Eyeworld

43 EW REFRACTIVE May 2017 "Perfectionists can be a prob- lem because we cannot make them young again, just provide different compromises to improve their abili- ty to function," Dr. Price said. The tone of a patient's voice, followed by their words, provides Dr. Waltz with the most insight. "If the conversation goes, 'I saw my optometrist and they said I wasn't seeing so great, but I'm OK. I'm not sure why I'm here, but here I am. What do you think?' their words and their tone don't encour- age me to do anything because they are not having symptoms that are really bothering them," Dr. Waltz said. "That compares to a patient who says 'Doc, I went to my doctor because I couldn't see and basically they said I was fine but I don't be- lieve them. What do you think?'" Among the questions Dr. Lee asks is whether the patient has worn contact lenses and whether they are visiting because they can't tolerate contacts any more or whether they are just annoying. He asks whether they tried monovision, and if so, what they thought of it. "The type of near activities they do are very important—do they need intermediate things like working on a desktop or playing the piano or close up things like reading small print?" Dr. Lee said. "Knowing their occupation is important, but so are their hobbies because some people are content to wear glasses at work or home but not vice versa." Diagnostics help Among the diagnostics Dr. Lee uses to understand the lenticular status of patients with 20/20 best-corrected vision but who are frustrated with their low light image quality is vi- sual acuity and glare testing using a reduced contrast sensitivity setting, which helps pick up some low light issues. "There is no diagnostic test that is as reliable as the history; although we have the iTrace [Tracey Technol- ogies, Houston], I do not rely on it," Dr. Lee said. Dr. Price has found iTrace best objectively measures dysfunction of the crystalline lens. "It simulates how a letter 'E' is distorted by aberrations of the anterior corneal surface, the internal optics, and both combined," Dr. Price said. Dr. Waltz also has found the HD Analyzer System (Visiometrics, Terrassa, Spain) and Optical Quality Analysis System (OQAS, Visiomet- rics) helpful in such patients. "What's helpful about the Visiometrics and the iTrace is that they provide an image so that you can have a conversation with the patient and the family," Dr. Waltz said. "Quite often the family doesn't understand what the patient does." Diagnostic tests also are helpful to educate patients, Dr. Waltz said, especially when they expected to get lens surgery but instead need to have a specialty contact lens. "They are not prepared for that," Waltz said. "So, additional diagnostics tests are very helpful." Approaches offered Monovision and blended vision are offered to patients who are presby- opic and correctable to 20/20 vision but who complain of poor low light image quality, Dr. Price said. But first, a trial frame is used to demon- strate different levels of correction in one or both eyes. "I typically tell patients mul- tifocal lenses will not work well in low light conditions and they need good light to read with," Dr. Price said. "For very detailed fine print, the Tecnis [Johnson & Johnson (J&J) Vision, formerly Abbott Medical Op- tics, Santa Ana, California] +4 and +3.25 adds work well, but interme- diate can be poor. The Symfony [J&J Vision] lens with extended depth of focus is great with less halos and better intermediate vision but is often a little weak for small detail up close." EW Editors' note: Dr. Lee has no financial interests related to his comments. Dr. Price is a consultant for Alcon (Fort Worth, Texas). Dr. Waltz is a consul- tant for Acufocus (Irvine, California), J&J Vision, and Mynosys, (Fremont, California). Contact information Lee: bryan@bryanlee.pro Price: francisprice@pricevisiongroup.net Waltz: kwaltz56@gmail.com

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