Mitchell Jackson, MD, and Melissa Bollinger, OD, of Jacksoneye in Lake Vila, Illinois discuss how offering presbyopia drops to emmetropic patients experiencing vision changes due to "The Big A.G.E." can open the door to long-term relationships.
TRANSCRIPT
Mitchell Jackson, MD: Hi, I am Dr. Mitch Jackson. I'm here with my associate, Dr. Melissa Bollinger, at Jackson Eye. We're really excited to talk about our paper in the November/December issue of Ophthalmology Management, “The Foundation of Future Care.”
So, presbyopia drops, that's where it's at. [Like] many of you, we encounter patients in our clinic every day. They're all frustrated by the effects of presbyopia, and I call it the “A.G.E.” syndrome because they're looking for solutions [when] they wake up and go, “Why can't I see any more up close?” As eyecare professionals, MDs and ODs, we treat these patients with optical glasses, contact lenses, multifocal contacts, and surgical devices. And if they get a cataract, we might have options, but if they don't have a cataract yet, we really have no options right now. So Dr. Bollinger, who's the ideal candidate for these presbyopia drops?
Melissa Bollinger, OD: Yeah, I think we've discovered there's some definite niches here. So, I think, number one, that patient who is just now…wearing glasses for the first time in their life—maybe it's their first eye exam. They come in, they've got reading glasses, they hate them, maybe they're embarrassed by them. They want a new solution. So, people like [presbyopia drops]. They love that—there is another idea. They're talking to their friends about reading glasses. They don't even know this exists.
Definitely post-LASIK patients. You and I both have talked about that many times: the type that comes in [saying] they had surgery 20 years ago and now it's worn off, according to them. In all actuality, they see great in the distance, and they of course just have presbyopia. So we all know LASIK patients definitely don't ever want to wear glasses in their entire life. So they love this idea of presbyopia drops.
Contact lens wearers: same thing. They went into contacts because maybe they don't like glasses, maybe they don't see as well with glasses, and now they don't want to concede to it just because they're aging. So they like the idea of a drop [and] that they're not having to grab glasses all the time. And post-cataract patients, I think the ones that maybe regret [that] they went with a monofocal and they realize how bad their near vision is now. Or somebody who just wants to enhance their blended vision or their monovision with an implant.
Dr. Jackson: So the great news [is] if they don't have a cataract yet—we know all of you do cataract surgery—we have options for those who don't do cataract surgery; we have glasses, contact lenses. But now we have 3 options. There are 3 presbyopia drops approved by the FDA. We've been involved in our practice in many of the clinical studies for these presbyopia drops, the current ones and some that are coming in the future. But Vuity was the first, 1.25% pilocarpine. It was approved in 2021, and they also did a follow-up study [demonstrating that] you can use it twice a day. But pilocarpine, we know there could be potential side effects. And Qlosi, the next one, the one we're currently using in our practice as well as Vizz, which is 1.44% aceclidine, which just recently got FDA approved, announced at the AAO meeting in Orlando. Qlosi is 0.4% of lower dose pilocarpine. And the good thing with this, with 2023, is it's preservative free, easy to use, and customizable. So, Dr. Bollinger, we have 3 drops. So how do we approach this with our presbyopiate patients? How do we introduce them and how do we choose?
Dr. Bollinger: Yeah, I think it's important that we educate the patients that just like any other disease—glaucoma, dry eye—that [presbyopia] is a progressive disease. There's going to be different stages. So if they're early in on this, they can kind of alternate maybe between glasses and the drop. I think they have to understand it's not a perfect solution and sometimes the drop is going to be better. Sometimes glasses will be better if they work on spreadsheets and they need more magnification than a drop is going to give them—setting realistic expectations. And I think a lot of these patients come in and they do feel like this is the first stage of aging. They're frustrated, they're embarrassed. They don't want to be seen with glasses. And I find people get really excited when you bring it up. I've talked to colleagues that say, I don't know my patients will like this every time I bring it up. They're all into this idea. People really hate glasses.
Dr. Jackson: What I'm learning—well, it's the aesthetic age. So unless you're very aesthetically known for wearing glasses, like Elton John or somebody like that, people really don't want to wear glasses right now.
So we see a lot of presbyopia patients. We've done a lot of refractive surgery on our patients, so we have to educate our staff, correct? Because unless we educate our staff—they're the ones first talking to a patient, to bring it up and tell them there are options now—because not everybody has a cataract that needs to come out yet and they're frustrated, these patients. And we need to perform a thorough evaluation, most importantly, with any of these presbyopia drops, because a couple of them are, they're working on the ciliary body or the pupil, and it can cause pulling on the retina, so to speak, or the vitreous, and cause potentially a retinal complication. So you must do a dilated retinal exam. Now, do you have to be a retinal specialist? No. You can refer to a retinal specialist if you see something kind of borderline, but you have to do a dilated retinal exam as part of this evaluation. And then you need to market to patients. You have to set realistic expectations—first of all, we have to, when patients come through the door, we have to set their realistic expectations. It's like, for example, Dr. Bollinger, what's the first you say to a patient [who says something] like, “I'm going to be on this presbyopia drop.” So they expect it to be the miracle drop, and then you have to tell them [that there can be] side effects. It’s going to take a while.
Dr. Bollinger: Yeah, definitely. I think you and I both have chatted about, we've learned along the way the whole neuroadaptation process, just like…a dry eye patient, the one that wants to try a drop for a couple days and declare it a failure. It's the same thing here. We have gotten better about realizing we need to explain that you’ve got to use it probably 2 weeks to let the brain neuro adapt. It's a completely different mechanism, this myosis, versus throwing a magnifying lens on and letting the brain adapt. And like you said, they definitely need to be educated on side effects. No different than any other medication. They should expect some transient headaches. Most patients get through that, maybe they get some redness or burning upon installation, usually transient. And definitely [tell them] that “You have to be patient with it and give yourself, your brain, time to adapt to it and decide if it really is for you.”
Dr. Jackson: Right. So we will bring patients in, we'll do a thorough evaluation, and then we'll prescribe the drop and then we tell them, “At least give it 2 weeks.” We tell them, as Dr. Bollinger eloquently said, what potential side effects are. If they notice flashes or floaters, [they’ve] got to call right away to come in. If they have a lot of redness, more than the normal, they’ve got to come in. We try and get them through the headache stage, if they get headaches. And we have to encourage their commitment to this, because it's like anything else—there's a change in the eyes. I mean, if we have a blue eye patient, for example, now their pupils are pinpoint. We’d better set that expectation [for] them, especially if they're like a model and they're doing filming. So there's a lot of different things you have to set expectations [for] with all these different drops. They all have different tolerances and side effects, but they all work. They're all FDA approved. There's more coming. And so, this is a great option now for our “A.G.E. syndrome,” as I like to call it. Our presbyopia patients—whether they're post-LASIK and a monofocal lens, or they're in glasses or contacts and frustrated. Dr. Bollinger, final comment.
Dr. Bollinger: I think the most interesting thing to me is [that] just in the US alone, a third of the population has presbyopia. So you definitely don't want to ignore it. You want to get involved in it, your patients are going to find it. You got to feel comfortable with it as far as setting those expectations, knowing what to look for. But I think if you give it a try in your practice, you'll be glad you did.
Dr. Jackson: And presbyopia, the A.G.E. syndrome, is not going away, unfortunately. It’s the next pandemic, because all of us don't like to be stuck not being able to see up close. So this has been great. Presbyopia drops, give 'em a try. There are options. And if one doesn't work for a patient, maybe the other one might work for the patient. But at least they exist. And that's what our paper's about in Ophthalmology Management. Thanks, Dr. Bollinger. Thanks, Ophthalmology Management. Thank you. I'm Dr. Mitch Jackson. And remember, once your patients are on eyedrops, they can say, “I did.” OM
