Multifocals: The New Standard of Care
Outperforming monovision in vision and long-term success, multifocal lenses should be the first choice for practitioners.
Dr. Schachet: With the last of the Baby Boomer generation now well into their 40s, presbyopia is prevalent in our patient populations. Although the onset of this age-related problem depends on such factors as refractive errors, lifestyle, genetics and geographic location, virtually every person over age 40 experiences some degree of presbyopia. Most have lost varying degrees of their accommodation capability by age 50.
By 2018, Baby Boomers will help boost presbyopes to the single largest group of potential contact lens wearers at a projected 28%.1 However, historically, contact lens usage has dropped off around age 45,2 when the onset of presbyopia makes multifocal lenses necessary, but the trend is poised to change with better multifocal contact lens technologies, easier fits and greater patient acceptance and success. As practitioners, this gives us a huge opportunity to satisfy an unmet need in a way that not only makes patients happier, but also increases profits and practice growth.
But how do practitioners view monovision and multifocal contact lenses? What are the advantages and disadvantages? Are multifocal lenses the new standard of care, and if so, why are so many patients still in monovision?
Dr. Schachet: What are the advantages of multifocals over monovision?
Dr. Schaeffer: Multifocal lenses provide natural vision at distance, mid-distance and near. Monovision has been a little bit better at near in low contrast,1 but then there's a problem with distance and mid-distance because the patient is over-plused for near. Multifocals replicate normal vision, while monovision is an adaption to a less-than-adequate seeing arrangement.
Dr. Lowinger: Obviously, multifocal lenses may not be supercrisp in low illumination, but they give patients the full range of vision. Another advantage is avoiding the long-term effect monovision has on the eye. Additional anisometropia between the eyes may develop, and then you're driving the patient's refractive error by changing their contact lenses.
Dr. Kading: Anisometropia changes things unnaturally. Do we want to preserve the natural binocularity that we can? Do we want to preserve the patient's prescriptions and follow them all the way through? Or do we want to create an unnatural situation where we've got one short arm and one long arm?
Dr. Sindt: When you say to a patient, “We have two choices: Both eyes with full-range vision as your eyes naturally work or one eye seeing distant and one seeing near,” they actually back up and say, “Why would I want that second choice?” Plus, we have to think about how the choice will affect the patient down the road, like when it's time to choose implants for cataract surgery.
Dr. Schaeffer: In the past, when only a few multifocal lenses were available, we didn't have much choice. But now we have a choice, and that choice is pretty obvious. I always want to obtain binocularity for the patient whenever possible.
|Patients don't seem to have a problem paying extra money to get eyeglasses without an unsightly line, even though their insurance doesn't cover the extra cost. Some practitioners seem to be reticent about recommending that patients do the same thing for multifocal contact lenses. But if we can suggest that patients pay a premium to avoid a line on their glasses, no one should be worried about having patients pay a premium to get a contact lens system that does everything for them.|
|— John L. Schachet, OD|
Furthermore, we require all patients in monovision to sign a legal release stating that we have instructed them to wear glasses over their contact lenses while driving, especially at night. Ten years ago, pilots were forbidden to wear monovision lenses because a pilot missed the runway. It's old news, but it still it points to the same question: Are we going to give our patients the best possible vision?
COMFORTABLE, CONSISTENT MATERIALS
Dr. Schachet: Because presbyopia sets in when patients are in their 40s, dryness can become more of an issue. Does that affect your choice between monovision and multifocals?
|With the introduction of any new technology, there are the early adopters, the mid-adopters, and finally a state of critical mass where the technology is really expected. I think we've reached critical mass with multifocal leness. They're considered the standard of care within the industry.|
|— Christine Sindt, OD|
Dr. Sindt: I choose the material and lens care solution that are appropriate for the eyes, and there are many great options on the market today. I partner with each patient to find the best lens for his lifestyle — optics, material and solution drive the choice.
Dr. Kading: I agree. This decision is no longer influenced by dryness concerns now that all of the multifocal designs are in the newest silicone hydrogel materials with monthly and 2-week modalities. We really can shift all of our patients directly into multifocal lenses.
Dr. Schaeffer: For patients with contact lens-related dryness, I think that having the clearest near, mid and distance vision encourages a normal blink pattern. When you change the way a person's vision has worked for the past 40-plus years with monovision, you change the way the body operates. I think, in the case of monovision, it could change the blink pattern. In our practice, I think choosing a multifocal for more natural vision may help emerging presbyopes who suffer from contact lens-related dryness.
Dr. Sindt: We also have many emerging presbyopes who are existing contact lens wearers. We're starting to fit the Gen-Xers who have been wearing soft contact lenses for 20 or 25 years. Even most Baby Boomers, who have past experience with other types of lenses, were moved into silicone hydrogel lenses 10 years ago.
Dr. Lowinger: Some multifocals are definitely better than others, but the good news is that all the materials have good oxygen transmissibility. It's an easy conversation compared to 10 years ago because although we're making a change, the change is going to work out great for the patient.
LINGERING ATTACHMENT TO MONOVISION
Dr. Schachet: A number of studies have shown that approximately seven out of 10 patients prefer multifocals over monovision in practical activities and real-world settings.3-5 So, why are practitioners still making monovision the most common form of contact lens correction for presbyopia?
Dr. Schaeffer: Some doctors don't feel confident or comfortable in their ability to fit multifocal lenses quickly and accurately. They may not have the necessary technicians or staff to keep multifocal patients moving through their exams smoothly and efficiently. And, of course, the monovision has worked for them for years. Some still believe, “If it ain't broke, don't fix it.” But they're not giving their patients the best care.
Dr. Kading: People stick with what they know, and they aren't always willing to invest the time to learn something new. I think that a fair number of practitioners who are still fitting monovision perceive that it would be time-consuming to learn to fit multifocal lenses. Monovision is not difficult to fit for emerging presbyopes in their early 40s; it becomes problematic and visually bothersome to patients later on in life.
Dr. Lowinger: That's right. If a patient in her early forties is a –5.75 and she's starting to have reading problems, we can put her in one 5.50 or 5.25 lens. She'll pick up a little reading vision right now. It's easy, and it really doesn't affect her distance vision all that much. But in each successive visit, we're dialing it back. Before we know it, she has a 1.0 or 1.5 diopter difference between the eyes. By saying, “If I just under-correct a little bit, she'll be fine for a few years,” we've positioned her for a much more difficult transition to multifocal lenses down the road.
|I think a fair number of practitioners who are still fitting monovision perceive that it would be time-consuming to learn to fit multifocal lenses. Monovision is not difficult to fit for emerging presbyopes in their early 40s; it becomes problematic and visually bothersome to patients later on in life.|
|— Dave Kading, OD|
Dr. Sindt: Once the patient is up to that 1.5-diopter difference between the two eyes, she's losing intermediate vision. If you start her in the multifocal lenses, she never loses intermediate vision.
Dr. Schaeffer: Another important issue is price. Monovision fees are usually much lower than fees to fit multifocal lenses — as they should be. Some practitioners don't want to explain a higher fee to patients. To fit multifocal lenses, you need additional time. You're not just replacing a lens, you're replacing a system, and that has to be built into your fee. When you and your staff discuss what's covered by insurance and what patients will pay out of pocket, you'll get into that patient conflict of “I want what's least expensive today.” Some practitioners aren't comfortable having that discussion.
Dr. Schachet: I compare it to progressive lenses. Patients don't seem to have a problem paying extra money to get eyeglasses without an unsightly line, even though their insurance doesn't cover the extra cost. Some practitioners seem to be reticent about recommending that patients do the same thing for multifocal contact lenses. But if we can suggest that patients pay a premium to avoid a line on their glasses, no one should be worried about having patients pay a premium to get a contact lens system that does everything for them.
MULTIFOCALS: THE NEW STANDARD OF CARE
Dr. Schachet: In this room, it sounds like we're in agreement that monovision probably should be a thing of the past?
Dr. Sindt: Monovision isn't completely off the table, but it's not my first line. For a normal patient with regular optics, multifocal lenses are my first line. Monovision is in my tool box, and I have a solid understanding of what it can and cannot do, but it's an exception that I use only for specific patients.
Dr. Lowinger: I don't take monovision off the table, either, but to me it's the last resort when everything else I've tried has gone nowhere because the patient just isn't adapting. I use it grudgingly because I know I'm not giving the patient the optimal choice.
Dr. Schaeffer: Multifocal lenses change people's lives. Monovision is dead. Why fit monovision? To put a 50-year-old patient who's starting to have crystalline lens changes into monovision and let him drive at night? That's ridiculous in the 21st century.
Dr. Schachet: So multifocals are the new standard?
Dr. Sindt: With the introduction of any new technology, there are the early adopters, the mid-adopters, and finally a state of critical mass where the technology is really expected. I think we've reached critical mass with multifocal leness. They're considered the standard of care within the industry.
Patients are expecting them, too. It doesn't involve a long conversation anymore. We say, “You're 43. You're having some near problems. Let's put you in a multifocal.” And that's the whole conversation because patients just get it. It gives them greater respect for our practices, and they respond to the fact that we're confident in and comfortable with multifocal lenses as well.
Dr. Kading: We recommend multifocal lenses in an assumptive way. “This is how we do things in our office. We don't fit monovision because it's not the right way to go. We prescribe lenses that are healthier and better for your vision.” Over time, patients go with that philosophy in our practice and realize that more expensive generally means more valuable. With a good explanation of the values and benefits of multifocal lenses, even the toughest patients generally see the value in multifocals and stop focusing solely on the price tag.
|Another drawback with monovision is the safety issue. The majority of monovision lenses are fit without driving glasses. We're taking vision away, and then sending people onto our streets and highways. I can't think of another medical example of that kind of induced public risk.|
|— Jack Schaeffer, OD|
Dr. Schaeffer: Because multifocals are the new standard of care, emerging presbyopes are starting young. If a patient wants monovision, we explain that it changes the visual system. Patients understand that it's going to change the way they see, and as their vision changes over time, we may have to reverse that change. If we start with multifocal lenses, we're keeping patients in the realm of high quality care. That's the place we assume they want to be. And when they start there, multifocal lenses are an easy change with an excellent success rate.
1. Studebaker J. Soft multifocals: Practice growth opportunity. Contact Lens Spectrum; June 2009. Available at: www.clspectrum.com/article.aspx?article=103013; last accessed April 16, 2012.
2. Alcon data on file, 2006.
3. Richdale K, Mitchell GL, Zadnik K. Comparison of multifocal and monovision soft contact lens corrections in patients with low-astigmatic presbyopia. Optom Vis Sci. 2006 May;83(5):266-73.
4. Benjamin WJ. Comparing multifocals and monovision. Contact Lens Spectrum. 2007;22(7):35-39.
5. Situ P, du Toit R, Fonn D, Simpson T. Successful monovision contact lens wearers refitted with bifocal contact lenses Eye Contact Lens 2003; 29; 181-184.