-Ed

Here is a naked truth: Most optometrists who write out prescriptions for presbyopes are not presbyopes themselves. They have not lived the life of a presbyope. I deemed it prudent to ask some older presbyopic optometrists to express their views on the matter. Their responses were diverse, meaningful and funny! As the saying goes; “Ten years’ experience takes ten years and twenty years’ experience takes twenty years”

I will refer to them as “The Wise O’s”

The Wise O’s Panel:

Deidre de Jong, Zena Jacobson, Dirk Booysen, Simon Sloane, Stef Kriel, Ilse Sloan, Peter Swanepoel, Peter Muller, Rita Frank, Steve Trimby.

Firstly, on the lighter side, I quote some utterances from their responses and this is factual:

• “A good screening test for success is, to play dance music, preferably a waltz, get them to dance with you and if they step on your toes within the first thirty seconds, then they cannot have multi focals”.
• “Sorry I can’t help, I’m too young.”
• “I hate rechecks. I loathe them with a passion. I go to find my next patient and if it is a recheck, I first go to my consulting room, hit my head on my desk three times, sob for thirty seconds, confirming that I need to retire, put on my best smile and walk out to greet the patient and assure them, that it is only a pleasure to try to solve whatever problem we have to deal with, and that there will be no charge for doing so!”
• “When I was actually genuinely young (not just childish), I decided I have to try and experience what people are moaning about, so I wore a pair of multis, but it was pointless – I had so much accommodation”.
• “Trouble is, we’ll change them for what your granddad wore: bifocals!!! You don’t want that, so just relax, keep wearing them and you’ll be fine.”
• “I’m my own worst patient (-,300 -3,25). I take myprodol for 2 weeks and the head-aches disappear and I magically adjust to the specs.”
• “I hear they’ve just brought out the new XYZ Exodus multifocal, digital design, reading corridor twice as wide as their competition’s lens, all the bells and whistles, adjusted for left and right-handed patients, best lens in the world. We call it the EXODUS lens, because, when we tell them the price the patients WALKS OUT !”
• “but first, how’s your music going – it’s been a very positive year music-wise here. I recorded the drums at my studio for the band I am in.”
• “we all did a full case history, so we know, if the patient only uses his lenses to whatsapp while bungy jumping, or lives in front of his computer and only moves to get redbull.” 
• “Oh, I forgot to tell you, I moonlight as Spiderman and need to see at 1,5 meters upside down “
• “A man who wears white socks is a problem!”

But then, we got down to serious business. I have endeavoured to consolidate all the comments, pick up the common thread through it all, and add their pearls of wisdom.

It was interesting to note, that not one of the Wise O’s suggested a particular brand of multi focal to be, the be-all and end-all. They also did not position lens design as the primary cause of patients’ problems or the ultimate solution.

A common thread was also the fact that the Wise O’s felt that they became wiser after becoming presbyopes themselves.

• “It was different when I got to the other side of the fence.”
• “All optometrists, when hitting early forties, should try multi focals for themselves, even if they feel they don’t need them”
• “This is where confidence comes in, and plays a huge part. I tell people they WILL get used to them, don’t worry. Some people take longer some shorter, but I guarantee you will get used to them or we’ll change them.”
• “All the technical data in the world on paper doesn’t replace the real-world experience.”

On lens designs

•  “I have tried all designs and find very little difference between them. This certainly seems to be the case with all top end expensive designs.”
• “I wear all the multi focals and often find my favourite to be the one with the best fitting frame and/or the best AR coating.”
• “There is not much difference between an expensive pair or design, and a cheaper / harder type multi focal.”
• “Really, is there a difference between all the major players in quality, vision, and the price is pretty much the same.”

Patient education

 A lot of emphasis was placed on assessing the patient’s real need, as well as patient education.

• “I have a long discussion with the patient to see what kind of correction they need. I ask:”

1. Describe your day to me?
2. What does your work entail?
3. What does your desk look like?
4. How many screens do you work on?
5. How far away is your computer and the screen(s)?
6. Do you spend most of your day doing near work or distance? 
7. What devices do you use most often, cell phone, tablet, laptop or desktop computer?
8. What sport and recreation do you part-take in?

• “I agree 100% that, needs assessment is critical and patient education on the effect of the aging lens and limitations of “man-made” solutions for the loss of an incredibly complex and flexible accommodative system, can’t be overstated. “
• “I make a point of reminding them that they do not rely on one type of shoes only, and that the current modern visual demands are totally different from way back then. I pave the way for two pairs straight away (MF and Office).”

First time multifocal prescriptions

The Wise O’s reached consensus when to prescribe multi focals for the first time, on a number of issues. Beware of the myopes. They need to display a desperate need before subjecting them to multi focals. Beware of those patients who do not wear specs permanently. They are not good candidates to go straight into multi focals. There must be no question that the patient must first complain of a shortfall in functional vision, e.g. the teacher. There must be a definite problem to solve and the decision must not be based on a clinical finding alone.

Measurements

When it came to measurements, The Wise O’s had a lot to say.

• “Take into consideration if a patient is short or tall when measuring segment heights. If you are shorter than the patient, stand on something, to ensure you are at the same level. If the patient is short, drop the segment a little, because they constantly elevate their chins, and the other way around for tall people.” Parallax is a major issue when taking measurements.
• “I used to attach a spirit level to a stick, so that the dispenser could be certain no parallax is in play. The stick is positioned from the patient’s eye level to the dispenser’s eye level.”
• “I take the monocular pupillary distance and segment heights, then also mark the centres on the dummy lens and cross check the centres on the chart provided for the specific lens. I also mark the reading circle for each lens, according to the chart, and sitting opposite the patient, who is holding a mirror (with a cross marked on it) in the reading position, looking at the cross. According to where the cross is in relation to his pupil, I decide on a 11 or 14 corridor depth.”
• “I have a set of multifocal (as well as bifocal and interview) trial lenses which I use to illustrate the lenses to the patient in office with a trial frame.”
• “Make sure you take time to measure monocular pupillary distance and segment height and use a template to mark the dummy lenses in the frame. Then place the frame on the patient while they are in your chair and check the markings with your penlight torch – this will save you lots of grief. Also check the ink markings for accuracy on the lenses from the lab, I have often found that the pupillary distances are out when I remark the lenses, while the fancy ink markings are suspiciously accurate according to your specifications.”
• “That focused me on getting all the parameters right – centration, height, vertex distance and panto angle, and it really was plain sailing after that. Multi focal bounces became rarities.”
• “With metal frames, I make the monocular pupillary distances the same, and adjust the nose pads for the lenses to line up with the pupils.”
• “With hyperopes, dot the lenses mid pupil, so they can get the full benefit of the add.”
• “Adjust the frame and make sure it fits properly before taking measurements.”
• “I do individual add measurements. If the adds differ, I triple check my distance findings. I prescribe different adds where appropriate.”
• “The size of the frame really matters”

Patient expectation

• “Patient expectations can be a problem, so I always point out, that there will be some peripheral distortion by showing them a schematic diagram of a multifocal lens.”
• “When it comes to multi focals, I explain how it’s going to help their work. I give them the whole spiel about the difference between readers only and multi focal readers.”
• “Patient’s expectations –  please be realistic!”
• “I see some marketing information bragging about the different reading zone widths for their MF lenses. I’ve been wearing MF for twenty years, and all I can say is; in your dreams! Once the patient is used to the full field of readers – can you beat it?”

The old Rx

• “The type of multi focal that the patient is presently wearing and have been happy with, is very important- soft or hard design. Look at the markings on the lens and identify it according to a chart, showing all the types of lenses and all the different markings. Stick to the same type.”
• “Be aware of previous issues with multi focals. It should be on the record card. Don’t fall into the same trap.”
• “It is vital to note the patient’s previous frame fitting, segment height, pupillary distance etc.”
• “An example would be, that the old segment height was unusually low or high. It may not be technically right, but it might be where the patient likes it.”
• “If they present with an old MF, don’t hand it off to your dispenser, who hands you a piece of paper saying: R +0.50 left +0.75 add +1.25.
• What’s the monocular pupillary distance, lens design, segment height, base curve, refractive index etc.? Where do the old lenses centre, relative to the pupils?”

Binocular Vision

• “What I find most interesting, is that many patients whom I see, referred from elsewhere, present with a small uncorrected binocular imbalance, that leads to decompensation of their phorias, when they start looking into the MF blur zone.The most notorious of these are the patients with SO4 paresis, A and V pattern deviations and there are many of those. As you know, it’s quite normal to see small vertical deviations with sagging eye syndrome, and many patients with age, have compromised CN IV’s, with associated non-concomitancy.” “Check for chin and head tilt – centre those dots off-centre.”
• “Many patients with years of MF difficulty, can be sorted out with low power H or V prism and/or low yoked prism.”

Patient posture and height

• “I also take into account the height of the patient, and where the computer sits on the desk. Like me, who is short, I sometimes don’t manage with a multifocal because I am sitting too low. Taller people have less problems with multi focals, as they can look down through the right part of the lens and manage better. “ 
• “Optometrists and physios have a conflict when it comes to reading. Physios say the computer screen should be straight in front of you at eye level for most comfortable reading and posture, but optometrists say, you have to look down about ten degrees, to read through the correct part of the lens. So, your computer screen must be below your line of vision, to get into the intermediate and near section of the lens.”
• “Check for chin lift when the centration is measured. Habitual chin lift at intermediate or near with longstanding MF wearers, and you could end up with segment height, way too low.”
• “If the patient is short, drop the segment height  a little, because they constantly elevate their chins, and the other way round for tall people.”

When they do come back

•  “Consider the divorcee, with two kids at school, having just paid big bucks beyond what her medical aid is prepared to cover, who is coming in because her multi focals are not working. She is stressed. The first thing to say to her is: Nancy, we will fix this, and whatever it takes, it won’t cost you anything!” “Once you have done that, you are talking to a person who is on board to fix the problem.”
• “She may be back because she doesn’t like the frame!”
• “I ask them: What’s the worst thing you are experiencing? Then we can home in on the problem and fix it.”

Pearls

• “We live in a different world in terms of visual demands than only ten years ago. The old Harmon distance is now replaced by the DDD (digital device distance). Sometimes, as much as +0.50DS has to be added to a 14b at 40cm.”
• “People work mostly on their cell phones or tablets, and not desktop computers so much anymore. Because these devices are hand-held, the working distance is likely to be closer to 30cms than 40cms.”
• “An old tip by Mo Jalie; don’t always trust the add engraving on the lens, sometimes it is not the same. Vert it to be sure.”
• “Always check binocular balances, vergence reserves and fixation disparity.”
• “We should also think about offering photochromic lenses in readers, as it does help a lot when reading outdoors.”
• “Watch out for engineers, they tend to be pedantic and tricky” Everybody agreed on this point.
• “At the time of collection, discuss the ergonomics of work station again!” 
• “Use the trial frame, to demo the add. This should be common practice.”
• “Take preferred head positions seriously.”
• “Past complaint re multi focals is important – be careful with the next pair, even if its ten years later.”
• “Be careful with pilots, the peripheral distortion experienced with these lenses does affect their ability to land an airplane – yes, peripheral vision is key to successful landings, rather recommend flat-top trifocals, for these patients.”
• “I am finding it increasingly difficult to justify the cost of these pieces of plastic to my patients, I don’t buy into all the R&D the manufactures use to justify the exorbitant costs of these products.”

Summary

• Understand what your patient’s functional visual requirement is. Establish the real need by asking questions.
• Acknowledge and convey, that one pair of specs cannot meet all visual requirements.
• Communication is key.
• Be meticulous about the measurements
• Take note of posture
• Avoid parallax
• Frame selection is very important
• Take note of what they were happy with previously
• Frame adjustment is vital in terms of optic centres, vertex distance and pantoscopic angle
• Take note of the fit of the previous specs
• Frame size matters
• Practitioner confidence is key
• Handle the expectation
• Do not assume that the lens design is the problem with a grief case