Prescribing for Presbyopia

The Visual Give and Take of Multifocal Correction

Prescribing for Presbyopia

The Visual Give and Take of Multifocal Correction

By Thomas G. Quinn, OD, MS, FAAO

I find that practitioners tend to think of multifocal spectacles, such as progressive addition lenses (PALs), as offering “perfect” vision, while there is “give and take” with multifocal contact lenses.

The truth is that there is give and take with any form of multifocal correction. Table 1, available in the online version of this article at, defines some of these. What gives?

Setting the Right Tone

Patients new to multifocals, be they spectacles or contact lenses, need to be taught what to expect and how to manage the inherent limitations of each design. I believe most of us are comfortable discussing adaptation with patients new to wearing PALs, but not patients new to multifocals.

I sense that some practitioners are quite concerned about over-promising performance from multifocals. In response, the presentation of this option tends to be quite guarded and sometimes downright negative, which potentially discourages patients from proceeding with this great option.

You can achieve the right balance by using the Sandwich Approach. This technique opens the conversation with a positive statement, followed by some of the challenges inherent with multifocal contact lens wear, followed with a statement that re-establishes a positive tone. (To read more, visit and click on Archives, June 2004 issue, Contact Lens Practice Pearls.)

Aiding Adaptation

Although today's multifocal contact lenses can deliver exceptional vision, some patients have trouble adapting to the optics. I find the following steps often ease patients from frustration to acceptance.

First Revelation “The goal is to meet most of your visual needs most of the time.”

Employ the expectation setting strategies discussed, then establish the above goal. After fitting and dispensing, if the patient returns unhappy with his vision, confirm the prescription and employ troubleshooting strategies as outlined by the manufacturer's fitting guide. If the patient is still unhappy, proceed to the Second Revelation.

Second Revelation “You may need to give up a little bit of crispness for freedom.”

Re-establish expectations as described in the first revelation, but be more pointed. Remind him of benefits such as freedom from peripheral distortion and ease of going up and down steps (compared to PALs) and that he may need to sacrifice some crispness to enjoy these advantages.

If the patient is still unhappy with his vision, sometimes it comes down to employing the Third Revelation.

Third Revelation “This is as good as it gets.”

This lays it on the line. Remind him of the many benefits of multifocal lens correction. It is up to him to decide if the benefits outweigh the slight loss of crispness. When faced with this ultimatum, I find that many choose to continue with multifocal lens wear. This three-step strategy helps us arrive at this point in an honest, straightforward, and, importantly, timely manner.

Is It All Worth It?

Don't be misled. Studies repeatedly have shown that patients prefer the performance of multifocals over monovision (Rajagopalan et al, 2006; Situ et al, 2003). But sometimes it takes a little time and conversation to arrive at a satisfactory endpoint. CLS

For references, please visit and click on document #198.

Dr. Quinn is in group practice in Athens, Ohio. He is an advisor to the GP Lens Institute and an area manager for Vision Source. He has been an advisor or consultant to Alcon, B+L, Ciba Vision, CooperVision, and Vistakon, has received research funding from Alcon, AMO, B+L, Ciba, CooperVision, and Vistakon, and has received lecture or authorship honoraria from Alcon, AMO, B+L, CooperVision, GPLI, SynergEyes, and Vistakon. You can reach him at