Unblurring the lines
Image below: Mile Brujic, O.D., and his patient Jane Gray (Photography by Steve Craft).
Excerpted from page 26 of the October 2023 edition of AOA Focus
Not long into her 40s, Jane Gray remembers reaching out to her doctor of optometry, Mile Brujic, O.D., about changes in her vision. She noticed the words on her computer monitor were blurry, making it more challenging to see.
“I couldn’t focus very well,” recalls Gray, noting that it wasn’t just at work that her vision was fuzzy. She had noticed while watching television at home, too. “That’s when I came in to see Dr. Brujic,” she says. “I was very frustrated. People would walk by my office, and they’d say, ‘Why are you squinting?’ I was hoping he could sharpen what I was seeing.”
In hindsight, Gray figured her vision might have worsened due to COVID-19—not from the infectious disease itself, though. Over the pandemic, as a school nurse, Gray had spent considerably more time than usual staring at her computer screen at work, tracking and documenting the coronavirus’ impact on her school community.
Further, there was her age. She wasn’t naïve about the normal aging process and its impact on her health. After a comprehensive eye examination, Dr. Brujic confirmed his suspicion: presbyopia. He had “The Talk” with Gray about her treatment options.
“Because doctors of optometry are the eye experts, we want to make sure we’re giving patients those options and calibrating expectations on why they are good candidates for certain treatments,” Dr. Brujic says.
So many presbyopes ...
Gray has lots of company. The United Nations put the number of presbyopes worldwide at 7.9 billion people. In the U.S. alone, there are an estimated 128 million presbyopes. Some estimates put the number even higher.
“When presbyopia is defined as a visual condition of everyone over the age of 45, the United States Census Bureau 2020 population estimates would suggest that about 139 million Americans have presbyopia,” according to the AOA evidence-based clinical practice guideline on the adult eye.
“Approximately 1 in 8 Americans ≥50 years of age have near-vision impairment due to uncorrected presbyopia.”
With age and without vision correction, Americans aren’t finding it any easier to read the tiny type on their amber pill bottles, follow the warming instructions on a can of soup or make out the words on a computer monitor. According to a June 2022 article in Presbyopia Physician, the global price tag in lost productivity from untreated presbyopia is in the billions of dollars, never mind the psychological effects when it comes to quality of life. A 2022 opinion article in Frontiers in Medicine suggests age-related eye diseases are biomarkers of pre-frailty and frailty, which can be predictors of poor health outcomes in the future.
The article also suggests a role for doctors of optometry.
“Because of these presbyopic symptoms, the entire population of middle-aged adults will visit eye care professionals seeking a solution,” say the authors, who are on the faculty at Universidad Complutense de Madrid in Madrid. “Probably no other biomedical professionals attend to the whole population of middle-aged adults. This fact is remarkable because, as we have commented above, screening frailty biomarkers in middle-aged adults is critical for timely interventions to prevent age-related diseases and mortality.”
... so many treatment options
Dr. Brujic can remember when he graduated from the New England College of Optometry and started in practice about 20 years ago. At the time, contact lenses fit with a monovision strategy were considered the main option to manage patients looking for independence from glasses for presbyopia.
“Monovision isn’t as commonly used as it once was because of technological advances in multifocal lenses, which allow the preservation of binocularity,” Dr. Brujic observes. “The number of options for presbyopes has absolutely exploded.”
In those two decades, industry has developed a range of treatments—from spectacles to contact lenses to eye drops to surgery. Not only did the growing numbers of presbyopes spark the launch of Presbyopia Physician two years ago, it led to a proposal in Ophthalmology and Therapy of a new classification of presbyopia into three stages: mild, moderate and advanced severity, and referred to the rise of new therapies for presbyopia as a “revolution.” These classifications can “provide consistency of diagnosis” among eye doctors and aid in patient expectations, those authors say.
“We’re blessed and fortunate to have a number of new options,” says Dr. Brujic, referring to the advent of advanced contact lens materials and designs and their impact on treatment options.
Dr. Brujic and an AOA Health Policy Institute (HPI) brief from June 2023 outline the four areas of clinical interventions for presbyopia:
“There are several options with glasses,” Dr. Brujic says.
Near vision or reading glasses: “Generally considered the simple treatment option, near vision glasses are designed to supply the additional focusing needs of the patient when needed,” the HPI brief reads.
“Typically, the patient puts them on for near tasks and then removes them. Usually, because left and right eyes are not identical and other refractive errors may be present, these glasses are prescribed by an eye doctor. However, some patients require only very simple prescriptions, which can be obtained in over-the-counter reading glasses.”
Bifocals: “Intended for people with a need for distance vision correction as well as a near correction,” the brief reads. “Both corrections are incorporated into the same spectacle frame with the distance correction on the top and the near correction on the bottom.”
Progressive addition lenses: “Progressive addition lenses treat presbyopia using the same concept as the bifocal but utilizing more modern technology wherein the transition from distance to near is gradual and results in giving the patient not only distance and near correction but an intermediate one (correction) as well.”
Multifocal contact lenses: Multifocal contact lenses help improve vision despite distance. Among the leading developers of multifocal technologies are Johnson & Johnson Vision, CooperVision, Alcon, and Bausch + Lomb. “Most people can adjust to and benefit from the optics of multifocal lenses, when they fit appropriately,” Dr. Brujic says. “Existing contact lens wearers, those new to contact lenses and those who have discontinued wear can often times be successfully fit in multifocal lenses.”
Monovision contact lenses: “Monovision contact lenses, in which one eye wears a distance prescription and the other eye a near vision prescription, are an option” also, the HPI brief says. “For the successful patient, the brain learns to switch between left and right eyes depending upon the task at hand.” Unfortunately, Dr. Brujic says, this strategy disrupts binocularity and isn’t utilized as frequently as multifocal designs.
Orthokeratology (ortho-k): Originally approved by the U.S. Food and Drug Administration (FDA) to correct for myopia, ortho-k lenses provide a flattening centrally and progressively steepens away from the center of the cornea. “This can provide a subtle multifocal effect for some patients when designed appropriately,” Dr. Brujic says.
Presbyopia eye drops contain prescription medication for constricting the pupil’s size to improve near vision, the HPI paper says. When the pupil constricts, patients’ range of vision increases, “resulting in an enhanced ability to accomplish near tasks without the need of lenses, either spectacles or contacts.”
Says Dr. Brujic: “I often tell patients that it may be difficult to meet all of your needs with one treatment option, so if we need to, we can combine options to get to your best visual outcome.”
FDA-approved VUITY TM by Allergan burst on the scene two years ago, but other options are in the pipeline. The investigational drug BRIMOCHOL TM PF, by Visus Therapeutics, finished its third trial in May. Orasis Pharmaceuticals announced in February that the FDA had accepted for review its New Drug Application for CSF-1. Ocuphire and Lenz therapies also are investigating pharmaceuticals for miosis and improving near vision.
Monovision LASIK: “Monovision LASIK is a refractive surgery that corrects one eye for distance vision and one eye for near vision,” the HPI brief says. “Akin to monovision contact lenses, this method requires the brain to adapt to relying on different eyes for different distances.” Monovision will be trialed typically with contact lenses before surgery, as not everyone will adapt well.
Refractive Lens Exchange: Refractive Lens Exchange is a surgery in which each eye’s natural lens is replaced with an advanced intraocular lens. It can correct a variety of refractive errors and reduce or eliminate the need for reading glasses. Often, multifocal lens implants are used, depending on the patient’s needs.
Again, one option does not fit all—it might take two or three options at a time or different combinations of options depending on the needs of a patient. The HPI brief reports: “With therapeutic drops for presbyopia, doctors emphasize that the intervention is not a full replacement for optical correction but may reduce a patient’s reliance on glasses or contacts for a portion of the day. Given the huge number of Americans impacted by presbyopia, additional interventions can trigger excitement in the patient community and provides an opportunity for doctors of optometry to work with patients to find treatments and interventions that best suit the patient’s unique needs.”
Nathan Lighthizer, O.D., has written for Presbyopia Physicians, whose authors include doctors of optometry and ophthalmology. Dr. Lighthizer practices and is associate dean at Northeastern State University Oklahoma College of Optometry. In Oklahoma, doctors of optometry can perform laser surgery to treat posterior capsular opacity and perform photorefractive keratectomy.
“Just like cataracts, we know that presbyopia is inevitable,” Dr. Lighthizer says. “It’s going to happen—and to all of us. But, if we can mitigate the effects of presbyopia, that leads to happier patients and better outcomes. Better, happy patients mean we’re doing things right. We can improve patients’ lives by helping them function better.”
Despite the demonstrable need—remember that nearly 90% of Americans over age 45 are presbyopes—the study “Exploring contact lens opportunities for patients above the age of 40 years” from December 2022 in Contact Lens and Anterior Eye questions whether eye doctors can do more to manage presbyopia, asking why more patients aren’t wearing multifocal contact lenses. For the study, patients were recruited from the United Kingdom, the United States, the Netherlands, Germany, France, Spain and Italy. Of note, the study was funded by Japan-based contact lenses material developer, designer and manufacturer Menicon Co. Ltd.
“It seems that patients of this age group (40 years and above) are seeking suggestions and recommendations from their eye care practitioner, including upgrading contact lenses and dual wear options,” the study’s authors write. “The day-to-day problems encountered by the contact lens wearers in this study seem to be, in the main, things that could be easily tackled by additional counselling and instruction from the eye care practitioners.”
A different perspective can be gleaned from the updated AOA Evidence-based Clinical Practice Guideline:Comprehensive Adult Eye and Vision Examination, Second Edition, released in January 2023 by the
AOA’s Evidence-based (EBO) Optometry Committee.
Patient education can be key. It can go a long way in managing presbyopia, perhaps softening the blow for patients and helping them focus on opportunities to address the gradual decline in their sight. A small U.K. study hints at patients’ attitudes toward presbyopia. Among its findings, 65% of the patients who took an online questionnaire lacked “familiarity” with the word presbyopia, and a variety of words were expressed when discussing its onset: acceptance, a sense of reluctance, dread and worry.
Says Carl Urbanski, O.D., chair of the AOA EBO Committee: “Optometrists do a fine job addressing uncorrected refractive error once the patient is seen for the examination. What we’re advocating for is support for annual comprehensive eye exams as the best tool to uncover uncorrected refractive error, which can affect quality of life and utility with regard to work and tasks that may be overlooked by the patient, who might not seek care since the changes to their vision are not severe enough yet for them to act. Patient and public education on presbyopia should emphasize the importance of vision in our day-to-day functions.”
Risk factors here to stay
The HPI brief lists top risk factors for presbyopia—none of which are on the decline:
Aging. The first of 73 million millennials turn 40 in 2023, while 61 million Gen Xers were between 41-56 in 2021—”substantially increasing the potential number of presbyopes,” the report says.
Associated conditions/diseases and pharmaceuticals. Conditions such as diabetes, cardiovascular disease and multiple sclerosis have been linked to a “higher risk of presbyopia,” while “certain drugs, such as antidepressants and antihistamines, are associated with premature presbyopic symptoms.”
Digital use. The “ubiquitous use of digital technologies” for professional and social purposes has jumped and has been linked to eyestrain or vision stress. The adoption of digital technology has made better near vision a necessity due to the exponential increase in the use of screens for work and leisure.
The consequence? For people with untreated presbyopia, quality of life suffers.
“Given the difficulty that people with presbyopia experience with reading and other near vision tasks, presbyopia has been found to be associated with negative impacts on quality of life,” the HPI brief continues.
“If left uncorrected or undercorrected, presbyopia could result in potential productivity losses and reduced vision-related quality of life. Further, nearly 80% of patients with uncorrected presbyopia have reported functional difficulty in performing daily activities such as reading, writing, threading needles and using mobile phones.”
Another satisfied patient
In the interval since Gray first saw Dr. Brujic about the fuzziness, they have worked to find the best solution for her presbyopia. They have tried glasses, contact lenses and eye drops. “He was very good and thorough in explaining my options. The contacts seem to work best for me,” says Gray, who now wears a daily disposable silicone hydrogel multifocal contact lens with center aspheric near power design.
Gray is confident Dr. Brujic will keep her apprised of any new innovations for treating her presbyopia and continue to help shape how she lives.
“It is a challenge, as I cannot see very well without the aid of my contacts,” Gray says. “But I am very grateful that we have options such as these as we age, and things change, and our vision just isn’t as sharp as it used to be. That’s just life, and I’m glad we have options that help. Thank you to all who work in the optometry field, to help people like me preserve the vision we have.”
Resources to note
The American Diabetes Association® (ADA) reported, in time for National Diabetes Month in November, that total annual costs of diabetes in 2022 was $412.9 billion, most of it in direct medical costs. How can doctors of optometry help in the fight to lower the prevalence of diabetes?
Doctors of optometry should consider the benefits of adding office-based laser procedures, such as YAG capsulotomy (after cataract surgery) or selective laser trabeculoplasty (SLT, for glaucoma), to their practice.