Article Date: 7/1/2012

Multifocals in Practice

Multifocals in Practice

Practitioners with a success rate of 85% offer their pearls for getting started and getting the right fit.

Dr. Schachet: We've established that multifocal contact lenses have replaced monovision as the standard of care. But how do you get started? And what outcomes can you expect?


Dr. Schaeffer: Once I recommend multifocals and explain what to expect, a technician comes in and explains the global fee, which covers the necessary visits. Next, the technician gets the lens that I chose and places it on the eye. After 5 minutes, the tech asks, “Are you seeing OK?” If the answer is “Yes,” we wait for the 15-minute mark and perform an autorefraction and then refract over the lens — binocular and monocular — so we can fine-tune that day. About 15% say, “I just can't see,” and I may try a different visual correction option. The other 85% will leave with lenses that get them close to 20/20 distance and 20/20 to 20/25 near.

If acuity isn't there, I'll switch to another lens and maybe perform topography to see why we're not getting the best result.

Dr. Sindt: This part of my practice relies heavily on my highly trained ancillary staff. My primary role is to ask questions, listen to the patient and choose a lens. I think patients really need to be heard, even if it's the eighteenth time that day that I've heard a similar presbyopia story. I know the patient is less likely to succeed if he doesn't think I've heard and understood his problem. My time is best spent having this conversation and fine-tuning the prescription. We dispense at the initial visit, and then I see the average patient back two more times.

Dr. Lowinger: It's a small group that won't succeed. At the first visit, when a good candidate has the lens in, we just ask, “How are you seeing?” We don't ask them to read a chart. We just want to hear, “Great.” If the patient naturally feels like he's getting some decent vision, then we're on a path to success.

Dr. Kading: I'm not as tied up in the initial visit. We do an autorefraction over the lens, as well as topography. If the pupillary axis doesn't line up with the line of sight, and if a contact lens does not line up with the line of sight, then the patient's vision will be skewed. It's a simple check. If the lens is decentered, then the patient needs a different lens design or monovision. We check patients' binocular vision, rather than asking them how things look with one eye covered.

Aside from those tests, I have just a couple of requirements for my patients when they leave the first visit. First, they must be able to see to drive. If they can't see distance, they're going to come back and return the lenses. They also must be able to use their cell phones.

 Early presbyopes are easy breezy. You just put them in the lens, it fits and they see great at all distances. Discussions become a bit longer with more mature presbyopes.

— Christine Sindt, OD

The most important visit to me is the second visit. They've already gone out and used the lenses in their everyday lives, so they have some feedback. And because the lenses have been on their eyes for several hours, I can fine-tune things.


Dr. Schachet: Do you use the fitting guidelines for Air Optix Aqua Multifocal contact lenses? Do you recommend that other practitioners utilize the fitting guidelines when they begin fitting multifocals?

Dr. Kading: I was always the type of person to ignore the fitting guidelines because I knew how to do it better than the company's way. But over the years, particularly with Alcon, I've seen a change. They've enhanced the fitting guidelines in ways that really improve the way it works.

It has blown me away that the fitting guidelines recommend pushing plus at distance to improve near vision and avoid impairing distance. We always think to give more minus in that case. The baffling thing is that it works. And by following the fitting guidelines and using unified adds, I find that I'm more successful than I was without them.

Dr. Lowinger: With the fitting guidelines, there's no wrong answer. If you're not comfortable fitting these lenses yet, it's a great place to start. Or if your fitting set is collecting dust, the fitting guidelines are the only way you'll take that first step. You'll change things based on how your patients react.

The current fitting guidelines match what I'd already been doing with Air Optix Aqua Multifocal lenses, aside from the fact that I push the plus for my presbyopes in South Florida.


Dr. Schachet: We have several options for multifocals: Air Optix Aqua Multifocal contact lenses (Alcon), Biofinity and Proclear Multifocals (CooperVision), Acuvue Oasys for Presbyopia (Johnson & Johnson), and PureVision Multifocal (Bausch & Lomb). In your experience, do they differ in fitting, comfort or vision at distance, intermediate and near?

Dr. Sindt: Well, those are four very different materials, and each one performs differently on the eye in terms of comfort, deposition and longevity of lens wear. You have to know the differences and how they affect the patient you're putting them on.

Dr. Kading: Absolutely. The other component is that all of these lenses work better or worse for certain individuals at certain times, so it's wonderful that we have all of them in our toolbox.

Dr. Schaeffer: I probably could fit 70% of patients in any one of the four lenses, but I feel there's a slight advantage to the Air Optix Aqua Multifocal lenses. At Day 1, most patients leave with good distance and near, and the lotrafilcon material helps maintain moisture by minimizing the rate of lens dehydration. The end-of-day comfort is amazing — especially for patients who have had comfort issues in the past.

Dr. Kading: I agree. One other nice component that really stands apart with the Air Optix Aqua Multifocal lens is the asphericity of the design, which supports a full range of vision.

Dr. Lowinger: The thing I appreciate the most about the Air Optix Aqua Multifocal lens is the distance vision clarity on the initial fit. If you start blurring patients' distance vision, they dismiss multifocal lenses entirely, so these lenses make it much easier to get the patient to believe in this system.

Dr. Sindt: And the Air Optix Aqua Multifocal lens offers not just good distance vision, but also good near vision. Before I started using these lenses, I typically needed a high add for my patients, but I had to back off to medium with these lenses or they'd be too strong at near.

Dr. Kading: And patients are in the ballpark of where you want them to be within 20 minutes — not a day or two like some of the other lenses.


Dr. Schachet: You've all been consistently fitting presbyopes with multifocal contact lenses for years. What's your current success rate?

Dr. Schaeffer: In my practice, it's 85%.

Dr. Kading: I'm in that realm.

Dr. Sindt: That's about right.

Dr. Schachet: Are you equally successful in fitting emerging, mid-range and full presbyopes?

Dr. Sindt: Early presbyopes are easy breezy. You just put them in the lens, it fits and they see great at all distances. Discussions become a bit longer with more mature presbyopes.

 It has blown me away that the fitting guide recommends pushing plus at distance to improve near vision and avoid impairing distance. We always think to give more minus in that case. The baffling thing is that it works. And by following the fitting guidelines and using unified adds, I find that I'm more successful than I was without the guidelines.

— Dave Kading, OD

Dr. Schaeffer: A pleasant and surprising change is that plano patients, who we couldn't help just 5 or 6 years ago, are now very easy to fit.

Dr. Lowinger: The other tough patients are high adds. They've had unsuccessful fits with other doctors because they have a high reading demand, and they take the most time in my office. But challenging cases aside, the technological advances over the past 10 years have really helped us achieve new success through an industry-wide effort. We're all benefiting from these advances.

Air Optix Aqua Multifocal contact lenses with Precision Profile Design
Air Optix Aqua Multifocal contact lenses have a Precision Profile Design that allows patients to experience clear vision and smooth visual transitions at all distances. This unique Precision Profile Design is composed of three key features:

Adaptive minus power profile
• Allows for a smooth progression of power gradients from center-near, to intermediate and distance
Bi-aspheric surface
• Enhances image quality and facilitates fit
Center-near design
• Works synergistically with the eye's natural function
These attributes work together to help presbyopic patients transition smoothly from different activities, without compromise. By following the Air Optix Aqua Multifocal contact lenses Fitting Guidelines you can help ensure quick fit success.

The Air Optix Aqua Multifocal lens is not hard to master after fitting five to 10 patients. The fitting guideline is the starting point in getting you comfortable with the lens and its design.

From there, you need to determine how your practice habits and patient responses on those first 10 or so patients “tweak” his initial lens decision.

In my case, I used the fitting guideline and realized that I was underpowering patients by about a quarter. I figured it was me not pushing plus enough or a vertex issue, but I added a quarter to my initial fits and that seemed to solve it.■

Contact Lens Spectrum, Issue: July 2012, page(s): 5 - 7