SO MUCH OF WHAT WE TALK about as optometrists is understanding patients’ needs and setting appropriate expectations. We do those things by listening and educating. I know it sounds simple, but those things truly are the foundation of virtually all of our patient encounters. Prescribing solutions for presbyopia, including our newest tool, Vuity (pilocarpine HCl ophthalmic solution 1.25%; Allergan/AbbVie), is no different.
First and foremost, to assess a patient’s candidacy for the pharmaceutical, we must perform a thorough comprehensive dilated examination, which includes examining the retina. I want to know the patient’s history, and if he or she has had LASIK. It’s important to have a discussion of risks, and the patient should be educated on signs and symptoms of retinal detachment. If the patient is at greater risk for retinal complications, I let them know the drop is not a good option.
Second, we need to discuss exactly what patients can expect. This is important because patients are already frustrated about losing near vision and needing to wear glasses or contacts to see up close. Ensuring that they understand that this pharmaceutical option will not eliminate the need for those things is key. In other words, the drop is not a cure. It is another tool in the toolbox that will be advantageous in many situations, but patients will require traditional correction part of the time.
Third, I recommend that patients use the drop for 30 days to evaluate its full benefit. I compare it to when one is sick and taking an antibiotic. I say that, although one might feel better in 3 days, if the medication is stopped too soon, it is not going to work as completely as it was intended.
I like to use my husband as an example when I discuss the side effects, such as dimming of distance vision. He is also an optometrist and happens to be a presbyope who is on the drop. I explain that the dimming lasts approximately 1 to 3 days and it improves every day. In his experience, there was a little bit of dimming for the first 30 minutes or so on the third day, after which it completely resolved. This is another reason why I tell patients to use the drop for a month to really get that full effect.
In the past, I would send all of my prescriptions directly to the pharmacy. The pharmacy may or may not have substituted generic medications and sometimes charged astronomical fees. Our experience would be all over the map, with no consistencies. Some pharmacies would not even have the drug. Now, I use UpScript, which works directly with patients. The service sets patients up on a program with which they can earn points toward a free bottle each time they fill a prescription. The cost is consistent, and UpScript sends the medication directly to the patient.
I have learned to consider many different types of patients as candidates, not just 40- to 50-year-old early presbyopes. For example, one of my patients is a 75-year-old avid golfer. He is a friend of my dad, which is how he heard about the drop. This gentleman’s goal was to see the scorecard better. When he walked in, I thought, “Well, he is not an ideal candidate.” After the comprehensive eye exam, I told him that the drop was not going to eliminate his need for reading glasses. He understood and emphasized that he just wanted to see the scorecard on the golf course. He was thrilled—he loves it! He can’t see a menu in a dimly lit restaurant, of course, but outside in the sunshine, it worked exactly how he wanted it to. This opened my eyes to our need to understand patients’ daily activities and goals and not have preconceived ideas about the “typical” patient.
I also love Vuity for my scleral lens patients, especially those with irregular corneas. I find it has the greatest impact on keratoconic patients. I have not had much success with multifocal sclerals in this group; therefore, I set them up for great distance vision. Although they see better at distance than they would with glasses, they cannot see well up close. The drop helps them with near vision, and the small aperture effect also decreases problems with glare and halo that these types of patients experience.
Some of my patients will take a second dose of the drop, off label. I let them know that it is not FDA approved for BID dosing, although there is a current study examining this dosage. My heavy computer users, for example, often use it twice per day. I make sure to recheck their retinas after a couple of months.
Other Pearls For Use
Ensure that your staff is aware of this drop. The biggest way we can lose patients is if they call the office or come in and ask questions, and the staff is not informed about the product. Educate your staff, especially the presbyopes among the staff members. Invite them to try the drop—after confirming their retinal health with a comprehensive exam—and get their thoughts. In the exam room, we have a limited amount of time, and if the patient is there for other reasons, presbyopia solutions might not always be on our radar. If the whole office is invested—from the front desk to the technicians—when a patient mentions having trouble with near vision, the staff can encourage him or her to discuss the situation with the doctor.
Do not limit your options. This technology will not take away from your optical; rather, it is another aid—a piece of technology that can help your patients see up close. They’re still going to need their other tools, their prescription reading glasses, computer glasses, everyday glasses, etc. You want to be able to say that there is something new we can offer and that you want to make sure the patient has all the technology available to correct his or her vision.
Having settled into a routine with prescribing Vuity, I recognize that the drop can be useful for a wide range of patients. Understanding patients’ goals and setting the proper expectations are integral to having success, once a comprehensive exam confirms that the patient is a good candidate. Being a full-service optometry practice means offering patients a range of options to meet their vision needs. This technology is complementary to our other presbyopia-correcting tools. ■