eyecare of Central Ohio, Columbus, OH
• Cecelia Koetting, OD, Virginia Eye Consultants, Virginia Beach, VA
• April Jasper, OD, Advanced Eyecare Specialists, West Palm Beach, FL
• David Kading, OD, Specialty Eye, Seattle, WA

In general, the majority of women respondents were a decade younger than their male counterparts, which may reflect the limited number of women in both fields until more recently. The younger age of the respondents likely impacted the results of this survey.

Interestingly, the majority of eyecare professionals (ECPs) offer all of the existing presbyopia treatments; however, only a small percentage would choose an option other than glasses or contacts for themselves. Let’s ask our expert panel its thoughts on this.

QUESTION #1

Most of the MDs and ODs polled said the presbyopic solution they would choose is glasses or contact lenses.

a. Why do you think most ECPs choose glasses or contact lenses, yet the majority of MDs and about one-third of ODs offer surgical solutions?

DR. NATTIS: Most ECPs stratify treatment strategies from least to most invasive, and therefore this may dictate responses favoring prescribing glasses or contact lenses prior to offering surgical options. In addition, despite the fact that many of the presbyopia-treating surgical technologies we have are incredibly successful, they are still considered “invasive,” and perhaps fewer patients are willing to choose surgery as a first option.

DR. VISCO: None of the current therapies or surgeries are perfect, and new advancements continue. Nonsurgical options leave the door open to take advantage of a future surgical opportunity, which might be a better fit.

DR. BECKMAN: I am not surprised by this. First, we need to consider the age of those completing the survey. Many were either not presbyopic or very early presbyopes. If a person has not experienced true presbyopia and how it impacts their daily life, they may not feel the urge to proceed with an intervention. In addition, since we do not have many great options for external eye surgery to help presbyopia, most would not wish to enter the eye. We have great intraocular lenses (IOLs), but if a patient has not reached cataract surgery levels, most docs would not consider lens-based surgery. Very few docs do clear lens surgery. I suspect that, if the question were to ask what type of IOL the person would want if they needed cataract surgery already, many of those who said they would not want IOL-based surgery would say they want to have a presbyopic IOL. I can speak about this personally. I was content with multifocal IOLs and would never have considered intraocular surgery for myself. Once I needed cataract surgery, I could not wait to get a presbyopic IOL.

DR. KOETTING: This may have to do with their particular experience or lack thereof with the newer enhanced depth of field and trifocal lenses and the success with range of vision that patients are experiencing. Another thought is that most people are adverse to surgery and more so those who rely solely on their vision for their careers, such as ECPs. We recognize the importance and respect the technologies outcomes yet are hesitant to implement this on ourselves.

DR. JASPER: Most MDs and ODs have easy access to glasses and contacts. Unfortunately, only 13% of docs fit multifocal lenses. It is likely they wear what is best for them, and they understand the compromise they might make with their choice. However, they either don’t want to, or don’t know how to, create meaningful, easy ways to converse with their patients about these same things, so they choose the easier-to-communicate route of glasses or monovision and then move on to the next patient.

DR. KADING: It’s because they don’t need surgery yet and because they are happy with their glasses and contact lenses.

b. Are you surprised by the proportion of MDs who would choose glasses or contact lenses vs an IOL, surgical, or refractive-based solution? What do you think accounts for this?

DR. NATTIS: I am both surprised and not surprised by the responses. As physicians, we want to do what is best, but also safest, for our patients. We also seek out reliable first-choice options. Though lens/surgical/refractive options are incredibly successful and effective ways of treating our patients, we tend to start with treatments that offer the least amount of risk — and in terms of prescribing glasses, there is not much else with a smaller risk! This is in contrast to some refractive or IOL-based technologies, which may offer some risk of under- or overcorrection and visual aberrations, such as glare and halos.

DR. VISCO: No, for the reasons I gave above. Also, if they are not particularly handicapped by their presbyopia, then they are not motivated to have surgery.

DR. KOETTING: I am surprised that the numbers are so similar for surgical-based solutions vs contacts and glasses for the MDs. I would have expected a larger gap with a higher percentage of patients being treated surgically by MDs. This may be a further reflection of the treatment decided for themselves and their true comfort with surgery as a means of treatment.

DR. JASPER: No, I’m not surprised. Most doctors are not comfortable having what they perceive as difficult discussions about products that they think have limitations. Barriers here include time, return on investment for them, and no desire to have patients who complain when the solution is not exactly what they envisioned. These issues can all be overcome with better education from peers who are successful.

Pre-cataract patients are the ones who account for some of this. I talk about presbyopia-correcting IOLs with everyone who has cataracts, and I feel most ophthalmologists do too. The ones that might not hear it are the presbyopes who are not ready for cataract surgery.

DR. KADING: They understand the drawbacks.

QUESTION #2

Given the current medical options on the horizon, what do you think will be the challenges for ECPs to incorporate this into their practice? How will this impact other options already offered in your practice?

DR. NATTIS: Currently, we have glasses and contact lenses as the most commonly used modalities to help correct presbyopia — whether that is in the form of readers, bifocals, or progressive glasses — or even monovision or multifocal contact lenses. Many patients and ECPs are happy with these noninvasive options, but as can be seen from the survey responses, many providers are looking forward to a pharmacologic option for presbyopia — to reduce the need for spectacle and contact-lens burden. If pharmacologic options prove successful, safe, and efficacious, this may decrease the number of patients requiring full-time spectacle/contact lens wear and change how these modalities are prescribed. Further data from studies demonstrating the efficacy and duration of effect of pharmacologic presbyopia medications are needed to make a definitive conclusion on how disruptive these innovations may be.

DR. VISCO: Chair time, staffing, and compensation. The impact short term will likely be negative for surgical procedures but could be positive long term. Having a medical option for presbyopia makes the conversation with the patient easier because the treatment is a readily available, low-risk solution for the patient. Most patients, if given an option, would choose the low-risk noninvasive solution for presbyopia over a surgical option. However, if they get tired of taking drops or develop an allergy to the drop, they might be more likely to take the next step toward a surgical solution than if the surgical solution were the only and first option presented (other than glasses and contact lenses, which is assumed). The result long term would increase the utilization of surgical options in the future.

DR. BECKMAN: I think that, because an effective treatment for presbyopia is the Holy Grail of eye care, there will be little difficulty adopting these treatments if they are effective, safe, and affordable. Patient demand will drive the market. This is why I feel drops will take off, if they are shown to truly work.

DR. KOETTING: I think that the challenge will be our willingness to adapt and embrace the new options. They could be viewed as direct competitors to glasses or contact lenses, which are revenue producing for most practices. But in truth, the options should be viewed as an enhancement to existing options and something that may bring in new patients who otherwise would not have come to the office. Patients like options. They will likely not choose just a drop, just glasses, or just contact lenses. It will be a combination to allow for freedom of what is best for that day or given situation.

DR. JASPER: Challenges will be first in understanding how the drop works and then in communicating this concisely with patients. In addition is the challenge of the doctors’ preconceived expectations of side effects because of the drug category and past experience. Any time a drug has been used for one thing and then repurposed for another, it takes greater education to get past the prior barriers in the literature and in colleagues’ perception and experience, which then unfortunately become reality for some doctors. Atropine for myopia is a good example of a similar predicament.

I believe this will bring in new patients and will add value to our practice by providing options for patients unhappy with the current options available. It’s super exciting for sure if one truly understands the needs, desires, and wants from our patients. Unfortunately, we docs many times don’t show concern for the patient’s needs and wants if we think it frivolous or unnecessary, so a good piece of the work of Presbyopia Physician will be in helping doctors, in a gentle way, to understand the perception of presbyopia from the “eyes” of the patient.

DR. KADING: Access will be a challenge and learning more about the treatments, especially if they do not have good reimbursements to make it worth their time.

Interestingly, both groups would consider adding these options to their practices but would not choose it for themselves. I found this, along with the next table of results, the most fascinating piece of information gathered from the survey. Let’s think about that. Most ECPs would offer a surgical solution to their patients but would choose glasses for themselves. Before I leap to any specific conclusion, I think this question deserves a deeper dive and a larger database. Stay tuned for a future article on this topic.

QUESTION #3

Most ECPs would consider adding a new nontraditional or surgical innovation in the treatment of presbyopia to their practice yet would not choose it for themselves. How does this impact acceptance and growth of new innovations in presbyopia treatment?

DR. NATTIS: As physicians, we are constantly putting our patients before ourselves. Though there may be new, exciting, and effective technologies that may benefit us personally, history shows that we usually first offer them to our patients and then try it ourselves. In addition, certain ECPs may feel more secure about new technologies after discussing the risks and benefits with their patients, as well as reviewing clinical trial data and discussing experiences from other colleagues.

DR. VISCO: I don’t find this unusual. Surgeons usually like to see how a procedure is panning out before committing personally. Raindrop comes to mind. If and when a procedure proves out, then providers begin to personally adopt. Thus, the adoption of new procedures and technologies is typically slow.

DR. BECKMAN: This is similar to my response above. Most doctors would offer new treatments if they are safe, effective, and affordable. These could be medical or surgical. As long as there is no great procedure, the doctors will be a little gun shy. Since many of the doctors in the survey are young and likely have not felt the full effect of presbyopia, it does not surprise me that they are less likely to want a new treatment for themselves. I suspect that, if we only surveyed doctors who are over 60, the responses would be different.

DR. KOETTING: It will be hard for new innovations to be implemented and accepted if the doctors who would be performing the surgeries aren’t willing to utilize the technology themselves. Discussing something with conviction is hard if you do not truly believe in it or the benefits that it presents.

DR. JASPER: I think they will need to experience it or hear from a colleague who has to be able to prescribe it with confidence and positivity. I think they will need influencers to give them direction in how to use and prescribe, and to show them how being on the cutting edge of new technology builds value for your patients and practice. It will also be important to share stories of success, including best practices in how to have conversations with patients.

DR. KADING: Recommending it and getting it are two different things.

In closing, some of our experts had some general thoughts they would like to share.

DR. NATTIS: The data were interesting in that they showed an overall interest and implied need for new presbyopia therapies. However, they also highlighted some hesitancy in providing newer or more invasive treatments to patients as first-line therapy. While this falls in line with keeping our patients’ interests and safety at heart, it also may speak to the deficiencies we have in both ophthalmology and optometry in effectively “curing” presbyopia. Though we have come leaps and bounds in terms of presbyopia correction in recent years, there is still much research to be done to better improve our patients’ quality of vision and therefore quality of life due to presbyopia.

DR. BECKMAN: I am not surprised at all by the responses. In general, I expect some hesitancy to try any new treatment until we hear more. We wait for the 3 main components: Is it effective? Is it safe? Is it affordable? Then we look to see if others are actually doing it. Even early adopters often wait until at least a few of their colleagues have tried it. Also, the concept of presbyopia is truly difficult to appreciate until one experiences it. I believe that most of the responses from a 35-year-old doctor would likely change dramatically when they are 65.

Finally, while many doctors say they are comfortable with lens-based treatment of presbyopia but would not do so themselves, I believe this response needs an asterisk. Most of these doctors do not do refractive clear lensectomies and therefore would not do it themselves. When the time comes for them to have cataract surgery, many more would consider a presbyopic IOL. These are well accepted and well tolerated in the appropriate patient. I have a multifocal IOL, and I am thrilled with it.

DR. JASPER: I see much opportunity here in education and success stories. I think focus groups will be awesome — have small groups get together to learn more and gain confidence in best practices for communication and the implementation of products. Also for a team to develop these protocols and best practices to start sharing soon will be tremendous.

In general, our experts are in agreement with the results of the survey. Will pharmacological solutions replace or displace refractive lens exchange? Will they significantly impact optical and contact lens sales? Or will they just add to the tools in our toolbox and allow us to further customize our treatment for presbyopic patients? As Dr. Beckman suggested, a survey of ECPs older than 65 might change the responses; however, most of the male respondents to this survey were older than 60 (59% of male ODs and 58% of male MDs). More focused questions directed at when an individual considers a surgical solution and why would help to clarify this issue. The information gathered here could be the beginning of a search to understand what motivates individuals, especially ECPs, to make choices for themselves and their patients. For now, we are still in search of the presbyopia Holy Grail. ■

References

1. Fricke TR, Tahhan N, Resnikoff S, et al. Global prevalence of presbyopia and vision impairment from uncorrected presbyopia. Ophthalmology. 2018;125(10):1492-1499.
2. Zebardast N, Friedman DS, Vitale S. The prevalence and demographic associations of presenting near-vision impairment among adults living in the United States. Am J Ophthalmol. 2017;174:134-144.
3. Organizational overview. The Vision Council website. Accessed June 22, 2021. https://www.thevisioncouncil.org/sites/default/files/TVC_OrgOverview_sheet_0419.pdf

Dr. Feulner is Founder and CEO of Advanced Eye Care & Aesthetics, Bel Air, MD. She specializes in cataract surgery, medical and surgical glaucoma care, and dry eye disease.

Disclosures
Dr. Feulner is a speaker for Johnson & Johnson, Bausch + Lomb, and Allergan, and she serves on the advisory boards of Orasis and Allergan.