Get Prepped for Multifocal Success

When it comes to correcting the vision of our patients with presbyopia, our profession has changed quite a bit. It seems like just a few years ago, manufacturers were trying to convince us to shift away from monovision. Today, we have multiple options that vary in material and modality with truly extended parameters. New materials that offer increased comfort make multifocal options much more appealing to our patients. Studies show that presbyopes of all refractive errors prefer contact lens correction to spectacle correction when good contact lens comfort is achieved.^1,2 Lens designs are helping as well, by optimizing outcomes over the complete range of distance to near vision.³

A key to the success of multifocal contact lens fitting is that each manufacturer is developing unique ways of catering to patients with varying pupil sizes, anterior segment concerns, lifestyles, and expectations. This shift could not have come at a better time, as the average age of the contact lens wearer is increasing,³ which means an expanding market for presbyopia-correcting contact lenses. Let’s review some topics that will help us prepare for the growth of multifocal contact lenses in our practices.

PATIENT EDUCATION AND AWARENESS

Regardless of lens design, understanding our audience is always the first step to prescribing for presbyopia. There is a lot of documented information about the importance of addressing the lifestyle needs of the presbyopic patient,^4-6 but there is more to the story when we consider patients with early presbyopia. This group may require a bit more education about the condition in general.

Explaining to patients with emerging presbyopia exactly what is happening to their eyes and why it is happening is generally a good place to start. We should remember that these patients may come to us with concerns around aging and the stigma associated with needing near vision correction. We shouldn’t overlook the nonvisual benefits of multifocal contact lenses that are so important to many patients. For some, this mode of vision correction provides that youthful feeling that comes with not having to wear reading glasses. Practitioners who are within their presbyopic years may find this conversation easy to have, while younger practitioners should approach this topic tactfully and empathetically to avoid making the patient feel uncomfortable.

During the education process, we must remain positive and enthusiastic. If we do not believe in the multifocal technology ourselves, it will be hard to convince our patients to give these lenses a try. Because the technology is constantly improving, it is important that we educate ourselves and talk to our patients about it early and often.

UNDERSTANDING THE FITTING PROCESS

Success cannot be achieved without first identifying patients who stand to benefit the most from multifocal contact lenses. Regardless of lens design, there are patients we should consider avoiding from a clinical standpoint. If we are using spherical soft lenses, most manufacturers recommend avoiding a refractive cylinder > 1.00 D. It is also strongly recommended to avoid patients with high levels of anisometropia, abnormal binocularity function, and anterior segment concerns, such as abnormalities within the tear film.

Other red flags may arise during the case history. Certain patients seeking perfection at all visual ranges or those who start off with time or financial restrictions might not be the best candidates. We are looking for highly motivated individuals who realize their vision may not be as sharp as it is with spectacles for some distances or lighting conditions.

Once we identify an ideal candidate, it is important that we follow the proper fitting process. There are certain basic fitting steps that are universal for all lens designs, including taking a thorough case history, getting an accurate spectacle refraction, performing keratometry and a slit-lamp evaluation, and making a proper lens assessment. After these steps, each manufacturer has its own unique method of obtaining optimal visual acuity with multifocal contact lenses, and you must follow their specific guidelines for the best chance at success.

The best way to illustrate this process is by reviewing an example, using the refraction of a hypothetical patient, and then applying this prescription to four different contact lens manufacturers to find the proper starting lens. See the Table below for a list of multifocals that have recently become available.

Let’s say our patient has a spectacle prescription of -1.75 -0.50 x 180 OD and -1.25 sphere OS with an addition of +1.75. Through testing, we determine that she is right eye dominant. Using each company’s fitting guide, we’ll demonstrate how the starting lens is different for each lens below.

For Dailies Total1 Multifocal contact lenses (Alcon), choose the initial lens based on vertex-corrected, least minus/most plus, and spherical equivalent distance prescription, then add +0.25 D for each eye using the manufacturer’s fitting table.⁷ Starting lens: OD -1.50 (MED); OS -1.00 (MED).

For Bausch + Lomb Ultra for Presbyopia contact lenses (Bausch + Lomb), choose the initial lens based on spherical equivalent from the patient’s spectacle prescription. The add is determined using the company’s fitting table.⁸ Starting lens: OD -2.00 (HIGH); OS -1.25 (HIGH).

For MyDay daily disposable multifocal (CooperVision), choose the initial lens based on the spherical equivalent from the patient’s spectacle prescription. After determining eye dominance, we select the sphere power for each eye using the manufacturer’s fitting table.⁹ Starting lens: OD -2.00 (LOW); OS -1.25 (MED).

For 1-Day Acuvue Moist Multifocal Contact Lenses (Johnson & Johnson Vision Care), choose the initial lens based on the spherical equivalent from the patient’s spectacle prescription. After determining eye dominance, we select the sphere power for each eye using the company’s fitting table.¹⁰ Starting lens: OD -2.00 (MED); OS -1.25 (MED).

Notice how the same patient will have completely different starting points depending on the contact lens manufacturer. Be sure to follow the specific fitting guides for whatever lens you choose. Doing so will save you chair time and greatly improve your chances of success.

GET IN THE RIGHT MINDSET

There are several benefits to offering multifocal contact lenses to patients, but to stimulate our motivation to offer them, it is helpful to recognize the potential benefits of offering these lenses to our practice, such as adding a revenue source, showing our practice is on the cutting edge, and building patient loyalty. However, many of our colleagues have not yet begun recommending or prescribing this lens modality. Although this can be unfortunate for patients who are unaware of their options, the slow uptake may present an opportunity for you as a competitor. Patients will recognize how you are bringing new technology to their attention, and they will love it. Making an effort to educate your patients is a huge practice builder because it improves patient retention and loyalty.

Yes, the technology is evolving, but we already have the tools to be successful while providing these amazing devices to our patients. Take advantage of the low barrier to entry and differentiate your practice from the competition.