A MULTISPECIALTY PRACTICE PERSPECTIVE

BY EVAN D. SCHOENBERG, MD, AND JOSH JOHNSTON, OD, FAAO

As eyedrops for presbyopia correction advanced through clinical studies the last few years, we followed their progress and discussed how they might affect our patients and our practice. Late last year, we got a chance to see the drops in action when pilocarpine HCl ophthalmic solution 1.25% (Vuity, Allergan, an AbbVie company) received FDA approval. Our practice began prescribing them and, in the process, developing the right patient education and carefully monitoring how the drops work for our patients.

During the last few months, we have developed a smooth, low-impact process for presbyopia eyedrops at Georgia Eye Partners, a large, multispecialty practice that offers the full range of medical and surgical services. We’re glad we did, because this modality is just getting started with more in the pipeline (see page 20).

Here, we provide some insights on our process.

WHO ARE THE CANDIDATES?

We prescribe presbyopia drops to patients with a refractive error who are symptomatic for presbyopia. The drops have worked well in our patients who have a low refractive error (-0.5 to +2.0), such as emmetropes, hyperopes and mild myopes. They are generally in their early 40s to late 50s, although we have prescribed drops to some patients in their 60s, including many who are pseudophakic. As near vision declines with age, there is less accommodative amplitude, so we generally expect to see the drops have less of an effect at age 60 than they do at 50.

Contraindications include high myopia, retinal lattice degeneration and history of retina tear or detachment. In a virgin eye, we can look to the eyeglass or contact lens prescription; however, in post-refractive-surgery patients, it can be harder to know the extent of anatomic myopia. We ask about their functional vision prior to surgery — if reading was possible at a comfortable working distance, it is unlikely that the patient was highly myopic. As for retinal health, the comprehensive eye history must include questions about previous conditions and treatments, and they need to have a normal dilated exam or widefield photo with an acceptable view of the peripheral retina.

Presbyopia drops are only part of a patient’s refractive plan, which also may include eyeglasses and contact lenses. We explain to presbyopes that refractive cataract surgery is likely in their future, after which they won’t need reading glasses in most cases. These eyedrops can allow them to spend more time without reading glasses now, then refractive surgery can keep them from needing reading glasses later. It actually gives them more confidence to move forward with an understanding of the changes on the horizon and how we will keep them spectacle-free if that’s their goal.

HOW DO PATIENTS PRESENT FOR PRESBYOPIA DROPS?

We are an all-medical practice, so patients don’t see us for regular exams, but this would be the most common way an MD-OD practice would connect with presbyopic patients. When optometrists see someone with a medical chief complaint, it’s an opportunity to discuss all their options, including eyedrops, and offer them an additional refractive modality to fit their lifestyle. Other patients call specifically because they’ve seen ads for presbyopia drops.

On the ophthalmology side, patients are referred for refractive surgery because they want to be out of eyeglasses, but not everyone is a candidate for surgery. With presbyopia drops, we can redirect them to a nonsurgical option that can meet their goal. For example, a 45-year-old emmetrope who needs +1.25 readers may not be the best candidate for LASIK or a lens exchange, but they’re at that sweet spot where their predominant problem is reading, so we reach for presbyopia eyedrops.

Some refractive surgeons are concerned that presbyopia drops might decrease their surgical volume, but we look at this as a marathon, not a sprint. We offer them a chance to live glasses-free, and when they come back as their vision progresses, we can discuss surgical options that allow them to keep reading clearly.

WHAT DOES THE PATIENT DISCUSSION COVER?

About 10% to 15% of our patients tell us they’ve seen advertising for presbyopia drops or heard about it from friends and want to know if drops are right for them. For every other candidate, we bring up the subject.

We explain that, aside from surgery, their vision correction options are eyeglasses, contact lenses and a new FDA-approved eyedrop to help their near and intermediate vision. They will put the drop in their eyes, and, about 15 minutes later, it will decrease their pupil size, increasing their intermediate and near functional vision. It usually lasts from 4 to 8 hours.

We also tell patients that the drops are not a replacement for eyeglasses — they still need those. Some people use the drops every day, but most people use them as a lifestyle solution for situations where they don’t want to wear their eyeglasses or contacts, such as playing sports or getting dressed up for an event.

Our patients trust that the drops are FDA approved, and they haven’t expressed any concerns. In fact, most are excited — so far, nine out of 10 candidates want to give drops a try.

WHAT SCHEDULING AND FOLLOW-UPS ARE REQUIRED?

Presbyopia drop scheduling is easier and more efficient than we anticipated. In fact, there’s no special scheduling at all — it’s just a matter of offering another option when the subject of refractive correction comes up. We do not trial these drops in the office, but we occasionally give out samples for patients to try at home.

There is also no follow-up in most cases. Early on, we scheduled in-person follow-up with patients after 4 to 6 weeks to see if they were having side effects, but we stopped when it was clear they weren’t having problems. Telemedicine could be a good fit if doctors want to check in with their early patients. We check in via a telemedicine call when we prescribe drops to someone outside the “sweet spot.” For example, we’ll ask a pseudophakic patient how it’s working and how long it works for them.

Again, we’ve found no problems. The ease of use and tolerability have been great. Most of our patients with presbyopia drops tell us they like using them. Headache and dimmed vision are the most common complaints, but they have been rare sources of discontinuation.

ARE THERE ANY HURDLES WITH PATIENT COSTS AND PRACTICE REIMBURSEMENT?

We explain to patients that insurance doesn’t cover presbyopia drops and outline the cost in advance (currently $79 for Vuity, after opting out of insurance). For our patients who want to try drops, they have some control over the costs based on how much they use drops. If they use drops every day, a bottle will last 1 month. But, if they only use them a few days a week as most people do, they’ll only need to refill them every 3 to 4 months. In addition, the manufacturer offers a loyalty card that serves as “buy four, get one free.” Some patients simply choose not to try the drops based on costs.

Our reimbursement has followed the same routine as other modalities for correcting presbyopia. We’re seeing patients for medical eye exams, so we code the medical chief complaint with a secondary diagnosis of presbyopia. Practitioners who do annual exams don’t code any differently, since presbyopia drops are a refractive modality.

If a patient calls the office specifically for presbyopia drops, they can come in for an annual exam or, if they normally see the doctor for a medical complaint, make a medical visit and discuss drops as well. Or, if a patient has already had an annual exam and has no medical complaint, they can have an out-of-pocket presbyopia consultation at the same rate that we would charge for a self-pay comprehensive exam.

WILL EVERY PRACTICE OFFER THIS MODALITY?

With some patients raising the subject of presbyopia eyedrops, eye-care providers should be ready to have the conversation and ensure they’re ready to make a recommendation to appropriate candidates.

We’re all judged on our standard of care and the level of technology we recommend, so we view presbyopia drops similarly to premium IOLs — we have to offer the latest options and meet patients’ high expectations. OM

Evan D. Schoenberg, MD, is director of refractive surgery at Georgia Eye Partners in Atlanta.

Josh Johnston, OD, FAAO, is clinical director and residency director at Georgia Eye Partners in Atlanta.

Relevant disclosures: Drs. Schoenberg and Johnston are paid consultants for Allergan but were not compensated in connection with this article.

A FEE-FOR-SERVICE MODEL

BY KARL G. STONECIPHER, MD

History repeats itself in many different forms, especially in medicine. Because of this, we must sometimes look to the past to see how we may respond better to the future.

One example is dry eye disease (DED). If you have been in practice long enough, you may remember a time when you did not want to treat a dry eye patient mainly because you had only tears to offer them. This left both the patient and the doctor easily frustrated. But, fast forward to today, and physicians have learned how to effectively manage DED patients — and to be profitable when doing so — thanks in large part to the advent of many dry eye treatments.

I feel we are presented with the same issue with presbyopia. For years, we have had options of eyeglasses, contact lenses and IOLs, but all have come with potential issues the patient did not or would not deal with. Again, fast forward to today and we have a plethora of options, all of which are better than before and getting better with each passing day.

With that as a backdrop, let me outline my current practice patterns for presbyopic patients, most of which I must admit has been influenced by my discussions with Drs. Marguerite McDonald and Ralph Chu on the best approach to treating this class of patient.

THE PRESBYOPIC VISIT

My practice has elected to treat the presbyopic patient as a “fee for service” as opposed to billable event. With each visit, they are screened by a technician using computed topography, OCT of the macula and optic nerve, ray tracing and widefield fundus photography to evaluate the peripheral retina. We charge the patient $100 for this initial screening.

At the end of the day, a physician reviews the charts and determines what the next step is the best option. The algorithm is simple. Of course, all patients have already tried or are currently using eyeglasses or contact lenses. However, if they have not had an option to use the latest presbyopia-correcting contact lenses, they are referred to one of our contact lens specialists. The remainder fit in to one of three categories: pharmaceutical options (ie, Vuity, Allergan/AbbVie), refractive surgical options or refractive cataract surgery.

PRESCRIBING PRESBYOPIA DROPS

Many presbyopia walk away from this initial screening with a Vuity prescription after the physician reviews their initial presentation.

Important to note is that recent research has shown complications with topical 1.25% pilocarpine.¹ High-risk patients are evaluated more thoroughly and referred to retina for screening if screening or subjective findings warrant intervention. All patients are educated on the potential side effects and complications associated with the treatment of presbyopia. We discuss headaches associated with initial use of the drops in approximately 10% of patients and encourage the patients to use the drops for a full 7 days prior to considering it a treatment failure. They are treated like any other patient to the practice and are always welcome should urgent or additional needs arise.

Other patients may schedule a refractive or a refractive cataract surgery formal evaluation once we have discussed options related to their objective findings, while some simply continue with their current option for treating their presbyopia.

PRACTICE AND PATIENT BENEFITS

This practice pattern has become a great referral source for the refractive and refractive cataract practice while taking care of new patients self-referred or referred in by advertising, word of mouth or patient referral. The surgical patients are absorbed as standard patients to the refractive or refractive cataract practice, and the routine patients are referred to our comanaging physicians based on where they live.

This is a win for the practice, the comanaging physicians and the patients, who have been so happy that they refer other patients to our practice.

With presbyopia drops providing another option in our armamentarium, history is repeating itself again. OM

REFERENCE

1. Al-Khersan H, Flynn HW Jr, Townsend JH. Retinal Detachments Associated With Topical Pilocarpine Use for Presbyopia. Am J Ophthalmol. 2022;242:52-55.

Karl G. Stonecipher, MD, is a cornea and refractive trained surgical specialist and the director of The Laser Center in Greensboro, N.C., which he joined in 2005. Also, he is a clinical professor of ophthalmology at the University of North Carolina, clinical adjunct professor of ophthalmology at Tulane University and assists in the refractive and refractive cataract surgery training of the residents in the departments of ophthalmology.

Relevant disclosures: Dr. Stonecipher revealed a relationship with Allergan.