Presbyopia matters

The scenario

I’ve been locuming for over three years now and, generally, in thepractices where I locum, I am largely seeing patients aged 40-plus. Do you have any advice for effectively raising with and educating them about presbyopia and its impact on vision, and their correction options?

Grant, locum optometrist

The advice

Nadia Siddiqi, optometrist, Johnson & Johnson Vision professional affairs consultant and faculty member

I find it is the most beneficial to advise patients prior to the onset of symptoms or when they are experiencing the earliest symptoms. I would structure the conversation by explaining what presbyopia is, the potential impact on vision, and the available effective vision correction options specific to the patient in front of me. Having this discussion with patients early ensures that they are educated and informed by the time presbyopia occurs. This proactive approach helps set expectations ahead of time and can greatly reduce the anxiety felt by patients when the inevitable vision changes occur.

When addressing presbyopia and the associated changes in vision, it’s important to emphasise that it is normal. It is helpful to avoid jargon and to use clear, relatable language. It is also important to acknowledge that, from the patient’s perspective, these changes can be disconcerting. For example, you might say: “As we get older, the lens inside your eye becomes less flexible. This makes it harder to focus on things up close. This process is called presbyopia and although it can be very frustrating when it happens we do have solutions to help you.”

The conversation

Clinicians should aim to keep conversations about presbyopia positive, highlighting that there are many effective correction solutions available when the time comes.

These options include separate reading glasses, varifocals or occupational spectacles, multifocal contact lenses, and refractive lens exchange options. While we may have these discussions with patients every day, each conversation should feel authentic and be tailored to the individual patient’s needs and preferences, so that we don’t risk sounding scripted or too general. Explaining that several options may suit a patient and that sometimes a combination of solutions can work best for different activities or preferences is often very well received.

Discussing presbyopia and understanding the various correction options can feel overwhelming for some patients. However, it doesn’t have to be. Using relatable analogies can make the conversation easier, such as explaining that you don’t wear the same type of shoes for every task or activity and it’s the same with correcting presbyopia. Occupational varifocals may be best in the office environment whereas multifocal contact lenses may be more suitable when heading to the gym.

Sharing personal experiences when educating patients about their eyes and vision can be very powerful. When it comes to presbyopia, because of its typical age of onset, some practitioners will not have this first-hand experience to draw upon. For those practitioners, I encourage them to talk to their colleagues and family members who are presbyopic to understand what it’s like and the impact presbyopia has on their day-to-day life. It is also very insightful to ask fellow presbyopic peers if their approach to explaining presbyopia has changed after they themselves became presbyopic, as this can reveal valuable perspectives and further improve patient communication. This added layer of understanding helps both the clinician and patient to be comfortable in the conversation.

It is important to focus the conversation with your presbyopic patient on their visual needs, lifestyle and hobbies and recommend all suitable available correction options without making any presumptions about what the patient may prefer. When giving your recommendation, you can clearly explain the reasons behind your suggestion and link it back to the information they have given you whilst always inviting the patient to share their thoughts and preferences. This collaborative approach ensures patients are fully informed and engaged in selecting the option that best suits their vision and daily activities and ensures the patient is invested in the solution. We have to be mindful that simply omitting an option may inadvertently suggest to a patient that an option is not appropriate for them, when that may not be the case.

By communicating effectively and educating patients prior to the onset of presbyopia, you are preventing them from potentially going through a very frustrating experience

Normalising presbyopia

As previously mentioned, when a patient in their late 30s upwards presents, I know that at some point during the examination I will want to raise the topic of presbyopia with them and as always, I aim to integrate it into the lifestyle conversation where possible. Generally, I will build it into our general conversation, for example when time using digital devices comes up. I explain that many patients report how their lifestyles have changed massively in recent years with most using digital devices for much longer periods of time. I reassure patients during these conversations that due to presbyopia which will occur at some point over the coming years, we may need to adjust their vision correction to help them focus more easily. I ensure they understand that this is a completely natural process and it happens to absolutely everybody. After all, even David Beckham is likely presbyopic now! It’s about normalising presbyopia and reducing anxiety around it.

Finally, after explaining and reassuring the patient, it’s important to ensure they feel they can revisit the practice if and when they start noticing this change to their vision – they don’t have to wait to be recalled. I highlight that they wouldn’t wait for their dental recall if they had toothache, so they should not wait to visit the opticians if they notice a change in their vision.

I emphasise that there’s no need to struggle in silence. Highlighting that addressing their visual changes earlier can even be beneficial because it can be easier for them to adjust to the new correction. Earlier intervention often leads to a smoother transition and better outcomes.

When I speak to patients about presbyopia, I also try to provide examples of the tell-tale signs they should be mindful of – I think this makes it simple for them to understand and relate to. For example, I’ll say: “You might start noticing that especially small print becomes more difficult to read or that you need more light when reading something – that is when you should come back and see us.”

It’s important to ensure they feel they can revisit the practice if and when they start noticing this change to their vision – they don’t have to wait to be recalled

An upgraded correction

When you see patients who are presbyopic and would benefit from a new vision correction, it’s important to explain why you have recommended that correction and the benefits they will gain.

There are generally three types of presbyopes we will come across, and our communication should be adapted accordingly. Whilst the recommendations may be similar, how they are presented to the patient varies according to their own individual visual experience.

For emmetropes who have never worn glasses and need first time vision correction, I explain, ‘As I mentioned your near vision has become more blurry due to presbyopia and I can help to correct that. There are glasses that will be able to help, but there are also contact lens options and even surgical interventions if you so wish.’

Then there are spectacle wearers who may start switching between different glasses for different tasks, or the myopes who take their glasses off to read. To these patients, I explain the practical frustrations they may experience when switching between visual corrections and the various solutions that could help.

For potential new contact lens wearers, I encourage them to look at and handle a lens and often offer a trial, if possible, while they are browsing spectacles. This approach demonstrates how accessible lenses can be and helps to demystify misconceptions about how they might feel on their eyes.

Finally, there are the existing contact lens wearers who become presbyopic and may start to wear their lenses less or may even drop out of contact lens wear altogether as their current lenses no longer meet their needs. With this group of patients I ensure they are aware that there are multifocal contact lenses available, I explain how they work and I try to book the patient in for a trial on the same day or the day they plan to collect any spectacle order. At this point, I always highlight that contact lenses are not a one size fits all option. Contact lens materials and designs are not all the same and adjustments can be made to maximise physical and visual comfort. I emphasise that if they decide to trial contact lenses, they have time during the trialling process to try a different lens if the first one chosen isn’t meeting their visual or comfort needs.

As clinicians, we should not underestimate the power of knowledge. While we don’t want to over complicate or overwhelm a patient, we do want to make sure they are prepared for what visual changes may occur and we should do so from a place of empathy

The impact of not educating

Failing to educate our patients about presbyopia can lead to a lot of avoidable stress and visual frustration. From a patient’s perspective, navigating these changes without understanding what’s happening can cause worry and may even prompt patients to seek help from a different clinician. We should not underestimate the power of knowledge. While we don’t want to overcomplicate presbyopia or overwhelm a patient, we do want to make sure they are prepared for what visual changes may occur and we should do so from a place of empathy.

My overall advice would be to not shy away from the conversation. Educating our patients about their eye health, vision and their correction needs builds trust between us and our patients. As a locum I know the practices I work for really appreciate this approach, it improves patient satisfaction and consequently benefits the business through increased patient retention.