Work to enhance patients’ functional vision
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Maximizing vision for our patients goes well beyond getting them to a visual acuity of 20/20.
How well a person sees in the exam lane is not the same as how they see to function in the real world. In fact, much of the data we have evaluating interventions and their impact on visual outcomes is artificially generated in a controlled environment.
Various conditions like low-lying eyelids, ocular surface disease and presbyopia affect patients' visual performance in their everyday activities. It is well established that declining visual function has a tremendous impact on quality of life. This makes it crucial that we treat patients holistically, going beyond acuity measured by lines on the eye chart and consider how patients truly use their vision.
Drooping eyelids
Mild to moderate ptosis affects about 12% of the population older than 50 years (Sridharan et al, Kim et al.). Not only can it cause patients to feel self-conscious about their appearance, but it also can affect higher-order aberrations, impacting activities of daily life.
It is important to realize that this begins to happen before the lid margin gets to the pupil, so even a fully unobstructed pupil can have higher-order aberration deterioration from an eyelid margin that is close. When the upper eyelid begins to lower it can affect the entire visual system. Many of these patients are not candidates for surgical correction yet can benefit from treatment to raise the lids.
A recently approved pharmaceutical option, Upneeq (oxymetazoline HCl 0.1%, RVL Pharmaceuticals), indicated for the treatment of acquired blepharoptosis in adults, has generated a huge positive response in my practice. It has also increased my awareness of ptosis and its impact on visual function.
FDA approval was based on two 6-week randomized, double-masked, placebo-controlled phase 3 efficacy studies of 304 patients that found oxymetazoline was associated with significant improvements compared with placebo in primary superior visual field and eyelid lift (Bacharach et al.).
We eye care specialists have an opportunity to treat this condition – one that has implications when it comes to how patients use their vision on a daily basis. I have had remarkable results with this novel treatment.
Dry eye disease
The tear film's lipid layer is the first lens of refraction in the camera of the eye. A poor-quality lipid layer leads to tear film break-up immediately upon blinking, causing fluctuating and blurry vision.
Treatments aimed at improving the quality of the lipid layer can extend tear break-up time, relieving the signs and symptoms of dry eye and enhancing good quality vision in between blinks.
Meibomian gland dysfunction (MGD) is the major cause of dry eye disease. Traditional treatment options for MGD such as hygiene, warm compresses, expression, nutraceuticals and prescription agents show some efficacy but may not be enough to keep the disease at bay over the long term. Intense pulsed light (IPL) (OptiLight, Lumenis) looks to directly address the lipid layer. A review published last year found that IPL is an effective and safe procedure for treating MGD (Tashbayev et al.).
In patients with poor tear film, point spread function and wave scans reveal deterioration in visual quality millisecond by millisecond as soon as patients open their eyes from a blink, which increases visual noise such as higher-order aberrations and glare (D'Souza et al., Yu et al.). In the real world this means decreased reaction times, a significant problem when it comes to driving, for example. Glare is one of the most significant factors contributing to confusion and slower reaction times.
Presbyopia
Presbyopia certainly affects vision outside the exam lane and its quality-of-life implications are huge. More and more Baby Boomers and Gen Xers are becoming presbyopic, and most prioritize maintaining their active lifestyle.
Some correction options like progressive spectacle lenses have significant drawbacks. Although all targets being viewed from any distance can be seen clearly, the viewer must be angled properly to see through the correct portion of the lens. Progressive spectacle lenses can distort peripheral vision, and these drawbacks can cause patients to stop participating in some activities. Add the increase in glare associated with presbyopia and we start to see a rapid decline of older patients who are comfortable driving in low light or at night.
Our treatments have consequences, and it is important that we as eye care providers are asking our patients the right questions about their lifestyle to prescribe the best solutions. Options such as refractive lens exchange for patients with dysfunctional lens syndrome as well as cataract surgery using recent advancements in presbyopia-correcting IOL technologies may be considered.
Presbyopia-correcting drops are creating a buzz, and they do show promise in clinical trials. We will ultimately need to evaluate these products based on real-world performance. What patients really want is to read a menu in a dimly lit restaurant, move around their environment comfortably, accurately judge steps and curbs, and drive.
A vast majority of our patients do not mind wearing spectacles at their computer. People do get annoyed, however, when they cannot see their watch or phone when they are on the go or see gauges when driving. People want solutions that help them navigate their world. Glare recovery goes down dramatically in presbyopes. If presbyopia-correcting drops can help that, it would be a key factor in their real-world success.
Helping our patients achieve their best possible functional vision should be the goal of all of our treatment; relieving symptoms or getting a patient to see 20/20 in the exam lane are only two pieces of the puzzle. Our patients depend on us to enhance their function in the real world.
References:
Aguirre RC, et al. J Opt Soc Am A Opt Image Sci Vis. 2008;doi:10.1364/josaa.25.001790.
Aguirre RC, et al. J Opt Soc Am A Opt Image Sci Vis. 2011;doi:10.1364/JOSAA.28.002187.
Bacharach J, et al. Clin Ophthalmol. 2021;doi:10.2147/OPTH.S306155.
Cahill KV, et al. Ophthalmol Plast Reconstr Surg. 1987;doi:10.1097/00002341-198703030-00001.
Chu BS, et al. Eye Contact Lens. 2009;doi:10.1097/icl.0b013e3181a1435e.
Cunningham D, et al. J Sports Perf Vis. 2021;doi:10.22374/jspv.v3i1.10.
D'Souza S, et al. Ind J Ophthalmol. 2020;doi:10.4103/ijo.IJO_2629_20.
Finsterer J. Aesthetic Plast Surg. 2003;doi:10.1007/s00266-003-0127-5.
Kim MH, et al. Eye. 2017;doi:10.1038/eye.2017.43.
Kumar DA, et al. Med Hypothesis Discov Innov Ophthalmol. 2013;2(3):86-91.
Lemp MA, et al. Cornea. 2012;doi:10.1097/ICO.0b013e318225415a.
Montés-Micó R, et al. Ocul Surf. 2010;doi:10.1016/s1542-0124(12)70233-1.
Richards, HS, et al. Eye. 2014;doi:10.1038/eye.2013.264.
Shen J, et al. J Ophthalmol. 2020doi:org/10.1155/2020/2653250.
Sivardeen A, et al. J Optom. 2020;doi:10.1016/j.optom.2018.12.004.
Sridharan GV, et al. Age Ageing. 1995;doi:10.1093/ageing/24.1.21.
Tashbayev B, et al. Ocul Surf. 2020;doi:10.1016/j.jtos.2020.06.002.
Tutt R, et al. Invest Ophthalmol Vis Sci. 2000;41(13):4117-23.
Yu AY, et al. Invest Ophthalmol Vis Sci. 2016;doi:10.1167/iovs.15-18985.
For more information:
Derek N. Cunningham, OD, FAAO, is director of the Dell Eye Institute for Dry Eye Research. He has a special interest in sports vision and performance and provides vision training services to several college and professional sports teams. He is the co-founder of SportsVisionPros.com. He may be reached at derek.n.cunningham@gmail.com.
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