Introduction

Near point complaints are common in optometry; this document offers guidance as how to effectively approach the most common of these complaints – those related to presbyopia

Indications

Near point complaints related to presbyopia

Contra-Indications

Allergy or sensitivity to any medications used during the process

Materials

1. Phoropter
2. Near point card
3. Trial frame and lenses
4. Tropicamide 1% or cyclopentolate 1%

Setup

Hx Hx Hx!  The history should include whether the complaint is with or without glasses, when it started (and all the other FODLAR information as appropriate), and what tasks/distances are involved in the complaint.  Not everyone works at 40 cm, so solving all near complaints at 40 cm may not ultimately solve the patient’s problem.

Measurement

1. Start by obtaining an accurate distance refraction.  Any near prescription is relative to this.  In cases of low prescription, consider a wet refraction to determine if the patient is a latent hyperope.
2. Consider an NPA, NPC, NRA, PRA and BCC as appropriate.  Note that the last three pieces of information are for a 40 cm working distance, and that your patient’s complaint(s) may not be at 40 cm.  Consider this data a starting point, and not the end point.
3. Trial frame a proposed near add and document visual acuities.  Then determine a range (the closest that things are in focus.  The farthest away that things are in focus).  Are all of the tasks presented during the history above within this range?  If so, you have likely solved the problem.  If not, fine tune until you have solved the problem.   Note that adds magnify images, and patients will often prefer a larger add simply because it makes things look bigger.  This doesn’t mean that the larger add is the best add – look at all the data, including the patient’s age before proposing a final add prescription.
4. Discuss modalities – bifocals, single vision readers, progressives, trifocals – with the patient.  Determine what modality works best for the patient from a functional/price point of view.

Results

Document what you trial framed, and what the patient preferred in the notes of the subjective line of the trial frame (“TF:  Prefers +200 v +225 and +175 add”).  Your documentation should demonstrate that your proposed solution solves the patient’s complaint(s) – ranges are a good way of doing this.  Your documentation should demonstrate what modalities you discussed with the patient, as well as the patient’s final choice (“BF/PAL/TF/SV RRx discussed with patient; patient elects to proceed with BF”).  Finally, a discussion of adaptation – including adaptation related to navigating stairs and proper use of a PAL – should be documented.