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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 • • • • • • 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 1 BACK SURFACE ASPHERIC MULTIFOCAL FITTING • • • • 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 2 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) 3 TRANSLATING VISION • • • • 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 ??? 4 TANGENT STREAK REPRESENTATIVE LENS DESIGNS • • • • • • 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 5 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 6 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 7 PRESBYOPIC APPLICATIONS IN 2013 • • • • • 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 8 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 9 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 10 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 11 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 • • • • • 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 12 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 13 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! 14