Download Contact Lens Multifocal Fitting and Troubleshooting

FINANCIAL DISCLOSURE:
Contact Lens Multifocals: Fitting and Troubleshooting
Edward S. Bennett, O.D., F.A.A.O. (Dipl), M.S. Ed
Brooke Messer, O.D., F.S.L.S.
Stephanie L. Woo, O.D., F.A.A.O., F.S.L.S.
• Ed Bennett is a paid consultant to the
Contact Lens Manufacturers Association
• Brooke Messer is a paid consultant for
Essilor, Alcon, Bausch & Lomb, and
Precilens
• Stephanie Woo is a paid consultant for
Blanchard Contact Lens and SpecialEyes
GP DESIGNS IN COMMON USE
• Aspheric Multifocal
• Concentric/Annular
• Translating Segmented
ASPHERIC ADVANCEMENTS
• Has evolved into a very popular type due to
advancements in technology
• New Technology resulting in better polished
surfaces, & higher refractive index materials
• Addition of higher add power lenses
• Lower eccentricity lens designs
• Translation???
ASPHERIC TRANSLATION
ASPHERIC CANDIDATES
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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
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BACK SURFACE ASPHERIC
MULTIFOCAL FITTING
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Low eccentricity
Avg. OAD = 9.5mm
Standard Material = Boston ES
Three Series of Adds: Series I (Low add), Series
II (IM add) and Series III (high add)
• Fit approximately 1.25D STK
• Xtra: Enhanced distance vision; increased
comfort
• Most designs fit 1 1.5D steeper than K
• Must center with
limited movement with
the blink
• Easy to fit via
manufacturers’ fitting
guide/user friendly
• Good design to start
with
Essential CSA
CSA ENHANCEMENT
Concentric S‐Form ADD
Distance\Intermediate Optical Zone Diameters
Parameter Changes To Fine Tune Performance
4.6mm
4.3mm
Increased Zone
ESSENTIALS
Standard Zone
4.0mm
Reduced Zone
• Keratometry: 42.50 @ 180; 43.50 @ 090 OU
• Refraction: -2.00 - 1.00 x 180; +2D Add
• 52 year old male; wearing Essentials II OD; III
OS c/o progressive near blur
• VA: 20/30- @ near OR: +0.75D
• Re-order same parameters with +0.75D CSA
4.3 mm Suitable for the Majority of Your Patients
4.6 mm Larger Pupils – Or Higher Riding Lenses
4.0 mm Small Pupils – Or Interpalpebral Positioned lenses
Topographic Changes with Posterior Aspheric Lens
Designs
FRONT SURFACE ASPHERIC
MULTIFOCAL DESIGNS
• Have the benefit of avoiding back
surface molding/topography changes
• Example: Naturalens Progressive
(Advanced Vision Technologies)
• GoldenEye AFM (Valley Contax)
• Magniclear & Renovations (Art)
• Reclaim™HD (Blanchard)
Pre-Fitting
Post-Fitting
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ASPHERIC
TROUBLESHOOTING
• Fit from Ks & Rx
– No trial set needed
• No prism or segmented
optics
• Centers well on most
patients
• Customized optics to meet
each patient’s expectations
• Inferior
Decentration/E
xcessive
Movement:
Steeper Base
Curve
– Three standard designs fit 85%
of patients
– Wide range of adds
– Wide range of anterior OZ
sizes
ASPHERIC TROUBLESHOOTING
• Insufficient Add Power:
– Select Higher Add Lens Design
– Use “Modified Bifocal”
EXCHANGE RATES: THE RESULTS OF A
LARGE PRACTICE
• Practitioner DB: 710 GP multifocal lenses
purchased over 3 years (10
patients/month)
• Average return rate of 42% (close to
national average)
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TRANSLATING VISION
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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
TRANSLATION
Reading Position of Translating
Bifocal
Base Curve Selection
• Proper base curve
selection helps the lens
to translate smoothly
upward to position the
seg line slightly above
the pupil center during
down gaze
TRANSLATING VISION:
CANDIDATES
• Critical vision demands
• Any add powers (high
add/limited IM)
• Lower lid near
limbus/good tonicity
• Aspheric does not
center
• Inferior Apex
Lid Position
FITTING NUGGETS
• 2 - 3 diagnostic sets
• Follow manufacturer’s
fitting guide
• Trial Lens O/R.
• Translating Pearls:
– Position of lower lid to
limbus
– Seg line to lower pupil
position
– Evaluate translation in
downward gaze
Optimal
Okay
???
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TANGENT STREAK
REPRESENTATIVE LENS DESIGNS
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• Solutions (X-Cel)/Tangent
Streak(Firestone)
• Solitaire (Tru-Form)
• Bi-Expert (Essilor/Art Optical)
One-piece executive with monocentric optics
Standard Lens = 9.4/9.0 OAD/OZD
4.2mm seg; 2.0PD, +2.00D Add
Fit approximately 0.50D flatter than K
Seg line at lower pupil margin
Biexpert
SOLUTIONS (X-CEL)
Slab Off Technology
• One-piece crescent with monocentric optics
• Standard Lens = 9.6mm OAD; medium
Thinner uniform edge
thickness 360°
Prism; seg line 1mm below geometric center
• +2.00D add, no truncation
• User Friendly
• Fit and seg position similar to Tangent Streak
Slab off, inverse curve
Design Order Sheet (DOS)
Right Eye
Left Eye
-1.50 -0.75 cx 05
Distance Rx
+2.00D
Reading Add
+2.00D
44.00 / 45.00 @ 095
K-readings
43.50 / 45.00 @ 090
a)
HVID
-1.50 -1.00 cx 180
a)
HVID
b) Pupil diameter
b) Pupil diameter
c) Lower lid height to lower pupil
c) Lower lid height to lower pupil
d) Palpebral fissure width
d) Palpebral fissure width
Lid position
Lid position
Tight, average, loose
MENIFOCAL (MENICON)
Lid tonicity
Tight, average, loose
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Translating Designs
Intermediate Need
•
Llevations Trifocal (Tru-Form)
Examples:
– Llevations Trifocal (Tru-Form)
– Triune (Tru-Form)
– Mandell Seamless (ABB-Concise)
– Tangent Streak (Firestone)
– Presbylite (Lens Dynamics)
– EZEyes (ABBA)
– Accent (Accu Lens)
– ESSential Solutions (X-Cel)
• Modified Bifocal
• Over-Spectacles
Courtesy of Ed Bennett, O.D.
TRANSLATING VISION PROBLEMSOLVING
Advanced Design Delivers Improved Performance!
• A Translating Design with Intermediate Vision
• Excessive Rotation
• Lens Positions Too High
• No Lens Translation
• Up to +3.50D Add in a Thinner Lens Profile
• Decreased Lens Mass for a More Comfortable
Fit
EXCESSIVE ROTATION
• Flatten Base Curve
Radius by 0.50D
• Increase Prism
0.50PD
LENS POSITIONS TOO HIGH
• Increase Prism by
0.50PD
• Flatten BCR 0.50D
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NO LENS TRANSLATION
• Flatten Base Curve
by 0.50D
• Increase prism
and/or truncation
BLUR AT DISTANCE
• Lens too high:
Increase prism
• Lens too low:
Increase OAD
• Seg Height is
too high
• Excessive
movement
BLUR AT NEAR
RULE OF 0.50
• WHEN MAKING A CHANGE IN BASE
CURVE OR PRISM, A 0.50D CHANGE
IS RECOMMENDED
Superior Flare
• Lens is too small
• Fit a larger lens to
increase vertical
height
Hom-Gallagher-Eiden GP Multifocal Grid (From
Bennett ES, Henry VA: CL Spectrum, March, 2012; accessed at
www.clspectrum.com)
Seg height too
low
No translation
Patient drops
head to read,
not eyes
Excessive lens
rotation
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PRESBYOPIC APPLICATIONS IN
2013
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POST-REFRACTIVE SURGERY
COMPLICATIONS
(www.lasikcomplications.com)
Empirical Fitting
High Refractive Index Materials
Scleral Lens Designs
Post Refractive Surgery Designs
Hybrid/Combination Designs
POST-REFRACTIVE SURGERY
MULTIFOCAL DESIGNS (Partial List)
• All reverse geometry designs with add on
the front surface
• LasikNear (Valley Contax)
• Reclaim RSS (Blanchard)
• New reverse geometry multifocal from Art
Optical – CLASIKcn
REFRACTIVE SURGERY SPECIFIC
(RSS)(Blanchard)
CLASIKcn (Art Optical)
• Reverse Geometry
front surface center near
Design
Std OAD = 10.8mm
Add: +1.00 to +3.50D
RESOURCES
• Your best resource is your laboratory
consultant
• They can can provide diagnostic fitting
sets, online resources for the fitting and
troubleshooting of their designs, and well
as very good advice based upon extensive
experience
• If possible, topographies and photos can
be beneficial as well
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Rx for SUCCESS: Building Your Practice With GP Bifocals & Multifocals
• Comprehensive Educational Program available www.gpli.info
soon on • Practitioner Education, Staff Education and Patient Education • Downloadable Printed Materials gpli.info)
contactlenses.org
Consumer Website
( available on • PowerPoints on Patient Selection, Fitting & Evaluation • Fee Calculator Tool
SUMMARY
• “Building your presbyopic multifocal
contact lens practice will result in
enthusiastic patients, tremendous
personal satisfaction and practice
growth.”
Fitting and Trouble Shooting Multifocal Lenses
Soft Contact Lenses
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Fitting Soft Multifocal Contact Lenses
• The How To
– Begin with normal exam
• Evaluate eyelid health and tonicity • Evaluate for signs of dry eye • Evaluate conjunctiva for any abnormalities that may affect lens centration and movement
Fitting Soft Multifocal Contact Lenses
• The How To
– Multifocal Specific Measurements
– Address most important vision need
• Computer? Newspaper? Reading music? Needlepoint?
– Evaluate refraction and add power
– Evaluate pupil size in normal, bright and dim illumination
– Evaluate pupil size in normal, bright and dim illumination
– Determine Eye Dominancy
– Determine Eye Dominancy
Soft Multifocal Lens Designs
• Aspheric
– Gradual change in the curvature of the lens surface to create a change in power toward the lens periphery
– Can be center distance or center near
• Annular / Concentric
– Defined area in the center of the lens with a single power surrounded by one
or more rings of alternating powers
Evaluation of Vision
• Distance
– Binocular VA, out of phoropter
• Near
– Binocular VA
• Intermediate
– I usually have the patient hold the card at arms length
Soft Multifocal Contact Lenses
• Use of fitting guides
– Tried and true methods! – Best to follow the fitting guide even when the patient is not making huge gains in VA with lens changes
• Strategic steps will make assessment easier at follow up
• Allows patient to work through the lens powers with you
– They appreciate the process and hopefully find improvement with each step
– When you reach the final step – the patient can then decide if the vision is acceptable
Evaluation of Vision
• Real life examples
– This is how I measure multifocal lens success
• Obviously I need to know the patient can drive safely
– Distance VA: street signs and license plates out the window
– Intermediate VA: Patient sits in my chair at the computer and looks at a news website like Yahoo! or USA Today
– Near VA: Work paperwork or smart phone emails
• Adaptation
– Now vs 2 weeks from now
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Trouble Shooting Soft Multifocal Lens Wear Trouble Shooting Soft Multifocal Lens Wear • Distance problems
• Near problems – Loose lens over‐refract
• Be careful not to mistake contrast improvement with acuity improvement when adding minus
• If acuity does not improve, consider decreasing add power in dominant eye or both
• Possibly needs design switch
– Should not need to change the distance power significantly to achieve good VA
– Prescribe unequal adds with lesser add in dominant eye
– Recheck eye dominancy
Trouble Shooting Soft Multifocal Lens Wear • Intermediate Vision Problems
– Low add power OU and encourage reading glasses at near
– Pushing a little plus in non‐dominant eye
• Modified Monovision
– Great option for computer users
– I always start with lower add powers to start the fitting and work my way up to higher powers
– If I can’t achieve good near VA with max add powers, what next?
• Consider prescribing unequal adds
• Push plus at distance in non‐dominant eye
– If near is a very demanding part of patients day, they may accept some distance blur and prefer the higher add power in the dominant eye
– Tell the patient to get arm extentions.
More Ways to Optimize Vision with Soft Multifocal Contact lenses
• Distance vision improvement
– SV distance dominant eye, multifocal non‐dominant eye
• Intermediate vision improvement
– Multifocal with intermediate add in dominant eye
– Multifocal with intermediate add as distance power with low‐moderate add
• SV Distance lens in dominant eye
• Multifocal lens in non‐dominant eye
– Power of lens is selected to be patients intermediate power
Trouble Shooting Soft Multifocal Lens Wear • Other issues
– Ghosting and Haloes
• Add a little minus power to dominant eye or both
• Re‐evaluate and treat tear film insufficiencies
• Ensure good lens centration
– If not centered well, may need to try another lens design
• Line of sight compared to center of lens optics
Managing Patient Expectations
• When to use reading glasses
– Remember the 80/20 rule
– If lens fitting was designed with the computer in mind • When to use distance glasses
– If patient feels more vision compromised with dim vision or night time driving
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Trouble Shooting Lens Comfort
• Dry lens and Discomfort
– Treat dry eye!
– Consider care solution switch
– Preservative Free Artificial Tears
– Review “other” products used like hand lotions, perfumes, moisturizing soaps, etc.
• Slit Lamp Evaluation
Fitting Multifocal Hybrid Lenses
• Do you have a fitting set? Great!
– Can do diagnostic fitting – Follow step by step directions
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Usually requires flat K. Choose lens based on flat K.
Insert lens
Let settle
Quickly check the fit (New fitting guide uses no NaFl!)
Over refract at distance and near
Soft Multifocal Contact Lenses
• Presbyopia is an underserved population in the current contact industry
• Get started with your early presbyopes! – Can begin with prescribing lower adds to aid in adaptation in the long run
• Use of fitting guide is very helpful
• Treat concurrent dry eye to improve overall experience
Fitting Multifocal Hybrid Lenses
• Don’t have a fitting set? Great!
• Hybrid lenses can be ordered empirically with success
– Info needed:
– K’s
– Subjective Refraction
– Add
– Dominant Eye (optional)
• Surprisingly successful with empirical ordering
Can even empirically order online
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Troubleshooting Hybrid Multifocals
Troubleshooting Multifocal Hybrids
• Patient education before the dispense is highly important!
• Most common problems:
• 1. Decreased wear time:
– Make sure the patient is prepared for what they might encounter
– “These lenses are different that your last lenses, so they might feel a little different on your eyes. The more you wear them, the more comfortable they will become.”
– “The distance vision and near vision may be strange, or have a 3‐D or shadow effect. This is normal and usually becomes less noticeable.”
• DO NOT see the patient back before 2 weeks!
Troubleshooting Multifocal Hybrids
• Most common problems
• 3. Lens Dryness
Change solution Flatten skirt
Flatten BC
Fitting scleral multifocals
• Patient not wearing sclerals?
• Fitting is highly recommended
• Although there are a few scleral designs which offer empirical ordering, fitting the patient with a diagnostic set is recommended to ensure proper fit and vision
– Observe the fit. Hybrids should exhibit movement similar to a soft lens. If the lens hardly moves, flatten the skirt. If the patient is already in the flat skirt, flatten the BC of the lens.
• 2. Distance vision unacceptable
Distance Vision not 20/25 Confirm distance power is ‐0.50 to ‐1.50 more than manifest
Adjust base curve so power falls in this range
Fitting scleral multifocals
Patient wearing sclerals
currently
Determine add power over scleral lenses
Call the lab and report results
Diagnostic fitting
• Use a diagnostic scleral lens set to fit the patient
• After determining a lens with the proper fit, over refract at distance and near.
• Determine eye dominancy (optional) • Report results to the lab
– They will create a lens they feel will work best
– Add power, zone sizes, lens diameter, etc can be modified with many different designs
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Troubleshooting scleral multifocals
Troubleshooting scleral multifocals
• Insertion and removal are one of the main reasons patients get discouraged easily
• Problems with distance or near vision
• dd
Dalsey Adaptives
“See Green”
• Be sure to review the techniques thoroughly at dispense
– Video?
– Patient handouts and resources
Tear Film Debris
– First assess their vision OU at distance and near
– If they are seeing relatively well (ex: 20/40 at near), patient education on expectations of vision
• If their vision is poor, perform over‐refraction at distance and near
– Best to report the results to a lab consultant
– Since the designs are highly customizable, they will be able to assist in appropriate design changes
Tear Film Debris
• About 50% of all scleral lens wearers remove their lenses at least once a day to clean the lens and refill due to tear film debris
• New research has determined that patients with dry eye, excessive central clearance, and tight edges are more likely to suffer from tear debris.*
Photo courtesy of Dr. Jason Jedlicka
Tear Film Debris
Dry Eye management
Excessive clearance
Edge too tight
• Ocular hygiene
• Adding artificial tears
• Decrease sagittal depth of lens
• Flatten edges (may decrease sag)
• Flatten edges
• Decrease sag
* Hot topics in scleral lenses. Paper. AAO, 2013
Final thoughts
• Does contact lens wear have to drop off after 45? NO!
• Is the only option for presbyopes eyeglasses? NO!
• Discuss the option of multifocal lenses with your patients – you may be surprised to see how many are interested and willing to try
• When you fit with multifocal contacts, they are your patient for life!
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