An Exercise Program For Crystalens Patients
How to use word search games to help crystalens patients.
PAUL S. KOCH, M.D., AND JACQUELINE HAMMETT

Ever since we began participating in the clinical trials for the crystalens (eyeonics, Aliso Viejo, Calif.), we have looked for a way to monitor the efforts that patients make to achieve maximum accommodation. Some of the measures that we were interested in included whether patients were performing the recommended exercises, and if they were, to what extent they were and how these exercises corresponded to final range of accommodation. Overwhelmingly, we found that these questions were never answered to our satisfaction. To get some answers, we developed our own series of accommodative exercises that are reasonably quantitative. These exercises allow us to monitor the size print a patient can read and follow the patient's improvement in accommodation. Additionally, we can measure whether the exercises are being performed successfully.

Success With the Crystalens

We have had very good success with the crystalens. Approximately three out of four patients that we implant with the crystalens do not need glasses at all, and the others need them only occasionally. Our results would be even better than that, had we not veered away from protocol for a while to use what turned out to be a less predictive IOL calculation formula. Still, even taking that into account our patients recover varying amounts of accommodation, from just a little to more than wildly imagined. The exercise program we developed is part of our effort to expand the accommodative range for every patient.

We do not really know how long it takes a typical patient to regain full accommodative range following crystalens surgery. Some patients seem to focus right away, others take a few weeks and some take longer. Our experience has been that it takes 3 to 6 months, occasionally a little longer, for the patient to get the maximum benefit from the implant.

Some patients do not get much accommodation, and it can be hard to tell why. I recall one Type-A patient who complained bitterly at each visit that she had no near vision at all. She later told me that she never tried to read without her reading glasses because it was too much of a bother. She always wore plus threes, and had ever since the day of surgery. I thought she was going to ask for a refund, but I headed that off by telling her that "she had wasted her money" if she wasn't going to get with the program.

We finally found a time when she was scheduled for an extended period of time off, so I had her bring large print books on her vacation. When she finished the large print books she began reading regular hard cover books, and by the time she returned a few weeks later she was beginning to read paperbacks.

Challenges of Using the Exercises

When a patient doesn't get very much accommodation, is it a problem with the movement of the lens within the eye, or is it simply the lack of effort on the part of the patient?

How can we know whether the patient is doing the exercises? Originally, we gave each patient a special reading card that had a series of paragraphs printed in progressively smaller type. We instructed the patients to read the card each day, working their way down to the smaller lines. There was one problem with this approach – it is BORING! After the third time they read a paragraph, they were tired of it. Imagine trying to read the same thing several times a day, day after day. I doubt many patients do it for long.

So, we tried suggesting patients read large print books, and then move on to hard cover books. That seemed like a good idea, until we realized that many crystalens patients did not have the time to read novels, and so they read the pages quickly.

That led us to question whether skimming a page really exercises the eye's accommodation. Many words can be identified from its context, so a story can be read without actually focusing on and reading each word. Actually, as long as the first and last letters of a word and the length of the word are correct, you can read a sentence of nonsense words. It raekly is troe, yiu cin raed quate a bjt jist frim hiw the ward loohs. Did you get it? "It really is true, you can read quite a bit just from how the word looks."

So, if a patient came to the office complaining of limited near vision, and said he/she had just read part of a novel, we still had no way of knowing if he/she had actually exercised his/her eyes, or whether he/she had exerted any effort at all!

Another problem we had was controlling a patient's expectations of how long it would take to recover near vision. Prior to surgery I tell every patient that it will take 3 to 6 months to get their best reading vision, but I learned to give each patient an appointment at 1 month, for what we called their whining visit. "I know you told me 3 to 6 months," they would whine, "but it's been 4 weeks already and I still can't read everything. When will I be able to?" "Three to 6 months," I patiently tell them.

So, here were the challenges:

• Devise exercises that are not boring

• Be sure the patients are actually focusing on something

• Keep them busy for at least 3 months

Our first foray into standardizing accommodative exercises was a trip to the local bookseller to see if we could find a selection of magazines with different sized print. We thought we might be able to recommend something like a sporting magazine for the first week, then a fashion magazine for the next, and perhaps a travel one after that. If we could identify which magazines used different size fonts, we could gently work the patient through progressively more demanding near focus. Unfortunately, there isn't a lot of variation among the major magazines, so that plan was a bust.

The Discovery of Word Games

While there, though, we came across some word game books and got inspired. If we could find word games of different sized fonts, we would have a program that was not boring, and was sure to make the eyes focus on the page. If we had enough books, it could take several months to finish them all. Unfortunately, there was not much variation in the sizes of the puzzles, so bust we were again.

We decided that the word game idea still had merit, but that we would have to design our own games. How many would we need? We thought enough for 3 months would do the trick. If a patient needed an exercise program to last longer than that, he/she could do some of the puzzles more than once.

How many puzzles should a patient do, especially if we wanted this to be entertaining? We decided one good puzzle a day would be fun, more than that drudgery. That gave us the number, a puzzle a day for 3 months, but how could we control accommodative effort (i.e., the size of the letters? We decided on 6 steps from largest to smallest size font).

That let us finalize the scope of the program: 12 weeks of puzzles, 6 sizes of fonts, leaving us with 2 weeks per font. That would be 6 books, 14 puzzles per book.

Great! Now, how could we possibly get enough words to make 84 puzzles? Happily, we have an office staff that enjoys having something to distract them from actually working, so the challenge went out: make up a list of words pertaining to some theme, any theme. We ended up with dozens of ideas, ranging from types of donuts to names of Hollywood hunks. From these suggestions, the 84 word search puzzles were constructed.

Using the Word Games

Two weeks after the patient has the second crystalens implanted, one of my counselors sits with him/her and presents the first booklet. The counselor shows him/her the 14 puzzles and explains how to find the words and circle them. We were surprised to discover that not all patients are familiar with word search games, and needed instruction. The counselor explains that they should do just 1 puzzle a day (remember, we want to control the time it takes to complete the series). After 2 weeks, they should return to the office with the completed booklet. The counselor will check their answers and see if they can move on to the next book.

The first booklet has large print, so it is easy to do. This way everyone gets an immediate sense of success. Some patients insist on jumping ahead to a booklet that is difficult for them to read. That is also okay, because it gives them a sense that they are already ahead of the average patient.

The patient is given an appointment to see the counselor again in 2 weeks, at which time they bring back the booklet. The counselor flips through each page, pretending to grade the results. When she is done she congratulates the patient and hands him the next booklet, along with another quick appointment for 2 weeks later. This process is repeated for the full 12 weeks, at which time almost everyone has pretty good near vision and appreciates the wide range of vision associated with using the crystalens.

Sometimes a patient will get so far, let's say book four, and can not go any further. In these cases we have the patient "repeat a grade." We give the patient the same book again, or even go back to the previous one with slightly larger print. Many times pausing for a few weeks at a certain level lets the ciliary muscle catch up and progress begins again.

How the Exercise Books Have Made a Difference

Using our exercise booklets we are confident that we have done everything we can to be sure the patient has done exercises, because we made a game out of it. We are also confidant that the exercises really help the eyes accommodate, because they had to focus on the puzzles, and because the puzzles got progressively smaller.

Eyeonics is making our six word search puzzles available to all crystalens users, and surgeons interested in using them should contact their company representative (not us). We have discussed adding the puzzles to the crystalens Web site, making them available for digital distribution, and perhaps one day that will be possible. 

Paul S. Koch, M.D., is the medical director at Koch Eye Associates located in Warwick, RI. Dr. Koch has no financial interest in this information. He can be reached at (401) 738-4800 or by e-mail at paulkoch@kocheye.com.