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MULTIFOCAL CONTACT LENS PATIENT SELECTION, FITTING, AND PROBLEMSOLVING
Edward S. Bennett OD, MSEd, FAAO
Vinita A. Henry OD, FAAO
I.
PRESBYOPIC MARKET TODAY
A. Current Contact Lens Use with Presbyopic Patients
B. Why this Population Represents Our Greatest Opportunity
II.
CURRENT OPTIONS
A. Single Vision Contact Lenses and Reading Glasses
1. Advantages and disadvantages
B. Monovision
1. Success rates
2. Benefits
3. Challenges:
• Depth Perception
• Possible Suppression
• Contrast Sensitivity/Vision Loss
• Night Driving
• Liability
4. Comparison studies versus contact lens multifocals
C. Soft Lens Multifocals
D. Hybrid and GP Multifocals
III.
PRE-FITTING EXAMINATION AND PATIENT SELECTION
A. Pre-Fit Factors
1. Pupil Size
2. Tear Film
3. Lower Lid Position/Tightness
4. Dominant eye
5. Motivation
ASSESS MOTIVATION/GOALS
• What distance(s) is most important to them/goals? Rank
Distance, IM, & Near
• Present all options (for their “chronological maturity”)
• Advise PT about compromises with CL correction
• Is motivation simply not to wear spectacles (cosmesis)
• If properly fit, they provide acceptable vision at distance and
near
• They may move up and down during blink cycle (unlike spectacles)
• They may experience transient blur with certain directions of
gaze
• Can the patient accept mild compromise in vision?
• Longer fitting process possible-multiple visits
• Some adaptation required
• Fit most of the needs most of the time
• Make them a partner in the process
• Try “real world” environment- not 20/20
BOTTOM LINE: IF PATIENT AND MOTIVATED, VERY LIKELY TO BE
SUCCESSFUL
IV.
SOFT MULTIFOCALS
A. Discuss Replacement Schedule
B. Fitting Tips
1. Use normal illumination
2. Let lenses settle 10-20 minutes
3. Assess binocularly
4. Hand-held trial over-refraction
5. Over-refract monocularly with both eyes open
6. Low Rx and emmetropes less successful
7. <0.75D astigmatism
8. Use everyday reading material
9. Use least minus/most plus
10. Best vision sphere, vertexed
11. Dispense trials
12. Follow-up in 3-5 days
C. Lens Selection
1. Soflens/PureVision* Multifocal, PureVision 2 MF coming
2. Dailies Progressive
3. Air Optix* Multifocal
4. Proclear/Biofinity* Multifocal, Proclear 1 day MF
5. Acuvue Bifocal/Acuvue Oasys* for Presbyopia
6. Proclear EP
7. Proclear Multifocal Toric
8. Essentials Soft Toric Multifocal
9. Intelliwave Multifocal & Toric (Definitive-Contamac) Art Optical
PureVision Multi-focal
E. Fitting Errors
1. Not allowed to settle full amount of time
2. Power correction made in too large of steps
3. Using too high of adds (Round down)
4. Reluctance to use unequal adds
5. Not starting with current refraction
6. Ignoring spherical equivalent
7. Not using hand-held trials
8. Not understanding patient’s visual needs
F. Problem-Solving
1. Poor distance VA – Add minus by 0.25 steps to dominant eye
only &/or decrease add dominant eye
2. Poor near VA – Add plus by 0.25 steps to non-dominant eye &/or
increase add non-dominant eye
3. Address distance problem first
4. Confirm dominant eye (especially if VA’s don’t meet expected
values)
5. Always recheck VA with an OR at distance & near
6. Monocular acuities are useful for determining which lens may
need to be altered
7. If >0.50D change is required in distance may need to alter add
powers
8. Use flippers for over-refraction
V.
GP AND HYBRID MULTIFOCAL LENSES
A. Options
1. Alternating - Translating
2. Concentric
3. Aspheric
4. Combination
B. Aspheric Designs
1. Advancements
• New Technology resulting in better polished surfaces, &
higher refractive index materials
• Addition of higher add power lenses
• Lower eccentricity lens designs
• Post Refractive Surgery Designs
• Scleral Lens Designs
2. Candidates
• Low - medium adds (Don’t R/O High)
• Computer use
• Athletes
• Low lower lid &/or loose lids
• Small-avg. pupil size
• Critical Vision not essential
3. Fitting Pearls: Testing/Fitting
• Accurate determination of pupil diameter in normal room
illumination
• Dominant eye
• Assess tear quality
• Use the manufacturer’s fitting guide for lens selection and
problem-solving. It is simplistic and successful.
• ‘REAL WORLD ENVIRONMENT
• Trial lens over-refraction
4. Back Surface versus Front Surface Fitting
• Most BS designs fit 1 - 1.5D steeper than “K”; front surface fit “On K”
• Must center with limited movement with the blink
• By fitting empirically it simulates soft lens multifocal fitting
• Easy to fit via manufacturers’ fitting guide/user friendly
• Good design to start with
5. Problem-Solving
• Inferior Decentration/Excessive Movement
• Insufficient Add Power:
C. Segmented, Translating Designs
1. Description
• Prism Ballasted & often Truncated
• Crescent/Executive Seg
• High Dk Material
• Near image moves in front of pupil with downgaze
• Typically rests on or near the lower lid
2. Candidates
• Critical vision demands
• Any add powers (high add/limited IM)
• Lower lid near limbus/good tonicity
• Aspheric does not center
• Inferior Apex
3. Fitting
• Diagnostic set
• Typically select BCR slightly flatter than “K”
• Position of lower lid to limbus
• Seg line to lower pupil position
• Evaluate translation in downward gaze
• Intermediate Need designs and fitting
4. Problem-Solving
• Excessive Rotation
• Lens Positions Too High
• No Lens Translation
• Blur at near
• Blur at Distance
D. GP Presbyopic Applications in 2013
1. High Refractive Index Materials
2. Scleral Lens Designs
3. Post Refractive Surgery Designs
4. Hybrid/Combination Designs
VI.
RESOURCES
A. Practitioner
B. Consumer
VII.
SUMMARY
A. Pearls
1. Distance vision will generally improve with wear
2. Let the patient be part of the process
3. Order lenses warranted
4. Use your laboratory consultant
B. Building your contact lens multifocal contact lens practice
will result in enthusiastic patients, tremendous personal
satisfaction and practice growth.