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ODs must ‘stay on top of all things presbyopia’
After completing the examination, I handed my 80-year-old patient his eyeglasses. With a wry smile, he held them up and queried, “Hey, doc, didn’t Ben Franklin invent these things?”
It was obvious he knew the answer before asking the question and, knowing his sense of wit, I knew exactly what he was inferring. It’s been well over 200 years since Franklin fashioned his first pair of bifocal lenses and, well, here we are, still managing presbyopia the same way – with bifocals.
Granted, we have so many more options than the executive style flat-top of Franklin’s era. There are digitally enhanced progressive eyeglass lenses, annular design bifocal contact lenses, premium channel IOLs and even intracorneal inlays. While each represents a creative optical solution, they all remain fundamentally unchanged. We are still attempting to crutch a weakening accommodative system with optical multifocality. His look said it all: Shouldn’t you guys have something better to offer by now?
In virtually every area of eye care, we’ve witnessed technology advance in leaps and bounds. Intracapsular cataract surgery has given way to micro-incisional, femtosecond-guided procedures with outcomes often within 0.50 D of target. Contact lens care has evolved from a time in which you needed to be a chemist to properly care for your lenses to the age of daily disposables. We’ve moved well beyond accepting the collateral damage associated with laser treatment of diabetic macular edema to the use of intravitreal injections, the results of which we monitor with micron accuracy. However, for some reason, a cure for presbyopia eludes us.
Yes, I get it. Presbyopia is not a disease. No one ever goes blind from it. But it does afflict virtually everyone at some point beyond their 40th birthday. And – unless you’ve been deaf to your patients’ pleas – it is very much a quality of life issue. Just ask any patient who has populated every room of their home with reading glasses.
The challenge, of course, is that preventing and treating presbyopia is akin to preventing or reversing the aging process. It hasn’t been an easy task in other aspects of human anatomy and it has proven equally challenging for the crystalline lens. It’s not for lack of trying; just consider how long variations of scleral expansion surgery have been around. It’s just that we usually end up stymied and back to the drawing board for, you got it, another twist on optical multifocality.
Fortunately, this may all soon be changing, as there are a variety of pharmacologic agents being developed in the pursuit of presbyopia’s cure. Some of these agents, such as pilocarpine, carbachol, tropicamide and diclofenac, are widely recognize throughout eye care. Others, such as aceclinidine and EVO6, are relatively new to us. Whether these agents are intended to dis-conjugate the accommodative-pupil link or reverse cross-linking within the crystalline lens, they share a commonality. They are our first serious attempts at treating presbyopia in a non-optical way.
In this month’s issue of Primary Care Optometry News, our feature article, “Clinicians anticipate treating presbyopia with eye drops,” offers a glimpse of what presbyopia management may well look like in a few short years. While many of these treatment options are just beginning phase 3 clinical trials, early feasibility studies have shown promise from both a safety and efficacy perspective.
As most folks depend on optometrists for their primary eye care, it’s essential we stay on top of all things presbyopia – the research, the development and the implementation.
I know my patient will be pleased with our progress. In fact, he’ll likely agree with Ben Franklin, who once quipped, “Well done is better than well said.”