Gaining the Loyalty of the Presbyopic Emmetrope


MILLIONS OF AMERICANS ARE PRESBYOPIC AND ARE “DEALING” with their vision in the worst way possible: with over-the-counter reading glasses. Ask any of them if they like their vision, and they will gladly tell you, “No, but I get by.”

While these patients want a solution that will get them back to 20-year-old near vision, the reality is that no solution that we have today will get them there. If only we could help these patients function in a more ideal world.

Here are 4 methods that we can use to improve our emmetropic patients’ near vision without the use of near reading glasses.

  1. Progressive addition lenses. Emmetropes everywhere have disdained full time glasses because “I see perfect in the distance.” But they also complain of their near reading glasses and having to have them everywhere they go. An alternative is to have them wear progressive addition lenses for most of the day. This option always comes with a requirement from me: “I won’t sell you these glasses unless you promise to wear them constantly for the first 2 weeks, even if you hate them.” If a patient says, “We will see,” I won’t sell them progressives. When patients wear progressives constantly for 2 weeks, it trains them to be able to see in them and adapt to the vision. Like riding a bike, if you only do it occasionally as a rookie, you will never learn, but if we get a child to ride a bike frequently in the first couple of weeks, he or she can come back to riding a bike anytime. For progressive-wearing emmetropes, the message is the same. I tell my patients that, after 2 weeks, they can see how the glasses will fit into their schedule, and they may find that they like to keep them on for hours at a time.
  2. Contact lenses. Just like with full time spectacles, emmetropic presbyopes tend to be a struggle to get to wear their contact lenses. There are three mechanisms that I try with these patients. With the phoropter in place looking at a distance target, I alternate the “R” lens on my phoropter between the patients’ eyes and ask the patient to describe what is happening. The patient will tell me one of three things: “Nothing,” “I see better with 1 of the eyes,” or “I hate both options.” The “hate both options” patient is not able to wear contact lenses. The patient who does not notice anything or the patient with a more dominant eye then is trialed in the same way for his or her near vision. If patients notice that they can see better at near with the add power, we will consider using monocular monovision or multifocal contact lenses for their nondominant eye.
  3. Presbyopic inlays. This surgical option is a great idea for the patient who shows a strong improvement in 1 eye for their near vision with the “R” lens test. Gaining depth of focus on the corneal plane can enhance a patient’s ability to see distance. While they have some limitations, these inlays work very well for many patients who are emmetropic and advancing in their presbyopia.
  4. Presbyopia drops. At the time of this publication, there is only 1 presbyopia drop on the market, but we will soon have multiple options and we should try them all. Emmetropic patients are the ideal people with whom to try these drops. They tend to never be using the right add, but instead use whatever power is around that gives them functional vision. These drops are more slated for patients’ functional vision than for 20/20 vision. Even the way they passed through the FDA — with 3 lines of statistically significant improvement without any distance vision loss — speaks to functional vision over a specific line of acuity.

All too often, we tend to think of a line of acuity vs functional vision. Emmetropic patients all desire us to work to enhance their visual outcomes for the tasks that they are struggling with, rather than for a specific line of acuity. It is imperative that we work with them to enhance that functional vision, and these 4 options are excellent ways to start to gain their loyalty. ■