Consider potential of traditional visual correction for older patients

When contemplating the management of older patients, some optometrists might immediately think low vision. But there is a growing population of active older people who are seeking glasses, contact lenses and even refractive surgery, and optometrists should be ready to meet the more conventional correction needs of this burgeoning group.

Jordan Kassalow, OD, MPH, in private contact lens and laser specialty practice in New York, said older people often come to him for contacts because they become tired of their glasses or because one of their friends got contact lenses. “They present with certain requests or complaints, and it’s our job to address those,” he said.

Contacts: an underused option

William L. Park, OD, FAAO, director of the Low Vision Service at the Wilmer Eye Institute, said that in many cases, older patients are incorrectly directed not to try contact lenses. “I see that all the time: patients who should be in contact lenses but aren’t,” he said.

Dr. Park said he is not sure why many practitioners shy away from fitting older patients — perhaps because it is often more demanding than fitting those who are younger. The added challenge may influence some practitioners who feel they cannot afford to sacrifice the chair time.

That being said, contact lenses are a viable option for many older patients, and issues for contact lens-wearing patients often have less to do with the correction than with how the patient is able to handle the lens in the eye. Dr. Park said, “With contact lens technology the way it is, you can fit just about anybody with a contact lens from an optical standpoint. It’s a question of whether they can tolerate it physiologically or can handle the lens and the care regimen.”

A primary issue, Dr. Park said, is whether a person can actually physically manipulate the lens: “Probably the number one issue is whether they can handle the lens and insert it and remove it.”

Physiological issues such as changes in the composition and quantity of patients’ tear film as they age are also crucial. Dr. Park said contact lens practitioners must consider that older people have reduced tear volume, so they should decide whether these patients can generate enough lubrication to wear a contact lens.

Choose the proper material

Dr. Kassalow agreed and said in fitting people older than 65, “The most important thing to consider is the use of proper materials. Because their eyes are naturally drier, contact lenses can be more difficult to accept or tolerate. As a result, it’s important to select your plastics carefully, plastics that tend to be better for the dry eye patient.”

He chooses lenses with lower water content or with special properties that prevent them from dehydrating. Good examples of the latter, he said, are Proclear Compatibles (Biocompatibles, Norfolk, Va.) and the Extreme H2O lens (Benz Scientific, Sarasota, Fla.), which have low dehydration rates. Another alternative, Kassalow said, is for patients to use a daily disposable lens, as the constant lens replacement will help reduce problems caused by drier eyes.

Gas-permeable bifocal lenses clearly outperform the soft bifocal lenses, Dr. Kassalow said, and these lenses can also be good for dry eyes because they do not require water. Some people do not accept monovision, he said, “and it’s simply a matter of testing them.”

Dr. Kassalow also pointed out that all older patients have presbyopia and will require either a bifocal contact lens, monovision or distance contact lens with a pair of reading glasses. He said it does not make sense to give people a good contact lens fit and then have them buy cheap reading glasses, “which can destroy the optics.” His practice uses optical-quality reading glasses that are fairly priced, about $50 to $60. “They fly off the shelf here,” he said.

In fitting older patients, it is important for the patients’ families to participate, particularly for very old patients — those in their late 80s or 90s. Dr. Kassalow described a 90-year-old man who was keratoconic in his left eye and had macular changes in his right eye. The ophthalmologist wanted a keratoconic lens, and Dr. Kassalow said he brought the family in to show them how to insert it. Dr. Park said he has patients with Parkinson’s disease who must wear contact lenses because of a disparity between their two eyes but must rely on a spouse to insert the lenses.

Determine function, activity level

Determining a patient’s level of function and activity is also highly important. Dr. Park said he gives patients a 20-page function/activity questionnaire that includes questions on kitchen-related activities and driving.

Dr. Kassalow assesses his patients’ level of activity and function through conversation. “Talking to them is the most important thing,” he said. “By talking to people, you get a sense of their lifestyles or visual needs.”

He asks a variety of questions, such as: What are your hobbies? Do you use the computer a lot? Dr. Kassalow said he sees an 84-year-old patient who still plays squash. “For someone like that, you treat him just like he’s a 25-year-old, but in an 84-year-old body.”

The value of conversation is “really true with any age group, but elderly people appreciate it, possibly more than anyone does,” Dr. Kassalow said. The most important thing, he said, is “to really take the time to listen to them. In our society, people don’t have time to listen to people, particularly elderly people, because their thought process can be hard to follow. But it’s really critical to take that extra time in the history portion of the exam, which will give a clearer sense of the issue you’re trying to solve. Additionally, you become a hero of the elderly patient because you’re a doctor who actually listens and spends some time.”

As an added benefit of being a good listener, these patients will often recommend him to their family and friends, he said.

Tinting, coating important, too

Tinting and coating are essential to consider when correcting older patients’ vision. Many elderly people come to his practice complaining of increased glare or decreased vision, Dr. Kassalow said, so choosing the proper coatings and lenses is important to their satisfaction.

Dr. Kassalow said because older people tend to have cataracts, “They are already subjected to an increased chance of experiencing more glare than the average person. Contact lenses can also lead to increased glare, which makes it imperative to choose a proper pair of sunglasses.”

Tinting is also important for protecting the eye against ultraviolet light. With spectacles, he said, an anti-reflection coating is important to consider. Sometimes, he even prescribes yellow-tinted driving glasses for those particularly susceptible to glare, especially those who tend to drive at night.

“With my patients, we do a lot of tinting,” said Dr. Park, and he uses a lot of absorptive lenses, especially CPF lenses from Corning Medical Optics (Corning, N.Y.) because of glare, flare and other complaints. He also finds these types of lenses helpful for those with macular degeneration or those who have cataract formation that is not ready for surgery.

“Every patient is evaluated to determine if he or she would benefit from absorptive lenses or tinted lenses,” Dr. Park continued. “We even have patients go outside to be evaluated outdoors before they make a decision.”

Dr. Park said tinting is important not only in reducing glare but also in improving contrast sensitivity capability. In most of his patients, he said, contrast sensitivity is greatly reduced. “When going down a flight of stairs, they don’t know where one stair ends and the next begins. And those lenses will help with that,” he said.

When to opt for refractive surgery

Dr. Kassalow said that in people 65 and older he rarely considers refractive surgery the best option. In his practice, only a small percentage of refractive procedures are done in those older than 65. “Many patients that age fail our laser surgery screening because of dryness,” he said. “Their eyes just don’t have the lubrication we feel they need.”

Older people in his practice also tend to fail because of early cataract formation. “It seems as if the laser can exacerbate and advance the symptomatology of cataracts,” he said.

Dr. Kassalow said his practice also does not recommend laser surgery in those with lenticular changes, which rules out most patients 75 or older.

Dr. Park, however, said he thinks a patient’s experience with refractive surgery probably varies considerably depending on the practitioner. “It depends on how comfortable practitioners are, even how ethical,” he said. “With refractive surgery, if patients have the appropriate corneal thickness, there’s no dystrophy and surgery indications are appropriate, I think age is irrelevant.”

He added that more and more older adults are having refractive surgery, as outcomes for the procedures are becoming more certain.

It is perhaps unfortunate that some practitioners can be reluctant to pursue laser vision correction in older people. “There will be more and more older adults who are very active and very involved, and they’re going to want and demand those services,” Dr. Park said.

Dr. Kassalow said when dealing with older patients, practitioners must primarily provide good medical care and good primary and secondary eye care, and they must spend the right amount of time diagnosing the patients’ eye disease. Surgically comanaging these patients will continue to be lucrative, he said.

Dr. Kassalow also recommends being sensitive to these patients’ optical accessory needs. Proper frames are important, as well as nose pads, because older people tend to have more sensitive skin. Finally, he said, low vision remains a major area. “Low vision will increasingly continue to be an issue here in the United States,” Dr. Kassalow said, “so practitioners will have to get better at providing low vision services.”

For Your Information:

• Jordan Kassalow, OD, MPH, can be reached at 30 E. 60th St., New York, NY 10022-1008; (212) 355-5145; fax: (212) 308-3262; e-mail: jkassalow@mindspring.com. Dr. Kassalow has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• William L. Park, OD, FAAO, can be reached at Johns Hopkins University, 550 North Broadway, Sixth Floor, Baltimore, MD 21205; (410) 455-0580; fax: (410) 955-1829; (410) 955-0580; fax: (410) 614-7965; e-mail: park@lions.med.jhu.edu. Dr. Park has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.