Optimizing Multifocals in Practice
A Roundtable Discussion
A group of contact lens practitioners share their patient management techniques and compare notes on today's multifocal options.
This roundtable was chaired by Contact Lens Spectrum Editor Joseph T. Barr, O.D., M.S., and included Rob Davis, O.D., Burt W. Dubow, O.D., Gary Edwards, O.D., Kenneth A. Lebow, O.D., Maurice Poster, O.D., and Leonard Seidner, O.D.
Contact Lens Spectrum: How do you prescribe for presbyopic contact lens patients beyond monovision?
Dr. Dubow: We explain what presbyopia is, that there are a number of options to correct it, and that we have a fee structure that enables us to select the correct option for them.
Dr. Lebow: During a screening visit, we perform a complete visual analysis and then have the patient try various bifocal contact lenses. We evaluate visual performance, comfort and patient perception using rigid and soft lenses in alternating and simultaneous designs. This allows patients to assess the lenses, and helps us determine if we can satisfy their goals. Since this visit can take up to an hour and a half, we inform patients in advance that we charge a fee for professional time even if the fitting is unsuccessful.
Dr. Davis: Our goal is to give patients optimal vision. So our lens of choice is whatever bifocal modality we can use to achieve this goal. We do use monovision, but it's our last resort.
Contact Lens Spectrum: It appears your fee for service averages about $350 to $500 in the first year.
Contact Lens Spectrum: Have you developed an efficient system to determine if a patient is a good candidate for multifocals?
Dr. Edwards: There are some patients you can screen out immediately. That leaves everybody else -- some good candidates and some who are questionable. You really won't know until you put lenses on eyes.
Having lenses in inventory is really important. Putting a diagnostic lens on, and then doing an overrefraction holding trial lenses in front of a patient and saying 'here's approximately what you're going to be seeing' is not a good option. You need enough lenses in inventory so you can fine-tune the prescription while the patient is in your office. If you can send him home with a pair of lenses, that's really the optimum situation.
Dr. Lebow: The two critical factors that determine patient success are the physical comfort of the lens on the eye and proper visual performance. While most patients achieve good comfort over time, visual performance may be slightly more difficult to achieve. At the screening visit we establish a baseline for these two levels of lens performance and, to the extent that patients are happy with their vision, the fit will be successful.
Contact Lens Spectrum: Regardless of the type of spectacles you use for presbyopia, there is adaptation. In fact, there's always a compromise relative to young, accommodating eyes. So what is the relative compromise? Is there any more compromise with multifocal contact lenses versus spectacles?
Dr. Edwards: I'll give $10,000 to anybody who can tell me the perfect correction for presbyopia. A flat-top 28 is great for a lot of things, but it's not ideal if you don't read or if you want intermediate vision. Progressives have their benefits, but they have drawbacks as well. There really is no perfect spectacle correction for presbyopia and, unfortunately, too many practitioners are waiting for the perfect, ideal, one-size-fits-all contact lens for presbyopia. That probably will never happen. So it's time to stop waiting for the perfect lens for presbyopia and start working with the tools that are available.
Dr. Lebow: Generally, the problem is not physically fitting these lenses to eyes. With time and clinical experience, most practitioners can achieve optimum lens-to-cornea fitting relationships. Excessive compromise to the patient's vision is more often the reason for failure. Proper lens choices can minimize this compromise. For example, because alternating designs should move on the eye, hydrogel lenses in this form tend to be unsuccessful. A better choice for the soft lens wearer would be a simultaneous design lens. The real key issue is achieving crisp, clear vision for bifocal contact lens patients.
Dr. Poster: We're also talking about the patient's expectations and the doctor's expectations. The doctor wants a perfect correction. Of course, we all do. But, there's no such thing in this world as a perfect heart or a perfect foot or a perfect pair of contact lenses. The point is to obtain the best correction and comfort and eye health that we can for patients and to manage their expectations. Nothing is going to be perfect for any given patient at any given time.
Contact Lens Spectrum: Patients say "Yes, it's okay. I'll accept the compromise," but you don't really know until they try if that's the compromise they'll accept.
Dr. Poster: Companies that make progressive bifocal spectacles offer a 60- or 90-day trial period to see if the patient can adapt. But the real beauty of having an extensive inventory of free trial pairs is to enable patients to put them on close to their prescription and give them a real life trial experience.
Dr. Seidner: In the past, a patient would come in having difficulty reading. The practitioner would say, "Would you like a pair of bifocal contact lenses?" The patient would say, "I didn't know there was such a thing." Now, the practitioner says "I'll order a pair of lenses for you. They will cost $500 to $600." He orders a pair of lenses for the patient. The patient tries them and says, "These are pretty good, but I can't read as well as I would like to read." So the practitioner pushes the plus as much as he possibly can and he orders another pair of lenses. The patient comes back a week later and says, "Oh, I can read much better, but now I can't see the distance." The practitioner has charged this patient a substantial fee and now he has to satisfy this patient. Otherwise, the patient is going to be disgruntled. So he keeps working with the patient, but often the practitioner has gotten to the point where he says, "I don't need this aggravation."
The reason he's got so many lenses on his shelf is that he didn't have a good modality for screening and fitting the presbyope. You have to screen patients before you take them on as patients.
Contact Lens Spectrum: It's been said that bifocal eyeglasses, post refractive surgery care and contact lens practice require a lot of hand-holding. Care to comment?
Dr. Dubow: We often forget that we teach our patients to report their symptoms to us. Sometimes we hear these comments as complaints and believe the patient doesn't like the lens. So, in my office, the last thing we do is say, "Oh, yes we understand those things are happening, but how do you like the lenses? How are they doing overall? Are you satisfied?" Very often the patient says, "Oh yeah, they're great." So don't forget that final step. Ask the patient how he likes his lenses.
Dr. Lebow: Burt is right on the money! Patients may appear to be unhappy with their lenses when you listen to their complaints, but they're just reporting everything about their new way of seeing. They're usually not ready to throw in the towel, they just want us to know how they're seeing and to learn if there are any options to satisfy their problems. In fact, if we'd just ask patients to rate their lenses on a scale from 1 to 10, most would give them high ratings.
It's crucial that we evaluate patients' goals during the interview and screening visits. Then we can match those goals with specific lens types. Also, remember that one correction may not be suitable for all working distances. If patients have difficulty with one aspect of their vision, they're usually willing to wear eyeglasses over their contact lenses for specific tasks such as reading or driving. We shouldn't lead patients to believe that bifocal contact lenses are going to be the only solution for their visual needs.
Contact Lens Spectrum: How do you educate your staff about multifocals?
Dr. Dubow: It's really important that practitioners prescribing for presbyopia educate their staff about what they're doing. You must have a really positive attitude. You can't be neutral. In this case, being neutral is the same as being negative.
Contact Lens Spectrum: Which type of lenses do you use most right now for presbyopic patients?
Dr. Davis: I use all the various types of bifocal lenses. Some of my patients wear one manufacturer's bifocal on one eye and another company's bifocal on the other eye. I work very hard to achieve binocular vision. I believe that a bifocal modality is better than any other modality that's available.
Dr. Lebow: Bifocal contact lenses are custom devices. Each lens, like each patient, has its own unique set of fitting and performance characteristics. To that extent, whatever combination of designs works for the patient is what we should use. While most of us here today prefer to fit bifocal designs, many patients and practitioners view monovision as a more economical alternative for presbyopia. So, if you're working with a patient who has major economic considerations, you may be driven towards monovision rather than bifocals. But, given the fact that we would prefer to fit a bifocal contact lens, no one lens is successful all of the time.
Dr. Dubow: I use a wide variety of multifocal lenses, but I prefer simultaneous designs because most of my patients work at intermediate distances on computers, and most of the alternating designs don't offer good vision at all distances.
Dr. Edwards: A practitioner who's just getting started in presbyopic fitting would need a couple of translating RGPs, an aspheric RGP and a soft bifocal or multifocal lens. The advantage with the new disposable multifocal lens is that you have powers in inventory so you can determine immediately if it's going to work. That's why disposable lenses in general have worked so well. The patient is sitting in your chair, you put a pair of lenses on and they can walk out with their own prescription that day. They return in a week and you can see how they're doing.
Dr. Davis: With this new disposable multifocal, you can put the patient into a lens very inexpensively, and he can try it in his own environment. Having the patient leave the office is a better indicator of potential success than having him read the third line on the chart. There's also the comfort factor. Comfort is more related to driving a car and sitting next to a fan at work than how the patient feels after an hour in your exam chair.
Dr. Dubow: Most patients need fine-tuning, so you must order new lenses, but by the time the patient returns, his vision might have changed again because the lenses are settling. With a disposable multifocal, you put the lenses on. It doesn't cost you anything. The patient goes home and returns in a week or two and, you're done. It solves a lot of the problems we've had to deal with in patient management where it caused them to drop out because they became frustrated before we reached our final point. Now we can reach the final point quickly and easily.
Contact Lens Spectrum: So, let's talk about a frequently replaced multifocal lens. We've already talked about how it's more efficient to assess patients and make sure they have some reasonable level of vision before they leave the office. What are the rules or values in having such a lens other than the ones we've already discussed?
Dr. Poster: When it comes to multifocal lenses, I believe that practitioners are more skeptical than patients. The patients are willing to try. It's the practitioners who are reluctant to spend time with a modality that they're not familiar with. They say, "What if it doesn't work? How do you find out if it works?" To find out if it works, you put the diagnostic lens on the patient and determine if he's a good candidate. If the patient complains immediately, then it doesn't work and there is no sense in trying to make it work. Having a lens available that you can immediately put on the eye -- that's the key to success. The big problem today is that practitioners are reluctant to get involved with bifocal contact lenses.
When patients leave the office wearing lenses it means that they're satisfied with their physical comfort and their vision. If they're not satisfied with their vision, they're never going to leave the office with the lenses. If they leave with the lenses, they stand a much better chance of being successful with the lenses.
Contact Lens Spectrum: Even if it's only as good as lenses we've had in the past, are practitioners more likely to try a disposable multifocal because they're familiar with the advantages of other frequently replaced lenses?
Dr. Dubow: I think they'll try them because patients want them. Presbyopes often ask me, "Doctor, why can't I wear those disposable lenses?" They all want them. We know about the safety and convenience factors. Our patients know about the safety and convenience factors. We've never had a true easily replaced multifocal that we could give them. Now we do.
Dr. Edwards: I think doctors will be more apt to try them because they'll now have inventories in their offices. Whenever I've worked with soft bifocals, I've had every available power in quarter-diopter steps. I could make those lenses work because I could put the exact power on a patient's eye and know immediately if it would work or not. So the opportunity for the average practitioner to have that inventory of diagnostic lenses in the office at a very reasonable cost, that's what's going to make this fly.
Dr. Poster: Another subtle, but major issue is the health of the eye. Patients may wear other bifocals for six months or a year. I've had patients come back in two years and their lenses were horrible. Presbyopic eyes are older eyes; they get more protein deposits; they're drier eyes. There's certainly an advantage in being able to replace a lens monthly and, in fact, we can prescribe this particular lens for two-week replacement if we wish.
We're also talking about confidence. We want patients to have confidence in their lenses and their vision. Practitioners should also have confidence in the lens and part of that confidence is frequent replacement, keeping the lens clean, having multiple lenses available.
Contact Lens Spectrum: Dr. Poster, why don't you tell us about this new disposable multifocal?
Dr. Poster: The back surface of the LifeStyle Frequency lens is a bi-curve; it has an 8.4 base curve and a 14.5mm diameter. The front surface has multiple visual areas, with the central area for distance and the ring around the central area for intermediate tasks such as computer work. It has another reading area beyond that for normal reading and another distance area for nighttime vision. The material is 55 percent water with a visibility tint. The lens is molded and comes six per box.
Contact Lens Spectrum: Do you care how much this lens moves?
Dr. Poster: Absolutely. There are subtleties in fitting this lens. As with any aspheric lens, centration is critical. Yet, there are some patients who will see well with a little movement. You also have to be careful if poor physiology appears.
Contact Lens Spectrum: Even if it is a little off-center, practitioners should continue?
Dr. Poster: You're really talking about a 'go or no-go' lens, with the single exception that a lens might be too tight on a very flat eye. The patients will give you the answer almost immediately. If they're happy and they feel that they see and you feel that they see, then they're perfectly fine regardless of whether the lens moves a little too much.
Contact Lens Spectrum: Dr. Poster, how do you determine the correct power?
Dr. Poster: Since the lens is a center distance design, the prescription is similar to that for a single-vision lens. For the mature presbyope, you may need to add more plus may to the non-dominant eye, but at no time does this difference need to be as great as +1.50D. Consequently, unlike monovision, as the patient gets older, a greater near add will not interfere with distance vision.
Contact Lens Spectrum: Now, forget about what the FDA says, forget about what your lab says, will you call this a frequently replaced lens? Will you call it a disposable?
Dr. Davis: It's basically the same issue as we saw with toric lenses. Patients view toric lenses that are replaced once as month as disposable. They say "I need toric lenses and I want a disposable lens." If you say that a frequent replacement lens is not disposable, then they don't want it. But if you say that this is a disposable lens with a somewhat longer period between disposing, it's a monthly disposable instead of a two-week disposable, then that's okay.
Contact Lens Spectrum: Why do some practitioners succeed with multifocals and some don't?
Dr. Dubow: Attitude. Attitude toward the lenses that are available. Attitude toward the patients and their management.
Dr. Edwards: Not long ago, some practitioners had a negative attitude toward disposable spheres, but you don't see many offices now that don't have disposable spheres. Perhaps the disposable multifocal will be an opportunity to change the attitude about multifocals as well. CLS
(This roundtable discussion was sponsored by The LifeStyle Co., Inc.)