Article Date: 12/1/2000

1200029

MULTIFOCALS

Multifocal Contact Lenses:
A Valuable Alternative for Your Presbyopic Patients

By Joe Schwallie, OD, MS
December 2000

A multifocal lens allows you to determine success quickly with minimal chair time and patient demonstrations.

It's a great time to be an eyecare practitioner. This may be an optimistic statement considering that I complain as much about managed care and mail order contact lenses as my colleagues. However, I believe that we are entering an economic boom in the realm of vision care. I don't need to quote statistics to tell you that the number of presbyopic patients is increasing dramatically. Thanks to the baby boomers, our opportunity to provide premium products and services has never been better. Eventually, all of these boomers are going to require help with their reading vision, and as I am sure you have noticed, many of them have no desire to wear spectacles.

As a result of this, I find myself fitting more presbyopes into contact lenses than I ever have. And interestingly, I find myself fitting fewer patients in traditional monovision than I ever have. With the advent of the newer generation of designs and the increased consumer awareness of my patients, multifocal contact lenses have become my number one option for presbyopes interested in decreasing their dependency on spectacles. Introducing Focus Progressives (CIBA Vision) into my practice has been one of the primary reasons for our success with fitting presbyopes into contact lenses. Our success has been a tremendous asset in building our practice. We have attracted new patients and our involvement with multifocal contact lenses assures our patients that we are up to date with the latest technology.

Harvesting Potential Candidates

One of the most important factors in determining success with Focus Progressives is identifying the potential candidates. I have found that almost anyone can be a potential candidate, but not everyone will be a complete success.

As with any type of vision correction, there are many factors to consider prior to fitting a patient with a multifocal contact lens. Just as you may not fit every patient into polycarbonate spectacle lenses, you may not fit everyone into multifocal contact lenses. Table 1 outlines some criteria to follow in identifying the potential success of a given patient. The optical considerations mentioned in the table are good guidelines, but it is worth mentioning that they are not absolute. I have successfully fitted enough patients with borderline astigmatism or minimal distance prescriptions to know that I shouldn't rule out anyone who is interested in trying the lens. In other words, don't discourage motivated patients, who may be less than ideal candidates, from a demonstration fitting. The availability of Focus Progressives trial lenses, and the simplicity of the lens design, eliminates concerns over chair time and profitability, allowing you to demonstrate the benefits of the lens to anyone interested.

 

TABLE 1: Guidelines for Determining Good Candidates

  • Patients needing correction for distance vision

  • Emerging presbyopes
  • Astigmatism less than 1.25D
  • Attainable vision demands at distance and near
  • Realistic expectations
  • Motivated to decrease their dependency on glasses
  • Unsatisfied with current contact lens correction
  • Beware of atypical conditions such as large pupil size, dry eye, irregular corneas, amblyopia

While optical considerations are important, I also consider occupational and recreational needs in order to tout areas where the lens may benefit the patient and to identify the potential for unrealistic expectations. Any patient with an active lifestyle will benefit from contact lenses. There are many advantages to wearing contact lenses compared to spectacles, and they are no different for multifocal contact lenses. I like to point out these benefits to new contact lens wearers to help pique their interest. The opposite consideration is where these needs may indicate unrealistic expectations. For example, driving to the market at night to pick up a gallon of milk is a realistic expectation; driving overnight to visit relatives on the other side to the continent is not. A similar example can be given for very demanding near tasks. Occupations or other activities with very demanding distance or near requirements may limit the success of a given patient during that activity. Therefore, it is important to determine if it is critical for the patient to be able to wear the lenses during that activity. If it's not important, then try not to let it become an issue.

Outside of the optical and occupational needs, I have found that patient motivation is a primary key to success. Patients who are interested in becoming less dependent on their spectacles tend to be very motivated. My most motivated patients seem to be the emerging presbyopes, especially those who have never worn any vision correction. While a great number of these patients tend to be the less than ideal near emmetropes, the fear of multifocal glasses and the inconvenience of reading glasses make multifocal contact lenses attractive.

Current contact lens wearers also tend to be some of my better candidates, particularly if their current lens is not meeting their needs. Recently, I have found that I have to probe a little deeper to determine if my patients are truly happy with their current contact lenses. If you ask a patient if they are happy with their current lenses, they almost always say yes. However, the answer may be no to a more direct question such as, "Are you still able to see clearly while driving and reading with your current contact lenses?"

Motivation is also directly linked to patient expectations. I try to identify the unbiased expectations of the patient. If they have what I consider to be unrealistic expectations, then I educate them on what a multifocal contact lens will provide.

 

TABLE 2: Focus Progressives Product Specifications

  • Material: Vifilcon A
  • Diameter: 14.0mm
  • Base Curves: 8.6mm and 8.9mm
  • Center Thickness: 0.10 mm at all minus power, 0.16 mm at +3.00D (varies with power)
  • Power: Distance of ­9.00D to +8.00D (0.25D steps)
  • Add: Single progressive add, effective range up to +3.00
  • Design: Center near, progressive aspheric

 

Patient Education and Instilling Realistic Expectations

Unfortunately, there is no optical device that will give patients the same visual performance they enjoyed prior to their pre-presbyopic days. I tell patients that they should expect a successfully-fitted multifocal contact lens to work for 80 to 90 percent of their daily activities. This is no different than limitations experienced with other types of optical correction. Just as multifocal spectacles are not ideal for all situations like sports or near activities not engaged in downward gaze, multifocal contact lenses may also have limitations. I try to give my patients real life examples of these limitations as well. For instance, while it may be possible to look up a favorite stock market listing in the local paper, reading through the entire stock market summary may not be a realistic expectation. As we know, the reason for this compromise is simultaneous vision. While this concept may be somewhat difficult for patients to grasp, they seem to understand the difficulty of attaining both distance and reading vision with their contact lenses. To gain adequate reading vision, they may have to give up some of the clarity at distance. The "robbing Peter to pay Paul" analogy seems to be understood and is helpful in detecting patients who may have an unrealistic expectation of razor sharp vision at all distances.

Patients should be aware of the time and effort involved with the fitting. While this is less of an issue with a more simplistic design such as Focus Progressives, it is still worth mentioning, particularly to avoid letting the patient become discouraged if the initial pair of lenses is not perfect. I let patients know they will likely wear more than one pair of lenses, they will be seen for more than one visit and a period of three to five days is needed to truly evaluate each pair of lenses. Patients are capable of understanding the added complexity in fitting a multifocal contact lens, but it needs to be explained.

While no one likes to talk about price, it is an issue that should be addressed before taking a course of action. In an era where marketing directly to the consumer is becoming more popular, patients may have false expectations regarding the cost of multifocal contact lenses. This is even more evident with the advent of disposable multifocal lenses. While I do consider price to be a factor, I try not to prejudge any patient's economic situation. I simply state my fees and then let the patient decide if price is an issue. In stating the fees, I emphasize what is included (follow-up visits, 12-month supply of lenses, etc.) and the cost of replacement lenses. I also like to mention that the cost is approximately equal to, or less than, a good pair of spectacles. Most importantly, I do not refer to the lenses as "expensive," and I try not to let price discourage an interested patient. Determining a patient's sensitivity will help you chart your course of action: whether to proceed with a full fitting, a demonstration fitting or to wait until another time.

 

TABLE 3: Fitting Procedure Summary

  • Consider patients needs and expectations

  • Assess ocular health
  • Determine spectacle refraction and add power
  • Select 8.6mm base curve lens (or 8.9mm if the eye is atypically flat) with power equal to the ver tex corrected spherical equivalent plus half the add.
  • Allow the lens to settle on the eye (approximately 10 minutes).
  • Determine maximum plus hand-held or trial frame over-refraction that allows good distance vision
  • Assess distance and near vision binocularly (use a magazine, clock on the wall, etc., not visual acuity)
  • Fine tune vision as necessary
  • Verify physical fit and dispense lenses
  • Schedule follow-up visit for three to five days

 

The Demonstration Fitting

As I have found, having the ability to entice a patient with a demonstration fitting is an exceptional advantage. The availability of Focus Progressives trial lenses allows patients to experience the benefits of multifocal contact lenses and permits you to capture potential patients, such as those with borderline astigmatism, those unsure of contact lens comfort and those who like to try before they buy. A big key to successfully fitting Focus Progressives is getting the patient to put the lens on and try it. The demonstration fitting could be done as a courtesy to the patient, or you could charge a nominal fee. We typically charge $25 for a demonstration fitting at our office, which includes a pair of lenses and a follow-up visit. I feel the small fee puts a value on the service and look at it as funds for replacing used trial lenses.

For the demonstration fitting, I select a pair of Focus Progressives lenses based upon the fitting guidelines (see Table 3). I let the lens settle briefly, and then check distance vision, near vision and lens fit. If the vision is adequate, I inform the patient that preliminary visual results are good, but the prescription may need to be modified to attain optimal performance following the demonstration period. Unless vision is completely inadequate, I avoid changing the prescription. Current contact lens wearers return in three to five days, while new contact lens wearers return later the same day so that lenses can be inserted and removed in a timely fashion. At the return visit, I usually find patients either really like the lens or that vision was completely unacceptable. A negative outcome from the demonstration fitting permits me to end the fitting without wasting further chair time. I don't mind the occasional failure if it allows me to easily rule out patients unable to attain adequate optical performance or patients with unrealistic expectations. Patients who like the lens are usually pleased with minor modifications to the prescription.

Final Comments

When working with Focus Progressives, don't get caught up in success rates. The more patients you expose, the more lenses you will fit, but you may also increase the number of failures, particularly those who are less than ideal candidates. This lens allows you to determine success quickly and use an affordable demonstration fitting for those patients who may be borderline. If you are not already working with multifocal contact lenses, make the commitment to start.

The Focus Progressive multifocal lens is an excellent primary option that allows for simplistic fitting, patient demonstrations and minimal chair time. If this is your only option, consider using the demonstration trial more often. Patients pay only a small fee, and you invest very little effort. If you are already using multifocal contact lenses, add this to your fitting options. It is an exceptional lens for early to moderate presbyopes who are trying to avoid spectacles. Integrate it into your normal multifocal contact lens fitting fee structure and utilize the benefits of a demonstration fitting to expose more patients to multifocal contact lenses.

This article was sponsored by CIBA Vision.

Dr. Schwallie is in private practice in Toledo, Oh. He is currently involved in clinical research studies including bifocal and extended wear contact lenses. He was previously clinical project manager with CIBA Vision.


Contact Lens Spectrum, Issue: December 2000