As eye care professionals are quick to point out, no two patients are ever alike. The diversity of patient experiences, expectations and visual needs can lead to a sprawling domain of individualised solutions. Three prominent eye care professionals Drs. Kokkinakis (Australia), Maino (United States) and Wolffsohn (United Kingdom) discuss important issues around eye care and vision. Their responses present a rich tapestry of interventions that can be embraced by your practice.
Q: What measures do you take to identify patient interests, needs and dissatisfaction related to vision correction?
Dr. Kokkinakis: We use an entry survey to identify the vision needs, expectations and perceived problems of new patients. Existing patients tend to tell us about new problems or changes in lifestyle.
Dr. Maino: I ask the right questions, pay attention to the answers, and then do everything I can to solve the problems, as perceived by the patient. If necessary, I refer to colleagues.
Single, clear, comfortable, binocular, and pathology-free vision should be sought for all our patients. If a binocular vision problem is suspected, a visual efficiency evaluation should be scheduled
Dr. Wolffsohn: History, symptoms and casual conversation help best. There are plenty of options to improve symptoms.
Q: What types of spectacle lenses do you recommend and why?
Dr. Kokkinakis: I tend to prescribe premium quality lenses, which are cosmetically more appealing and can correct for optical aberrations.
Dr. Maino: I prefer the latest lens technology as a part of my visual therapy program. I often use progressive addition lenses (PALs) to improve appearance and functionality. I also use single-vision spectacles for specific tasks, such as computer use.
Q: What are the primary reasons for patient dissatisfaction with vision correction in
your practice?
Dr. Kokkinakis: We see two main causes – night vision aberrations due to increased pupil size and irregular corneal shapes, such as keratoconus. Both issues are best corrected with aberration-controlled contact lenses. We also deal with dryness, eye-strain or other ocular symptoms of computer vision syndrome.
Dr. Maino: Squinting, headaches and other discomforts are associated with myopia but are well addressed with new light-weight and thin lens materials, as well as the various tints, coatings and finishing options that make even the higher magnitude prescriptions acceptable. Those with hyperopia often need ongoing patient education to help them realise the benefits of corrective eyewear.
Dr. Wolffsohn: Patients complain of end-of-day dryness and resulting restriction of lens wear, especially if they have worked on computers all day. Being required to stop lens wear due to illness or infection is another concern. Uncorrected astigmatism and presbyopia are also patient concerns.
Q: What can be done to reduce or eliminate focusing problems?
Dr. Maino: Non-presbyopic adults can experience focusing problems, just like children, frequently for the same reasons. Single, clear, comfortable, binocular, and pathology-free vision should be sought for all our patients. If a binocular vision problem is suspected, a visual efficiency evaluation should be scheduled. If a patient confuses tear film anomalies and their associated symptoms as representing a focusing problem, a further evaluation of tear production and quality may
be required.
Dr. Wolffsohn: Generally, patients overcome presbyopia in one of the following ways: Wearing reading glasses (replacing contact lenses or supplementing distance-correcting refractive surgery); wearing multifocal spectacles (although peripheral vision is distorted); turning to multifocal contact lenses, intraocular lenses or refractive surgery (although light passing through the pupil needs to be split between different distances, reducing the ability to distinguish low contrast and also causing glare and halo effects in many cases); adopting monovision; and using a combination of the methods mentioned above. Future technologies will include better multifocal designs that will minimise visual compromise.
Q: What is your typical approach to treatment of visual dysfunction?
Dr. Maino: I tweak the treatment program to meet the individual needs of each patient. This approach continues until the problems are resolved.
Dr. Wolffsohn: I add one element at a time, under-promise, over-achieve and monitor regularly.
Q: How important is it to have rotationally stable designs for soft and hard contact lenses that can be imprinted with an individual’s aberration profile?
Dr. Kokkinakis: Nearly three-quarters of the patients in my practice could benefit from such a lens. A significant minority of contact lens patients fail or complain due to uncorrected aberration profile. Also, if we could customise contact lenses every year or two, we could curb loss of patients to the internet.
Dr. Wolffsohn: These lenses would be essential, as would centration and a stable tear film.
Q: How does contrast affect vision and how can vision be optimised for low-contrast tasks?
Dr. Kokkinakis: Contrast may prompt me to recommend cataract surgery, a change from soft contact lenses to rigid gas permeable lenses or the addition of anti-reflective coating to spectacle lenses.
Dr. Maino: After personally experiencing cataracts, I know that contrast plays a significant role in our daily ability to function. We need to make sure patients affected by this problem know to use extra caution when driving, especially when it rains or when it is foggy.
Dr. Wolffsohn: Contrast can usually only be directly altered on electronic devices, but can be affected by lighting. Adjustable, focal lighting is important.
Q: How much of an issue is the presence of glare and halos for your patients, particularly when encountering high intensity headlights?
Dr. Kokkinakis: When probed, most patients will at least say they have noticed this.
Dr. Wolffsohn: Many patients reduce their night driving. Problems can go under-reported.
Q: What solutions do you recommend for glare and halos?
Dr. Kokkinakis: The solution depends on what is causing the problems.
Dr. Wolffsohn: I use anti-reflective coatings, full visual correction
(including astigmatism) and careful selection of multifocals.
Q: What visual correction for presbyopia provides the least strain on vision and the best range of clear vision?
Dr. Kokkinakis: Any patient who works for more than a couple of hours on a computer each day is best suited for an intermediate or near office lens.
Dr. Maino: I use the most appropriate PAL available for the visual demands of the patient. Then I move on to standard bifocals and/or multiple pairs of glasses and contacts.
Dr. Wolffsohn: I use multifocals, but I expect that they will be surpassed by accommodating intraocular lenses in five to 15 years.
Q: How does standard measurement of visual acuity relate to everyday vision on the move?
Dr. Kokkinakis: There is some correlation, especially for the young. As the patient ages or if he or she has some irregularity anywhere in the ocular media, the correlation seems to drop off.
Dr. Wolffsohn: Dynamic vision is influenced by cortical factors, quality of the tear film and stability of the
visual correction.
Q: How often do you make a change in vision correction to address patient convenience?
Dr. Kokkinakis: This occurs often. During an examination or interview, we establish as many vision requirements as possible. We then present vision solutions, dependent on task, in a menu format.
Q: Why do patients want vision that is as natural as possible and how do you provide correction that will create this effect for them?
Dr. Kokkinakis: Patients who have achieved good vision in contact lenses prefer contact lenses because it spares them peripheral distortion. This desire increases with higher levels of ametropia and even small levels of astigmatism. However, many first-time multifocal wearers are quite distressed at the small reading areas and peripheral distortion associated with most designs.
Dr. Maino: All patients want natural vision. For adult presbyopes, PALS usually represent the best approach. I also use PALs for non-presbyopes who have binocular vision dysfunctions.
Q: How do you meet the vision correction needs of patients who are involved in sporting activities?
Dr. Kokkinakis: These solutions typically involve contact lenses.
Dr. Maino: Protective sports glasses are often recommended.
Q: What other occupational or activity-based recommendations do you make?
Dr. Maino: For presbyopes who need clear vision while looking up, I may use a reverse add or multiple pairs of glasses. For computer users, a separate pair of computer glasses may be needed. For patients who are competitive shooters or hunters, I will use various tints and or prism.
Dr. Wolffsohn: Ultraviolet protection is desired for those with outside jobs or pastimes, such as sailing or skiing.
Q: What can be done to decrease or eliminate asthenopia?
Dr. Kokkinakis: Patient education can play a significant role. I also recommend careful binocular vision assessment and careful refraction, looking for small refractive errors combined with small adds and prisms.
Dr. Maino: Diagnose and address the problems you find. Improve the tear film layer and conduct optometric vision therapy.
Dr. Wolffsohn: Optimise the visual correction and oculomotor function.
Q: If someone has noticed decreased performance at school, work or play due to vision problems, what can be done to diagnose and treat these problems so that outcomes improve in all areas?
Dr. Maino: Assess the presence of any vision information processing anomalies. Research sponsored by the National Eye Institute at the National Institutes of Health has clearly shown that optometric vision therapy is the most efficacious and long-lasting intervention for binocular vision problems. Either enrol your patient into a therapy program or refer them to someone who provides therapy.
Q: How do the vision problems that affect school, work or play differ? How are they the same? Please elaborate.
Dr. Kokkinakis: Vision problems depend on environment, lighting, concentration times, refractive and binocular status and the age of the patient. Some vision needs require stability while others require excellent peripheral vision.
Dr. Maino: Learning-related vision problems can affect all areas and will take many forms. Some of these
problems involve binocular vision anomalies. Others, such as strabismus and amblyopia, can be more complicated.
A third possibility can include dysfunctions associated with vision perception. Finally, a combination of any of the above can occur. As primary eye care providers, we must diagnose, treat and refer for treatment those patients suffering from this disorder, which is frequently encountered and affects
quality of life.
Dr. Wolffsohn: The severity of visual problems are dictated by lighting, contrast, dynamics, resolution, complexity and distance of task, so they will differ between work and play, depending on the environment in which the activity occurs.
Conclusion
Whether for school, work or play, vision is of paramount importance to patients. For eye care professionals, that means it is essential to focus on more than just high contrast letter acuity. Measurement of visual function and vision correction should be targeted toward each individual patient’s lifestyle and concerns.
Dr. Jim Kokkinakis is a Fellow of American Academy of Optometry and partner in The Eye Practice, a Sydney-based optometry practice that specialises in using cutting-edge diagnostic technology including Retinal Digital Photography, Optical Coherence Tomography and Corneal Topography.
Dr. Dominick M. Maino, OD, MEd, FAAO, FCOVD-A is a Professor of Pediatrics/Binocular Vision at the Illinois Eye Institute/Illinois College of Optometry, USA and is in private practice. He is the editor of Optometry & Vision Development and has authored 200 books, chapters, and articles.
Professor James Wolffsohn is Deputy Executive Dean for the School of Life and Health Sciences at Birmingham Science City in the UK. His research and teaching interests mainly revolve around intraocular lenses, contact lenses, low vision and the measurement of accommodation. Prof. Wolffsohn is a past President of the British Contact Lens Association and has been extensively published.
