Practitioner Opinions on Soft Multifocal Contact Lenses
BY FARID EGHBALI, OD, FAAO; QUANG CHUNG, OD; & CYNTHIA ARATA, OD
Soft multifocal contact lenses have been in use for well over a decade. However, even with advancements in contact lens technology, many eyecare practitioners shy away from prescribing them. Commonly reported reasons are increased chair time, increased cost to both patient and practitioner and, finally, suboptimal success rates.
We held the following discussion to gain insight into contact lens experts' perspectives of soft multifocal contact lenses including fitting techniques and patient management.
We approached a well-respected organization in Southern California called the Optometric Consultants in Contact Lenses (OCCL) to gather their opinions on the ins-and-outs of multifocal contact lens fitting. In all there are 17 member optometrists, among them eight Diplomates in the Cornea and Contact Lenses section of the American Academy of Optometry. Most members including the primary author actively see patients in private practices and many are active in teaching as well.
A round-table dinner was organized by the group and sponsored by Vistakon. No representative from Vistakon was present during the discussion session of the dinner meeting.
We e-mailed a questionnaire to the members of the group. Their responses were gathered and discussed at the dinner meeting. Twelve members participated in the dinner meeting and two members responded via e-mail.
The following summarizes all responses and general comments for each question from members of the group. Not all members responded to each question. Additionally, we recorded only one response if more than one member gave the same response.
1. What are the two types of multifocal soft contact lenses that you use successfully in your practice? Table 1 shows these results.
2. When do you choose/recommend soft multifocal lenses over monovision?
• When presbyopes need an add of greater than +1.50D OU.
• Prescribe bilateral multifocal contact lenses for patients who require better near vision.
• Advise patients that bilateral multifocal fitting can compromise distance vision so they may require glasses over the lenses for near or distance.
• Soft multifocals work better than monovision for men.
• In general, hyperopic patients have better success with soft multifocal lenses compared to myopes.
3. When do you choose/recommend monovision over soft multifocal lenses?
• For emerging presbyopes.
• Women tend to adapt better to monovision compared to men.
• When near tasks are more important and compromise of a multifocal lens is not acceptable, unless binocularity is an issue.
• Monovision success rates are usually higher in low-to-moderate presbyopes.
• For patients between 40-to-50 years of age; prescribe a distance driving prescription to enhance night driving abilities.
4. Are soft multifocals successful in post-refractive surgery patients who are emmetropic and presbyopic? None of the members felt that they had enough experience in this area to make any comments other than such patients will wear spectacles to improve near vision as a first option as opposed to resuming lens wear.
5. What changes would you like to see in multifocal soft lens industry/technology?
• More options for varying the size of distance/near optic zones.
• Some members want to see more soft translating multifocal lens options.
• Larger or more visible eversion marks.
6. What pearls can you give to increase the success rate of soft multifocal lens fitting?
• Have patients come back for follow up in two-to-three days versus two-to-three weeks to fine-tune the lens prescription.
• The best results are obtained with modified monovision. It's generally difficult to obtain perfect binocular vision for both distance and near. In patients who have moderate astigmatism, monovision with astigmatism correction might give a better result.
• Allow for more chair time and patient education because some visual compromise will occur.
• Use various multifocal lenses to accommodate various pupil sizes and visual needs.
• Always bias one eye toward distance and bias the other eye toward near when fitting multifocal contact lenses.
• Don't fit both eyes with the same add. Try fitting the dominant eye with a spherical contact lens and the other eye with a multifocal contact lens.
• Most members felt that the "N" lens in CooperVision's Frequency multifocal design is too strong and that you shouldn't go above +2.00D for most patients. If a higher add is needed, it's better to change the sphere component versus using a higher add power. The N lens may work better on hyperopes, but it provides a narrower field of view.
• Aim for 20/30 or better OU at distance and J1 OU at near.
• One member uses what he calls the "W" test — or what patients see out of the window rather than on the eye chart in the exam room. He takes them to the window with ±0.25D flippers.
• Let patients make the choices.
• We can modify a patient's expectations to prevent making a happy lens wearer unhappy.
• The initial evaluation is generally a key indicator of whether the patient will succeed. If a lens type isn't working at the first visit, changing to various different lenses will not necessarily increase the success rate. Sometimes it's best to recommend other contact lens options and thus lose your ego and not the patient.
• When educating patients about the pros and cons of each modality, use the phrase "give and take" rather than "compromise."
• Prescribe distance glasses over the monovision or multifocal contact lenses to protect yourself medico-legally.
• Always start with monovision — even for higher presbyopes, max out plus at distance.
• Modified monovision is a great option for patients' "social vision" if they can't tolerate full monovision.
Understand that each of the recommendations from the OCCL outlined here was made by at least one member of the group. You may agree with some of the statements or strongly disagree with others. Just as one size won't fit all, we should emphasize that one method of managing presbyopes won't fit all. A modified monovision fit in which one eye is fitted with a spherical distance lens and one eye with a multifocal lens biased for near vision may work for a retired executive who is 55 years old and plays golf three times a week, but not for a male truck driver.
We believe multifocal contact lens fitting is an art as much as science and should be treated this way. Dealing with the patients' expectations and reassessing and reformatting their objectives/goals based on what you can deliver is as important as knowing the vertex of the contact lens power, which is the dominant eye and other eye-related factors.
If you fit patients with multifocal lenses without educating them about their inherent limitations, this could ultimately lead to frustration and dissatisfaction for both you and your patients. CLS
Dr. Eghbali is in private practice in Beverly Hills and Burbank, Calif. He is also an assistant clinical professor in ophthalmology at UCLA, assistant professor at Southern California College of Optometry and director of clinical care at the Maloney Vision Institute.
Dr. Chung is in private practice in Santa Monica, Calif., and is a staff optometrist at the Harbor UCLA Medical Center.
Dr. Arata is in private practice in Los Angeles.