Final: Presbyopia/Prescribing Errors
What is the Plus Build-Up method (Shifts and favours NRA everytime)?
- Add plus over subjective until sees BVA - If BVA at distance is 20/40 = Add plus until sees RS40 clearly
Lesson: What should you look for in patient history when prescribing?
- Age - Complaints - Occupational/Avocational visual needs - Listen to their complaints
What is a multi-focal IOL?
- An intraocular lens that allows the person to see at distance, intermediate and near without glasses - Each has its own advantages - Developing Toric MF IOLs also
Explain why the NRA going up and PRA going down is relative in presbyopic patients who need an add?
- Both numbers will go down but the NRA relative to the PRA will be larger
What is the Age (Donder's table method)?
- Choose the best add based on a patients age and amplitude of accommodation - Patients can only maintain 1/2 amplitude of accommodation
Lesson: What must you remember when prescribing a higher add?
- Clear range shifts towards the patient and it gets smaller - The blurred intermediate range gets wider
What are Monovision contact lenses?
- Distance Rx contact lens fit over dominant eye - Near Rx contact lens fit over non-dominant eye - Brain picks clear image over blurred
Lesson: When do uncorrected low hyperopes encounter presbyopia?
- Earlier than corrected ametropias (Hyperopes, atigmats etc) - They get sad because they start needing glasses when they never had to wear them - Remember that they havent had to wear glasses for 30+ years, adaptation is a long process - Because they dont wear them all the time, educate them about proper care
What is a good predictor of Prognosis?
- Entering VA
Lesson: Why shouldnt we just do a test to fill a box?
- Every test you do should tell you something - You should know the answer to a question or test before you do it
Lesson: What is different about computer glasses from prgressives?
- For intermediate/near - Gives much wider channel for intermediate distances
What are the side effects of Vuity?
- Headaches/browaches - Retinal detachments - Decreased vision in dim lighting - Eye pain - Redness
What are the important guidelines to note about prescribing?
- If it isnt broken, dont fix it - Compare old to new - Present all options and let patient choose - Wow response
What are the key points about Pinhole?
- If you pinhole to 20/40 you will need to refract to that point = JCC will be almost impossible so stop trying - If you pinhole and there is no improvement an Rx is not going to help = Do health check to determine cause
What is the Binocular Cross Cylinder Method (variable responses by patient)?
- Illumination dim - Target = set of horizontal/vertical lines - Add cross-cylinders Horizontal lines = Add plus Vertical lines = Add minus until subjective
How does the Autorefraction help with the refraction?
- Look at mires when performing test - Look at reliability indices - Look at consistency of refractive error = if consistent then most likely the Rx - Look at keratometry readings
What do you need to be careful of when using the Lensometry data?
- Lost Rx - Wearing older Rx - Wearing someone elses glasses
Lesson: What happens as you increase plus at near?
- Material has to be held closer - However, you create a gap in between near range and distance range
What is the age method for determining an Add?
- Meant for at 40 cm WD
What are the Aging trends?
- Myopia increase in school years and then plateaus in adulthood - Stable then shifts towards hyperopia starting at 40 y/o - Astigmatism: ATR to about age 6, then WTR to 40, then shift to ATR -- But stable axis
Lesson: What is important about readers for presbyopes?
- Patients should always have custom pair of glasses designed for them especially the PD - Recommend OTC readers for short periods of reading time like maps and readers
Why do some pre-presbyopes get blur at distance after looking at near?
- Patients who over-exert themselves in accommodation at near will have problems relaxing their accommodation - Accommodative spasm/excess - VEE = similar to accommodative infacility
Lesson: Why is range thru important?
- Perform a range thru to determine the range in which the patient sees clearly - A +0.75 or +1.00D change combining distance and near will increase the add GREATLY = over-plussing at near - Adds increase in +0.25D every 4 years - A large increase in add requires the reading material to be very close
What is Monovision refractive surgery?
- Successful monovision contact lens patients can have it permanently with surgery - Advantage = No glasses whatsoever
What is the previous sRX method?
- Tells you what the patient is currently wearing and what the near VA is - Rarely prescribe less than the add in previous sRX (relative to distance Rx)
Why doesnt a progressive or bifocal work for the following patient: OD: +1.25 -0.50 x 135 OS +1.00 DS Tentative Add: +0.50 PRA: +1.00 NRA: -2.00 Amps: 5.50 D
- To balance NRA/PRA: Add -0.50 to tentative Add which yields zero - A distance prescription with an add of zero is just a SV distance Rx
What are the components of vergence?
- Tonic - Proximal - Fusional = compensates for loss of accommodation - Accommodative = decreases with age
Lesson: How do you prescribe for computer glasses?
- Trial frame half the add and have the patient sit in front of the computer at their computer WD - Add is now half of the original add - Educate patient that they are only used for intermediate/near and will be blurry at distance = no driving
Lesson: Although the patient saw 20/20 with the subjectove, the plus is way too much to give, what should you do to prevent this from happening in the future?
- Trust objective testing over subjective testing - Trial frame with subjective and add minus until patient no longer sees 20/20 at distance = you should not have to go beyond Habitual - Then check near VA and add to it if necessary
Why does the Rx work for the following patient if they were experiencing difficulty up close before? OD: +1.25 -0.50 x 135 OS +1.00 DS Tentative Add: +0.50 PRA: +1.00 NRA: -2.00 Amps: 5.50 D
- With your sRX, accommodative demand for 40 cm is 2.50 D - Her amps are 5.50 D/ sustained 2.75 D - Just enough accommodation for a few more years - If you measure amps through the sRx it will increase
When does the Add power increase and by how much?
0.25 D every 4 years
If you do decide to change the Rx from the habitual glasses, what is the maximum change that should have been made to the new Rx?
0.50 D or less
Example: What is the Add using the NRA/PRA balance method? NRA: +1.50 PRA: -0.75 Tentative Add: +0.75
1) Add NRA to PRA (+1.50) + (-0.75) = +0.75 2) Divide by 2 +0.375 3) Add to Tentative Add +0.75 + 0.375 = +1.12 Final Add = +1.00 or +1.25
Example: What is the final add using the Balance PRA/NRA method: Subj: Plano NRA: +1.50D PRA: -2.00 D Tentative Add: +1.75D
1) Add NRA to PRA (-2.00) + (1.50) = -0.50 2) Divide by 2 -0.50/2 = -0.25 3) Add to tentative Add +1.75 + - 0.25 = +1.50 4) Final add over subj +1.50 + pl = +1.50
What are the signs and symptoms of Presbyopia?
1) Hard time reading small print 2) Having to hold material farther than arms length 3) Headaches 4) Eyestrain/Eye pain 5) Avoidance of near/intermediate tasks
What part of the objective data is most important regarding Presbyopia?
1) History (age late 30's early 40's) 2) Distance VA 3) Near VA 4) Habitual SRx 5) Subjective Refraction and VA 6) Near Add determination and VA 7) NRA/PRA 8) Amplitudes of Accommodation
If the patient is not capable of reaching 20/20 vision due to an ocular pathology, what are the most common structures affected?
1) Lens = 50% 2) Macula = 20% 3) Front of eye 4) Optic Nerve
What are the take away points about Presbyopia?
1) Low myopes can take off their glasses for near work 2) Hyperopes need reading glasses earlier than myopes and takes them longer to adjust 3) Adds go up 0.25D every four years - Adds are equal between the two eyes if accommodation is balanced 4) As Adds go higher, the intermediate range is a problem = consider occupational glasses 5) Perform a range thru if you change the near Rx a lot 6) Consider prism if your patient starts seeing double, even if only at near 7) Trial Frame, have them read, watch over-plus
Lesson: What is the MOST COMMON problem encountered in the clinic?
1) Over-plussing at distance 2) Over-plussing at near
What is Presbyopia?
100% age related Blur at near when fully corrected at distance Usually starts between 35 and 45 years of age The lens hardens and the muscles can no longer flex the lens for proper focus of light rays onto the fovea
Example: What is the tentative add using Hoffstetter's equation for a 52 year old patient?
15 - 0.25 x (52) = 2.00 D 1/2 of 2.00 = 1.00 D Accommodative demand @40 cm is 2.50 D 2.50 - 1.00 = +1.50 D
What is Hofstetter's Equation method?
15 - 0.25 x AGE - Maintain 1/2 amplitude of accommodation - Reads at 40 cm - Tentative Add
What are the advantages and disadvantages of Monovision CL?
Advantages: - Can use conventional lenses - Costs cheaper than multifocal lenses Disadvantages: - Loss of binocularity - Some problems with adaptation
What are the Major components of Prescribing?
Age History VA Pinhole Lensometry Autorefraction Retinoscopy Subjective Refraction Tentative Add Trial Frame
Lesson: If a patient is a low hyperope of +1.00, and they are pre-presbyopic, how much accommodation are they able to sustain at 40 cm (Amps were measured to be 5.50D)?
At 40 cm = 3.50 D Amps are 5.50/2 = 2.75 D She can only sustain 2.75 D 3.50 - 2.75= 0.75 D needed to sustain
What is the second best starting point for refraction?
Autorefraction - if patient complains of blur, then see how much of a change from lensometry - If no complaints of blur, should be similar to lensometry - See if patient appreciates SMALL changes
What is important regarding Age and prescribing?
Before School Age children (5 and below)= To prevent Amblyopia you Prescribe School Age children = Prescribe to improve ability to learn Adult = Stable refractive error, maybe very small changes to RX if at all Adults around age 40 = Rx distance and near, introduction to MF lenses All Ages = Watch for ocular disease that impacts refractive error/VA
Case 5
Cae 5
Case 1
Case 1
Case 2
Case 2
Case 3
Case 3
Case 4
Case 4
What is more important regarding Presbyopia, comfort or clarity?
Comfort
What are the intermediate powers in the following trifocal Rx: OD: -1.00 DS Add +2.50 Int. +1.25 OS: -1.00 DS Add +2.50 Int. +1.25
Distance = -1.00 Intermediate = +0.25 Near = +1.50
What are the things that change in Presbyopic patients during entrance testing?
Distance VA = very little change Near VA = decreased VA Cover test near = More exophoric Stereo = Decreased as you need good near VA to have good stereopsis Pupils = Smaller with age Near refraction = New Add/Increase plus Near Lateral Phoria = Slightly more exophoric Base Out range = very slight decrease NRA = Goes UP PRA = Goes DOWN
What is the pharmaceutical Vuity?
First pharmaceutical approved for Presbyopia Improves VA by extending depth of focus by miosis of both pupils Works well with low Adds, not high Adds
Lesson: What is important about Early presbyopes who are low myopes?
Have the advantage of taking off their distance Rx for near work - A 70 year old -1.00 DS wont be able to read at 40 cm comfortable because they have no accommodation - Remind them that they should remember where they put their glasses. They tend to forget where they placed their glasses - Dont overplus at near unless they already are
What is the single most important step in the treatment process?
History
What shift occurs as people hit the age of 60?
Hyperopic shift
What is Corneal Inlay: Kamra?
Improves near VA by extending depth of focus - Better depth perception - Better night driving Need distance to be plano to -1.00 Inlay in non-dominant eye If ametropia, LASIK first then Kamra
What is the best refractive information you can have?
Lensometry
What is the best starting point for refraction?
Lensometry
What are the future treatments coming?
Multifocal LASIK - PresbyLASIK - Supracor - Intracor
Write the following Rx into a Bifocal Rx: OD: -1.00 DS Add +2.50 OS: -1.00 DS Add +2.50
New Add (Near): +2.50/2 = +1.25 New Sphere (Intermediate): (-1.00) + (1.25) = +0.25 OD: +0.25 DS Add +1.25 OS: +0.25 DS Add +1.25
If a patients entering unaided VA is 20/20 or better, are you likely to prescribe anything?
No = very unlikely - Most common exception is Blur at night = Night myopia (-0.25 or -0.50)
For presbyopic patients without cataracts, what are the appropriate treatment options if they dont want glasses?
Non-surgical - Multifocal CL - Monovision CL Surgical - Monovision refractive surgery - Uniocular corneal inlay Pharmacological - Extended depth of focus = Vuity
Write the following Rx into a Computer Rx Progressive: OD: -1.00 DS Add +2.50 OS: -1.00 DS Add +2.50
OD: -1.00 DS Add +2.50 OS: -1.00 DS Add +2.50
Write the following Rx into a Trifocal: OD: -1.00 DS Add +2.50 OS: -1.00 DS Add +2.50
OD: -1.00 DS Add +2.50 Int. +1.25 OS: -1.00 DS Add +2.50 Int. +1.25
If you are going to lose money at your practice to re-do someones glasses, what is the reason why?
Over-plussing at distance
How do you know a patient needs an add regarding the PRA and NRA over time when you dont give a tentative add to the patient?
PRA goes down because they dont have as much accommodation - P = Minus, giving them more minus and they have to clear it with accommodation - Since they cant do it anymore = it starts to decrease
Presbyopia
Presbyopia
Prescribing Errors 101
Prescribing Errors 101
What method do most doctors prefer?
Previous sRX Age Balance NRA/PRA
What happens to the near power when you increase the Plus power (ADDING) to distance?
SRx of near increases
What are the important steps when prescribing for presbyopia?
Trial Frame Range of clarity in cm Patient education
What is the Balance NRA/PRA method?
Want to keep the add half way between the NRA and PRA Performed After tentative Add - If NRA = PRA ; You have found your final add - If NRA > PRA add Plus - If PRA > NRA add Minus Add to the sign that is bigger!
What are the best questions to ask regarding Rx checks?
Which pair of glasses are you most comfortable with? Are you happy with them? Do you have them with you?
If entering VA is worse than 20/20 and there is complaint of blur, should you prescribe?
Yes - But some patients like it to be a little blurry = choose for comfort - goal is 20/Happy
Even if a trial frame was performed and the patient liked it, what is the MOST important piece of data to consider? a) Distance and Near VA b) Habitual sRx c) Subjective Refraction d) Tentative Add
a) Distance and Near VA
A 38 year old female states she is having problems reading up close. Her distance vision is fine. It takes a while for her eyes to get clear at near but after reading for a while, everything far away becomes blurry for a while. What is your differential diagnosis? a) Pre-presbyopia b) Accommodative insufficiency c) Accomodative infacility d) Latent Hyperopia e) Pseudo-Myopia
a) Pre-presbyopia
What is the most likely cause of blur at near for a 45 year old who has never had an eye exam? a) Presbyopia b) Latent Hyperopia c) Accommodative insufficiency d) Convergence insufficiency e) A tumor
a) Presbyopia
Why does the patient get more exo at near with age? a) They lose accommodation b) They lose fusional vergence c) They lose both accommodation and fusional vergence d) They are losing their minds
a) They lose accommodation = leading to loss of accommodative convergence NOT fusional
A patient comes into clinic and states, "My glasses are okay at distance and near but when I play piano, I have to move my head back and forth like a bobble-head". What question do you want to ask? a) Which two distances do you need when you play the piano? b) Do you see double when you play the piano? c) Does the distortion on your glasses drive you crazy? d) Can I have your autograph?
a) Which two distances do you need when you play the piano? - Distance and Intermediate or - Intermediate and near - Progressives are bad for intermediate so not progressives
Why does a patient with Myopic shifts, BVA not 20/20 and PHNI need a +3.00 D Add? a) At this age, their arms are shorter due to osteoporosis so their reading distance is shorter b) It magnifies near work c) It brings more light into the eye d) It compensates for lost accommodation
b) It magnifies near work - Usually for the older-older population - WD is 33 cm - Important to emphasize good lighting
What if the patient refuses to wear a progressive? a) Educate the patient about the importance of seeing at near through the progressive b) Prescribe SV distance only c) Prescribe SV near only d) Prescribe SV distance and near e) Low vision referral and seeing eye dog
b) Prescribe SV distance only
A patient comes into clinic and states, "My glasses are okay at distance and near but when I play piano, I have to move my head back and forth like a bobble-head" What is the problem? a) Hes not adapting to the glasses b) The intermediate distance is not working for him c) The near add is too strong d) The testing was wrong and we didnt check our work e) He misses playing at Ceasars in Las Vegas
b) The intermediate distance is not working for him - Intermediate channel is too narrow to see the entire sheet
Lastly, why are Adds 99% of the time equal between the two eyes? a) To balance the refraction b) To balance accommodation c) To balance the visual acuity d) Its cheaper e) Just because
b) To balance accommodation
If a person is hyperopic, why wont we consider a pair for full time wear, All of these are true but what is the most likely reason? a) Hyperopes dont like plus b) No complaints at distance, leave it alone c) Can compensate at this time for distance, will need to wear it at distance in future
c) Can compensate at this time for distance, will need to wear it at distance in future
How many ways are there to determine an ADD? a) One and only one b) three c) eight d) Dozens
c) Dozens
The majority of pre-presbyopic adults in US are: a) Myopic b) Hyperopic c) Emmetropic d) Astigmatic e) Anisometropic
c) Emmetropic
Myopic shifts, BVA not 20/20 and PHNI most likely points to what kind of problem? a) Refractive b) Binocular c) Lens (cataracts) d) Systemic (diabetes) e) Retina (mac degen)
c) Lens (Cataracts) Differential Diagnosis: 1) Cataracts 2) Mac degen 3) Diabetes 4) Dry eye = intermittant blur
Rx Recheck sent from optical same day. 65 year old male came in last week for an eye exam. Got the glasses today and the glasses are too strong. The old glasses were too weak for reading: What is your tentative diagnosis? a) Adaptation issues, give it two weeks b) Over plus at distance c) Over plus at near d) over minus a distance e) over minus at near
c) Over plus at near
A 55 year old patient says that they cant see up close any more, what is the most likely cause? a) Cataracts b) Glaucoma c) Presbyopia d) macular degeneration
c) Presbyopia
What is the most likely treatment for a 45 y/o patient with presbyopia? a) Bifocals b) Progressives c) SV near d) Vision therapy e) brain surgery
c) SV near - Only have complaints of near
If a patient doesnt want to get another pair of lgasses and they didnt like progressive, what would you recommend? a) tough it out b) refer to VT c) Trifocal d) Hire someone to play the music as he writes e) memorize the music when working at near
c) Trifocal
A 45 year old who has never had an eye exam before is MOST likely going to complain of? a) Frontal Headaches b) Bilateral Eye pain c) Eyestrain d) Blur at Near
d) Blur at Near
Why does a patient with Myopic shifts, BVA not 20/20 and PHNI and has Cataracts, how would you ideally treat this patient if they refuse to wear glasses? a) Monovision CL b) Multifocal CL c) LASIK monovision d) Cataract surgery with multifocal IOL e) Traditional Cataract Surgery
d) Cataract surgery with multifocal IOL - Refer for cataract work-up - Need to establish that after cataract surgery, VA will improve = Use the RAM
What additional information is helpful? a) Near phoria b) Near vergence ranges c) NRA/PRA d) Range thru e) Amplitudes of Accommodation
d) Range thru
The patient is 65 years old, What test could we skip because it does not give us any more information? a) Near horizontal phoria b) BI range c) Near vertical phoria d) Stereo e) Amplitudes of Accommodation
e) Amplitudes of Accommodation = because hes got practically zero accommodation left
A patient comes into clinic and states, "My glasses are okay at distance and near but when I play piano, I have to move my head back and forth like a bobble-head". So how do you solve the problem? a) Try it for two more weeks and see b) Try using his older pair of glasses and see c) Use the near portion and sit closer to the piano d) Sit farther away and use the distance portion for the piano e) Separate pair of glasses for intermediate distance
e) Separate pair of glasses for intermediate distance
