THE ART OF MEDICINE ALLOWS for differences in how physicians manage their patients, and advancing technologies allow adaptation for greater success. Taking a look at how some of the experts do it can be fascinating.

Capturing Patients

Presbyopia patients often don’t understand the cause of their loss of near vision.

Gregory Parkhurst, MD, has a practice that is focused on vision correction, primarily refractive surgery. Patients coming to see him want to be able to see without glasses or contact lenses. Dr. Parkhurst says, “They usually associate the new problem with something going wrong with their eyes and think they need to get checked. But the general public doesn’t know about presbyopia.”

He explained that these patients just know something is changing with their eyes, and they’re concerned about it, and come in specifically asking about what they’re noticing.

“So they find us either through referral—since we work with a lot of doctors in the community—or by an online search,” he says. “They’re coming because they’re symptomatic, and they want a solution.”

The Waring Vision Institute is a surgical vision correction practice that employs a concept called “surgical vision for a lifetime.” George Waring IV, MD, explains this means they offer vision correction procedures for each stage of ocular maturity.

He says as patients begin to lose reading vision in their mid-to-late 40s and early 50s, they can be categorized into stages of dysfunctional lens syndrome, with stage 1 being mild presbyopia, stage 2 being moderate presbyopia with early opacity and higher order aberrations, and stage 3 being advanced presbyopia with opacities significant enough to adversely affect a patient’s daily activities, which is a cataract and in the United States, qualifies for submitting to insurance or Medicare. (Waring GO, Rocha KM. Characterization of the Dysfunctional Lens Syndrome and a Review of the Literature. Curr Ophthalmol Rep 6, 249–255, 2018).

Dr. Waring says the Waring Vision Institute has developed a standard work-up track for each stage of the dysfunctional lens, or each stage of ocular maturity for each patient, and said, “Because of this, we are also known as a surgical practice with one of our core competencies being the surgical correction of presbyopia.”

Cathleen McCabe, MD, focuses on cataract surgery and refractive surgery, so the majority of early presbyopia patients coming to her practice are seen by the practice’s optometrists, who are usually the primary care doctors.

“The place I encounter them for the first time,” she said, “is if they come in for either a LASIK evaluation, or a clear lens replacement evaluation. There will be a significant number of patients who have never needed glasses before, and once they realize they need help to see up close, the first thing they think of is a surgical intervention. Most commonly that would be LASIK, but they don’t realize that LASIK doesn’t solve that for them in a way that they’re anticipating.”

She said for those at an age where they’re presbyopic, the discussion will often include at least the option of a more permanent solution like a clear lens replacement. The patient will ask whether they should have it done now, versus waiting, and what the pros and cons of waiting are. But she said before making the decision, the patient needs to understand what’s happening.

Diagnosis

Dr. Waring helps patients understand what is happening with their eyes by using digital visual imaging of the patients eyes. “In our advanced vision analysis center,” he said, “everybody gets high resolution tomography (Pentacam) which includes a Scheimpflug image of their lens, with lens densitometry, and then a high resolution macular OCT as well. We take patients on a tour of their eyes, and not only does it help us make better decisions in terms of helping them understand what they’re going to be a good candidate for, if anything, but it also helps us educate them.”

Dr. Parkhurst considers several factors in determining what is going on. He looks at a patient’s vision prescription, and the overall health of the front of the eye. His practice does corneal topography and tomography (Pentacam), wavefront aberrometry (iTrace), and scans of the crystalline lens, as well as looking at the anterior chamber depth, and the health of the endothelium. They use an HD analyzer to look at the internal aberrations or optical light scatter, and measure not only distance vision but near vision, and then determine the total refractive error problem. “It’s usually not just presbyopia alone,” Dr. Parkhurst said. “It’s more often presbyopia along with some other refractive error, so then we talk through the difference. Depending on the patient’s age, stage, refraction, and their anatomy, we embark on a discussion about the different procedures we can do to help.”

“These types of diagnostics are important,” Dr. McCabe said, “because we want to make sure the reason they’re not seeing well at near is not that they also can’t see well at distance. They may have some other pathology going on. Sometimes they come in and we think that they’re presbyopic, but when we really check they’re not seeing well at distance either, and they have some other disease process or a need for glasses that include both distance and near.”

She said what can happen is the natural aging changes that cause presbyopia may reveal that the patient needs to start wearing distance glasses as well. This is especially true for latent hyperopes, who, because their natural lens was still able to change shape effectively, could overcome their need for glasses. But now with a stiffer lens that can no longer happen.

Dr. Parkhurst also commented on latent hyperopes, saying, “When people are young they can accommodate through farsightedness, and see distance clearly and see intermediate and even see near clearly. But then over time as their presbyopia sets in and they lose the ability to accommodate, they first tend to notice their near vision going out. Then over time, as they age and presbyopia worsens, even their distance vision can deteriorate further on in the progression.”

Determining the Best Solution

When he talks with his patients, Dr. Parkhurst lets them know their presbyopia is totally normal. “I say things like ‘Welcome to the club, this happens to all of us, this is no surprise, no cause for alarm, don’t worry, this is just part of the normal aging process,’” he said. “I assure them they’re not going blind, and say ‘By the way we can absolutely fix this. There are a few different ways and we can work together to figure out which of those ways is best for you.’”

After looking at the patient’s prescription, anatomy, age and where they are in progression, Dr. Parkhurst puts the patients into categories, separated by refractive error, and by age.

“Based on all that,” he said, “we determine which of the treatment options fits their eyes best from an anatomical perspective. And we usually give a specific recommendation, such as ‘In your case we recommend blended vision LASIK, with some drops as a boost, because you’re myopic, and you’re young.’ We don’t generally recommend doing a lens exchange for a young myope, who is potentially at risk of peripheral retinal tears. But if we have a 60-year-old hyperope with similar complaints we’re going to say ‘With your anatomy you’re an awesome candidate for a trifocal IOL.’ But the nice thing is that we have so many different options to custom fit and prescribe to our patients, the right surgery, and possibly soon in combination with a pharmaceutical.”

Dr. McCabe sees the upcoming pharmacologic treatments as a way to let patients delay a lens-based procedure. Especially when patients come in with healthy eyes, not needing help with distance vision, her conversations often focus around how important it is for them to be glasses free now.

“With a clear lens replacement,” she said, “or in a permanent change to the ocular surface like hyperopic LASIK, you’re committing them for life rather than giving them something that’s easily reversible.” She said an advantage of waiting is that new technology is always coming out, so unless the patient has a cataract, the benefit may outweigh the negatives of waiting for newer technology, and she sees the drops as a way to bridge the gap until they need to commit to a permanent solution.

Dr. Waring says the drops will be “a gateway drug for those with first experiencing presbyopia, or stage 1 dysfunctional lens,” providing an opportunity to help patients earlier.

Treatment

The Waring Institute has developed an algorithm for present and future presbyopia management (Figure 1).

“Very soon, we will be utilizing pharmacological options in the earliest stages of presbyopia when these are available,” Dr. Waring said. “We look at not only the stage of the dysfunctional lens, which typically correlates with age, but also the other important factor—refractive error. And those are the three key elements of our decision making for the correction of presbyopia.”

He said in the context of refractive error, the more myopic somebody is, the later they may recommend a lens-based intervention. But with more hyperopic or farsighted patients, they intervene with a lens-based procedure earlier. Lens clarity, vitreous status and patient input are also taken into account.

Dr. Waring said, “Overall, we are moving more and more toward lens-based procedures, thereby treating the source of the dysfunction. Historically, however, for stage 1, if the patient has other congenital ametropia, we may do a corneal-based procedure like LASIK, particularly if they are nearsighted. However if they’re stage 1 and farsighted, we will typically do a lens-based procedure. For stage 2 we usually do a lens-based procedure, because now we’re also trying to fix early opacity at the lens level. The rare exceptions to this are people with high myopia, because of the risk of retinal detachment. For these patients we may recommend a corneal-based procedure or an implantable contact lens as a bridge with blended vision until the vitreous separates. For stage 3, which is cataract, we do lens-based procedures.”

Dr. Waring said this has evolved over the years and they now do lens-based procedures earlier than in the past. “The reasons are multifold,” he said. “The patients are usually coming for LASIK, and now we can offer a lens-based procedure with femtosecond laser. It has similar benefits to LASIK—it’s a laser-based procedure, it’s quick and takes about the same amount of time as LASIK, and usually they’re seeing well the next day like LASIK. But it has a number of additional benefits above and beyond LASIK for presbyopia or lens dysfunction. It goes to the source of the problem, it maintains depth perception and stereo acuity by allowing use of presbyopia-correcting implants, which improves patient satisfaction, and it prevents cataracts.”

Dr. Parkhurst said, “What we’re dealing with here is dysfunctional lens syndrome, manifesting itself as trouble seeing, so we’re trying to place the patient onto the continuum of the different stages. Is it strictly presbyopia with an otherwise perfectly clear lens, or are they starting to have some loss of clarity or aberrations developing within the crystalline lens, or are they showing some early signs of cataract? We want to separate out what is the health, clarity, and function of the crystalline lens, and what is their age, because that’s often going to direct us between offering a lens based treatment or a corneal treatment.”

For someone who is relatively young, their lens is perfectly clear and all they’re having trouble with is accommodation—especially if they’re emmetropic or myopic—Dr. Parkhurst usually will consider laser vision correction, which they most commonly do with the technique of blended vision. He explained that with blended vision, there is overlap in terms of the two eyes’ accommodative zones. So the brain adapts and fuses that with good stereopsis into one seamless range of vision. “Especially with younger patients,” he said, “we can usually accomplish a blend where they’re still using both eyes together, and we have a lot of patients these days that we’re using this strategy on. And we’re letting them know as their presbyopia advances over the next few years we’re going to augment their laser vision correction with eye drops that are in the pipeline.”

Dr. Parkhurst says another group of patients presents with presbyopia as the first vision problem they’ve ever had, and ask about getting LASIK or a refractive lens exchange. He’s looking forward to presbyopia-correcting drops as a way to give those patients some time, so they can be kept happy until they’re older, at which time a refractive lens exchange may be most appropriate. “And then there are the ones that show up when they’re 75,” he said, “and say their presbyopia is driving them crazy. We look in and say ‘Well yes, and you have a cataract, so let’s fix that.’”

Educating Patients

A large part of educating patients comes during the in-person visits. Dr. Waring said, “Our whole team is educated on being educators.” He said for his practice it starts with community outreach, letting people know it’s a normal part of aging for our near vision and reading vision to deteriorate, and we have options to fix this. “We invite people in for an advanced vision analysis, and run educational symposia for the public, where we teach them about the different stages of the aging lens and lens dysfunction, as well as some of the options,” he explains. “We can show them why they lost their ability to focus for reading, in layman’s terms. We don’t even use the term presbyopia. We also reassure them that there’s nothing scary or dangerous going on, but left unmanaged it will get worse. And we explain how we can help them.”

Dr. Parkhurst uses an electronic messaging platform called Ocular Innovations to reach patients before and after consultations. He describes it as an educational engagement arc, using text messaging as the primary communication medium. Patients are entered into the channel via a QR code, often at the time of referral. Scanning the QR code captures the patient’s cell phone, and when they opt in you can drip educational content over time.

“For example,” Dr. Parkhurst said, “we can send a little video that says ‘Hey I know you’re having surgery tomorrow, make sure you get a good night’s sleep, we’ll see you in the morning.’ And then same thing in the post-op engagement arc, you can continue to send educational content.” He also recorded custom videos for each of his co-managing doctors, to be distributed to the patients of those doctors.

Dr. McCabe has focused her educational efforts on in-person conversation so far, but she says presbyopia-correcting drops may change that. “Because we have something that will be easily accessible, and accepted by patients,” she said, “the need and the advantage of a greater effort and outreach has come to light. So certainly we, along with ophthalmology in general, will be looking for ways of educating the population, now that we have a good solution to present to them.” ■

Cathleen McCabe, MD, serves as Chief Medical Officer at Eye Health America. She specializes in refractive cataract surgery and LASIK at The Eye Associates in Sarasota, FL.

George O. Waring IV, MD, is founder and medical director of the Waring Vision Institute in Mt. Pleasant, SC, director of refractive surgery at Medical University of South Carolina, Storm Eye Institute, and medical director at Magill Vision Center.

Gregory Parkhurst, MD, is the founder of Parkhurst NuVision, a San Antonio LASIK and vision correction practice, specializing in all forms of modern refractive surgery.