April 27, 2022
3 min read
Disclosures: Kannarr reports being a paid consultant for Allergan (an AbbVie Company) and Johnson & Johnson Vision Care.
In the digital age, intermediate vision is extremely important when people are using screens for as many as 12 hours a day.
Our patients’ visual needs are changing as they experience presbyopia, and we must update the way we think of our vision endpoints.
Seeing 20/20 at near on an eye chart at an optometrist’s office is not a true reflection of how well someone sees at all distances in real life. Even 20/20 on a near card varies from doctor to doctor — how many eye care providers are exacting when it comes to the distance at which they are holding the card? In truth, the standard visual acuity exam is performed in an environment that does not represent the real world. It is no surprise when patients — presbyopes in particular — struggle with their near vision in the exam room.
New tools, new times
We know that 20/40 near type is functional for 95% of a patient’s day in terms of working at a computer, reading a magazine or looking at a phone. That is why I believe this should be our standard. I have found that whether it is with the newly FDA-approved presbyopia-correcting drop Vuity (pilocarpine HCl ophthalmic solution 1.25%, Allergan) or multifocal contact lenses like Johnson & Johnson Vision’s Acuvue Oasys 1-day (which may help alleviate digital eye strain), patients experience little compromise to their distance vision when they are corrected to 20/40 vision at near. This endpoint represents functional vision that will accommodate most of their day.
Shane R. Kannarr
Vuity’s approval was based on data from two pivotal phase 3 clinical studies, GEMINI 1 and GEMINI 2, which included 750 presbyopic participants, 40 to 55 years old, who self-administered one drop of the product or placebo once daily in each eye. Both studies met their primary endpoints, with a statistically significant proportion of participants treated with Vuity gaining three lines or more in mesopic, high-contrast, binocular distance corrected near visual acuity, without losing more than one line of corrected distance visual acuity at day 30, hour 3, vs. placebo.
In my experience with the drop, patients can achieve 20/40 at near or intermediate, which allows them to be functional for approximately 10 hours a day. That lets most people commute to work, get home and meet the day’s near-task demand. Complaints such as experiencing dim vision or a sensation of inadequate lighting resolve over the course of a week for most of my patients.
How we are responding
To address the changing visual demands on today’s patients, we have redone our near cards to 20/40. We have repeated the 20/40 line several times, as we know that patients feel best when they can achieve the bottom line. In addition, we try to recreate real-world lighting conditions by turning on the lights in the exam room and having patients read their phones.
We also have to talk to our presbyopic patients about self-adjusting to help them to see their best. Using Vuity as an example, a drop in the morning might allow patients 3 or 4 hours of great vision at 16 inches. If they slowly increase the viewing distance as the drop’s effect wanes, they can see well for 8 or 10 hours. I let patients know that during the day, they may need to adjust and ensure they are not crowded up to their desktop at work; instead, they should maintain a more comfortable distance. Remember, too, that most computer screens are high contrast, whereas a newspaper (or a near card) is black and white or gray on gray.
Understanding that with varying real-world visual demands, there can be no one solution that always works for all patients, so we need to reset patient and doctor expectations. I believe Vuity is a great product for people to use during the workday, and they may need to supplement with progressives at home. I advise eye care providers to develop treatment protocols for presbyopia, instead of a one-size-fits-all approach.
I believe we should completely involve patients for an interactive decision-making process, asking them about their needs and how they use their vision day to day. If we expose them to a variety of presbyopia-correcting solutions, we can find out how each option fits their lifestyle, keeping in mind that presbyopia is a progressive condition.
As optometrists, we should stay open-minded to a variety of treatments and not be afraid of failure. Not everything works perfectly every time for every patient. It is a process, and we can make tweaks as necessary. With Vuity and other presbyopia advances in our tool kit, it is time for a fresh look at how we define and achieve successful outcomes for our patients.
For more information:
Shane R. Kannarr, OD, is in private practice at Kannarr Eye Care in Pittsburg, Kansas. He may be reached at email@example.com.