Reading the Fine Print
The Herald, May 13, 2005
By Nick Vagnoni

Sooner or later, you'll find yourself holding the phone book at arm's length when you look up a number.

The stock listings in the newspaper will be blurry.

You'll wonder when the restaurant started using smaller type on its menu.

And then you'll acknowledge an inevitability: Like death and taxes, presbyopia is something you can't escape.

Also known as "old eyes," presbyopia generally begins for people in their 40s, said Bradenton ophthalmologist Murray Friedberg. "By 50 it's pretty consistent," he added.

Tiny muscles in the eye, called the ciliary muscles, move the lens to change its focus. But the lens becomes increasingly rigid with aging, and the little muscles can't move it as well. Eventually, they give up. The result: an inability to focus on nearby objects.

No, you can't go to the eye gym to keep those little muscles in shape, despite infomercials' claims. "There's really nothing you can do about it," said Friedberg. "It's really pretty universal."

Genetics play a big role in when presbyopia begins, said Wichita, Kan., ophthalmologist Mark Wellemeyer. By the time most people are in their mid- to late 50s, their presbyopia is as bad as it's going to get.

If you're nearsighted, taking your glasses off for close-up work may get you by for a time. But sooner or later, your arm won't stretch enough to get objects out where you can focus.

What are your choices when that day comes? You have several:

Reading glasses

For people who have otherwise normal vision, these "Wal-Mart glasses," as Wellemeyer calls them, work just fine.

Readers are available in a range of strengths, from 1.0 to 3.25 or so. You can buy them on your own, testing them in the store to see which suits your needs, or your eye doctor can prescribe them. They are inexpensive (unless you opt for the expensive ones).

People should "help their eyes as much as they can," Friedberg said. "The thing to remember," he continued, "is when you feel you need reading glasses, use them. People are afraid to use them because they fear they'll become dependent."

Friedberg also suggested that those with presbyopia should weigh the options of using reading glasses versus developing eye-strain-related headaches.

Readers can also be worn over contacts.

Bifocals

People who wear glasses to correct vision usually move to these prescription lenses. Two options are available: traditional bifocals, in which a visible horizontal line separates the part of the lens for close-up vision from the part for distance vision, and progressive bifocals, in which the parts gradually blend into each other.

Wellemeyer estimates that more than half of people getting their first bifocals choose the "no-line" glasses. People who have worn traditional bifocals often have difficulty adjusting to the no-line version.

Trifocals, which include a middle distance area for computer work, for example, also are available in traditional and no-line versions.

Contacts

There is a bifocal contact lens, Wellemeyer said, but only about 50 percent of those who try it can wear it successfully. More common is the "monovision" approach, in which the dominant eye wears a lens to correct distance vision and the other eye wears a lens for close-up vision.

Getting used to monovision contacts takes two to three weeks, Wellemeyer said, and "some people never adapt." Younger people usually do better at adapting.

Vision-correcting surgery

"There really are not a lot of surgical options for treating presbyopia," Wellemeyer said, though it can be done with the same procedures, such as lasik surgery, used to correct other vision problems.

But because presbyopia can worsen and because a monovision approach has to be used, surgery isn't a common approach.

If a person doesn't get suitable results with monovision contact lenses, there's no point in trying surgery. And surgery is a compromise: You don't get the best of either distance or close-up vision.

However, Friedberg said, if a patient does have good results with monovision contact lenses, that's a good indicator that surgical options may have similarly positive results. "That's the beauty of monovision," he said. "When you take the time to do a trial (with contact lenses), you're pretty confident that people are going to like it."

Lens replacement surgery

Traditional cataract surgery, in which an artificial lens replaces the natural one, doesn't correct close-up vision.

Seven or eight years ago, the Array multifocal lens implant became available for people having cataract surgery. Concentric rings allowed good distance and near vision - but created night-glare problems in many wearers. The Array lens still is available but not widely used, and it wouldn't be used just for presbyopia.

About a year ago, the crystalens replacement lens became available. It has tiny hinges that allow the lens to move, as a natural lens does. And those tiny ciliary muscles seem to start doing their job again, gently moving the crystalens.

But after implantation, the patient must do eye exercises to strengthen the muscles, a process that can take a year. "You have to be pretty motivated," Wellemeyer said. "And you have to do the exercises."

Another lens said to offer even better multifocal vision, called Restor, recently won Food and Drug Administration approval. It should be available beginning next month, Wellemeyer says.

Obviously, there are a wide variety of options available to people seeking to improve their vision. Different options have different virtues, and selecting the right one is a very personal process, Friedberg said.

"It's rare to have something that's so fantastic that it wipes everything else off the map. You need to talk to your surgeon to get a feel for what's best for you," he said. "We have to match the proper procedure, the proper lens, to the right person."

This report was written by Karen Shideler of the Wichita Eagle writer with local inserts by Herald staff writer Nick Vagnoni.

Medicare changes payment policy

This week, a ruling from the Centers for Medicare & Medicaid Services changed the policy on coverage for presbyopia-correcting intraocular lenses (IOLs) such as crystalens or Restor.

While Medicare covers most cataract surgery, it would not, until now, permit patients to pay the difference for an "upgrade" from a conventional replacement lens to a presbyopia-correcting lens.

While the new ruling would allow those receiving Medicare coverage to opt for a presbyopia-correcting IOL, patients would still be responsible for the additional costs of the "upgrade."

According to a recent article posted on the Web site of Cataract and Refractive Surgery Today (www.crstoday.com), costs to physicians for crystalens or Restor lenses approached $900 per lens. In some cases, this is nearly four times as much as costs for conventional replacement lenses. Lens cost to patients varies by practice.