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Maximizing Success with the New Contact Lens Multifocals
(Cope ID: 13072-CL)
Wm. Edmondson, MAT, O.D., FAAO
Oklahoma’s College of Optometry at Northeastern State University
918-456-5511 X 4015; [email protected]
Description
This presentation provides clinicians with guidelines based on clinical research for the most successful
techniques in fitting the new generation of hydrogel, silicone hydrogel & GP contact lens multifocals.
Discussion of popular, recent multifocal designs are included.
Objectives
1.
To utilize universal principles in fitting most Soft & GP CL multifocals.
2.
To identify & select patients with the most appropriate presbyopic corrections
3
To become acquainted with the basic “out-of-phoropter” techniques to evaluate the performance of the
multifocal contact lens.
4.
To become familiar with techniques for utilizing patient feedback to modify the distance & add power
of the lens.
5.
To incorporate the most current presbyopic contact lens options to maximize patient success
Outline
A.
Using the New Generation of Multifocal Contact Lenses–> Simultaneous Vision
B
1.
Soflens/ PureVision Multifocal - Bausch & Lomb
2.
Focus Progressive/ Focus Dailies Progressive - CIBA Vision
3.
Proclear / Frequency 55 Multifocal – CooperVision
4.
Soft Toric Multifocals – CooperVision / CIBA
5.
GP Multifocals
Multifocal Terms
1.
Binocular Multifocal: Multifocal on both eyes; Binocular Balanced
2.
Enhanced Multifocal: Multifocal on both eyes;
One eye enhanced for either dist.or near
3.
Modified Monovision: Multifocal on one eye; single vision (dist.or near) on other eye
4.
Standard Monovision: SV lenses on both eyes; One for distance and one for near
C.
Universal Truths to maximize success in presbyopic fitting
1.
2.
Don’t rely on current glasses (or SV CL) Rx
Learn how to Evaluate spectacle Rx and astigmatism
a.
Selecting patients: Initial “suggested” for maximum early success
Significant Distance spherical spectacle Rx –> greater than +/- 1.00D
Yes ---------> RGP or Hydrogel Multifocal
No ----------> Alternatives to multifocals:
- Multifocal in one eye only
- Traditional Monovision or near lens only
- Distance contact lenses plus reading spectacles
- Other
b.
Refractive cylinder:
1.
0.75D or less ---------------> Soft Multifocal or RGP Multifocal
2.
0.75D -2.50D -----> RGP Multifocal / Soft Toric Multifocal
3.
Other options:
3.
Pre-fitting Consultation
a.
Evaluation: Visual needs, & Ocular health & Physical characteristics
b,
Pre-fitting Consultation: Patient expectations
c.
Protocol: Review findings make recommendation
d.
Emphasize correcting presbyopia (not fitting this new bifocal)
4.
Selecting, Evaluating & Modifying the Initial Lenses on the Patient
a.
Identify patient’s Dominant eye
b.
Selecting the distance power for the initial multifocal trial lens
1.
Distance spectacle correction -----> Vertexed to corneal plane
a.
Sphere only ---------- gas perm. multifocals
b.
Sphero-cyl equivalent -- most current hydrogels
2.
Diagnostic distance lens power Rx->
a.
Make sure exactly corneal plane Rx or more (+)
b.
If more minus –> patient will use some of the (+) “add power” for
distance
c.
Use Free lenses, Trial frame, or Flippers <------> Out of the Phoropter
1. Normal “room” illumination ( Avoid mirrored rooms if possible)
2. Evaluate Binocularly -----> Both eyes open —> “How do things look”
a.
Dist. ---> Initially use whole chart with 20/30 as bottom row
b.
Near ---> use magazines or newspapers: 20/40 to 20/30 print
d.
Time to let lenses settle & motor activity: Have patient walk out of exam lane
5.
Problem Solving: Modification based on Patient Feedback
a.
Add trial lenses binocularly until you obtain the best balance between:
Distance vision vs. near vision
1.
Add (+) O.U. ------------> if clarity needed at near
Add (-) O.U. ------------> to enhance distance vision
2.
Maximum plus to maximum acuity
b.
“Cannot binocularly make distance sharp without losing near vision”
1.
Monocularly add minus to dominant eye,
a.
do not occlude non-dominant eye while testing
b.
typically -0.25D to -0.50D
c.
Both eyes still have a dist. and near Rx;
“Enhancing” distance in one eye
2.
Use the next lower add in the dominant eye;
Enhances distance clarity:
c.
“Near vision not good, but distance isn’t bad”
1.
Monocularly add plus to non-dominant eye
a.
Both eyes still have a dist. and near Rx
b.
“Enhanced” vision at near in non-dominant eye
2.
Monocularly use the next higher add in the non-dominant eye
d.
Monocular addition of 0.25 - 0.50D power typically all that is needed
---> Success vs. failure
6.
Insert final lenses to be dispensed
a.
Binocular acuity: for you and patient
b.
Monocular acuity: for medico-legal documentation in chart
c
Reconfirm appropriate lens movement with slit-lamp
7.
Patient education:  Let the patient know
a.
You will be working with them to “fine tune” their Rx to meet problems
and there may yet be lens changes
b.
There may be an adaptation period (including slight shadowing of letters)
c.
Night driving, be cautious (halos around lights)
8.
Return to office in 3 about days: Long enough to evaluate vision, short enough to prevent
frustration. Use patient feedback to modify CL prescription
2.
9.
Patient Feedback, including Hx & requirements
a.
Patient displeased with “Crispness” of vision with soft -> RGP Multifocals
b.
c.
d.
e
Specific Lenses:
Health issues with hydrogel lenses ---------------> RGP Multifocal
Pt displeased with comfort of RGP’s --------------> Soft Multifocal
Part time wearer --------------------------------------> Soft Multifocal
Alternatives
Frequency 55 Multifocal: -------› methafilcon A (group 4, 55%, Dk 18.8)
& Proclear Multifocal ----------- omafilcon A (group 2, 62% Dk 34.0
1.
2.
3.
Design: Center near progressive multifocal for dominant (dist. enhanced eye) & center near
progressive multifocal for non-dominant (near enhanced eye)
Parameters
a.
Three add powers: +1.00, +1.50, +2.00, +2.50
b.
Distance Rx: +4.00 to -6.00 dist power (use vertexed spherical equiv. power)
c.
Other: 8.7mm b.c. / 14.4 dia / monthly replacement: 6-pack
For Rx’s
a.
for near: between adds round down to lower add
b.
for dist: with sphero-cyl equivalent between to 0.25 powers -> more minus
Soflens / PureVison Multi-Focal
(Bausch & Lomb)
1.
Dist. Rx: +6.00D to -10.00D
2.
Add Powers: Low (up to +1.50); High (+1.75 to +2.50)
3.
Base Curves: 8.5mm or 8.8mm , Dia.: 14.5mm
4.
Polymacon / 38% / Group 1 / Dk 8.4, 2 wk replacement
Initial Lens Selection
a.
Distance Power: Vertexed spherical-equivalent
b.
Base Curve: » 8.5mm base curve
c.
Add:
Low add +1.50 or less OU ( Early presbyope under 50)
a.
+1.75D to +2.25D add: Enhanced Multifocal
Dominant Eye --› Low Add ; Non-Dominant Eye --› high Add
b.
+2.50 add & up  High Add O.U.
Silicone Hydrogel Multifocal PureVison material : New from Bausch & Lomb
Focus Progressives & Focus Dailies Progressives:
1.
Single progressive add up to +3.00 / aspheric, center near design
2.
One trial power designated on box for distance and near
Focus Progressives: --------> vifilcon A (group 4, 55%, Dk 16)
a.
; Rx: +6.00 to -7.00; BC: 8.6mm/8.9mm with a 14.0 dia
c.
One month replacement ( option of 2 weeks): available as 6-pack
Focus Dailies Progressives: -----------> nelfilcon (group 2, 69%, Dk 26)
a.
Rx: : +5.00 to -6.00; BC: 8.6 with a 13.8 dia
b.
Daily replacement: available as 30- or 90-pack
Initial Focus Progressive lens selected from:
Trial CL Power = Spherical Equivalent Distance Power + 1/2 the add power
Exp.: Spec Rx: -3.00 dist / +1.50 add —> Trial = (-3.00 plus +0.75D) –> -2.25D
Focus Progessive lens selection, “Initial Power Selection Table”
1.
Uses distance BVA spectacle Rx ( —> spherical equivalent)
2.
Table vertexes the sphero-cyl Rx to spectacle plane
3.
Spectacle add
4.
How good is the “Initial Power Selection Table “ ???
Gas Permeable Multifocals: Benefits: Parameters, eye health, crisp vision
1.
National and practitioner/patient friendly
.
Envision: Bausch & Lomb & Others
2.
National Lenses: Recent & higher adds
Essentials: Blanchard , Essential Solutions: X-Cel (Walman), & Others
Other Alternatives