Let’s talk about… Presbyopia

Or when it becomes increasingly hard to tell what bottle is shampoo and what is conditioner when you are in the shower.

These are the markers that chart the gradual journey from using your phone as a beacon at a concert to using that same light to read a menu at a restaurant.

Johnson & Johnson faculty member and locum optometrist, Clair Bulpin explained to OT that while presbyopia is a normal part of ageing, the emotional aspect of presbyopia can be overlooked.

“Presbyopia just unceremoniously and indiscriminately arrives and clouts you with the realisation that everything is changing and even when you are prepared, it still comes as a shock,” she said.

A study by Wolffsohn et al in 2020 analysed comments across different social media platforms to understand common themes in how people experienced presbyopia.

Seven in 10 posts discussed the emotional impact of the condition. Perhaps unexpectedly, this was a more common discussion point in relation to presbyopia than reading difficulties (discussed in 57% of posts).

“Practitioners should not underestimate the emotional impact of these visual changes,” Bulpin emphasised.

She highlighted that while there is no method for preventing presbyopia, eye care professionals can play a key role in supporting patients and their changing needs.

“The wellbeing of the patient is about more than just ensuring they see well – it includes feeling good about seeing well too. The freedom that contact lens wear provides can contribute positively to a patient’s overall wellbeing,” Bulpin shared.

Tell-tale signs

Bulpin explained that most presbyopes know there is something not quite right with their vision.

In the past, emerging presbyopes may have been identified by stretched out arms or a jaunty angle of the head trying to capture the best light.

However, with developments in technology, there are more subtle ways for adjusting to the vision changes that accompany presbyopia – such as using a larger screen or font size.

“Life is spent on a screen, and whilst that longer working distance may buy some time, it doesn’t prevent the inevitable,” Bulpin said.

“It does mean though that symptoms can be avoided more easily, and as practitioners, we may need to rethink our lines of investigations,” she highlighted.

The wellbeing of the patient is about more than just ensuring they see well – it includes feeling good about seeing well too

The optometrist added that a patient who presents without initial symptoms but struggles to read N5 on a test type chart has probably found their own solutions to their changing sight.

Bulpin recommended asking the patient questions about changing habits – such as whether the patient has moved to a larger screen or font size, or if there is anything they used to be able to do easily that now requires a different approach.

“Many patients may simply lose interest in a hobby or activity which they can no longer see with ease,” she said.

Bulpin highlighted that contact lens wearers may present with a change in wearing habits rather than visual symptoms.

“A long-term contact lens lover with reduced wearing time should be viewed with caution. We understand the science, the fact that accommodative demand in contact lenses is higher for myopes than hyperopes, and presbyopia happens to us all, but all they know is that they can’t see as comfortably as they used to,” she said.

Locum considerations

Bulpin highlighted the importance of considering the unique needs of each patient in order to provide the best recommendations and advice.

While a resident optometrist will often see patients regularly over the course of several years, locum optometrists may be seeing a patient for the first time.

“You will often have a single interaction with a patient, rather than the opportunity to build a relationship over multiple visits. You must gain the trust of the patient to elicit these finer details in a single encounter,” she said.

“You will need to know the available presbyopic options in the practice you are in, and fully engage with these, even if this requires onward referral to another practitioner to complete the process,” Bulpin shared.

Turning to developments in presbyopia, Bulpin highlighted the importance of keeping up-to-date with the latest advancements.

She shared that a study by Professor Philip Morgan et al in 2023 of soft contact lens wearers suggested that around 34% of wearers were potentially not having their presbyopic visual needs met.

“Fitting presbyopic contact lenses is not the dark art it used to be: materials are better, parameter ranges are larger, and designs are ever improving,” Bulpin said.

Trusting the fitting guides is a key element to success for Bulpin.

“There is a reason that companies invest time and energy into helping you to get it right. These vary across the board but have all carefully been put together to aim for the best initial outcome,” she shared.

Presbyopic pearls

When asked for her words of wisdom on fitting presbyopic patients, Bulpin returns to advice she was given when working as a pre-registration optometrist: if you were fitting the patient for the first time today, what would you recommend and why?

“As a locum optometrist many years down the line, this mantra continues to serve me well. It ensures that I have an honest conversation with my contact lens patients both for new and existing wearers,” she shared.

“Even if an existing wearer seems happy with their current set up, this approach allows you to simply offer up latest the available options,” Bulpin added.

Prioritising clear communication is also a core element of successful contact lens fitting, Bulpin emphasised.

“When we get this right, we all benefit. Recognising when the patient’s wellbeing and vision can both be helped, can only lead to positive outcomes for patient and practitioner alike,” she said.