Article

PRESCRIBING FOR PRESBYOPIA

YOU CAN’T WIN THEM ALL

The title of this article holds true for sports and for life in general. No matter how well prepared you might be, sometimes success eludes you. This is also a correct statement when it comes to multifocal contact lenses. The success rate for multifocals is around 80% to 85% with most designs. Despite our best efforts, sometimes a patient simply is not fully satisfied. If that happens, it is time to review your evaluation process, reassess your approach to that particular patient, and contemplate remedies.

Review

It could be that we did not pick a good candidate. Also, we may not have done an adequate job with our patient education before, during, and after the initial contact lens evaluation. Of course, it could be that a patient had unrealistic expectations, despite a complete discussion of all appropriate options for that patient.

So now what? Are your patient’s needs and expectations for contact lens use realistic? If the answer is yes, you could try different multifocal options in an attempt to please the patient. You could suggest distance-only lenses, with readers over the contact lenses for near tasks. You could even consider monovision.

If the patient is not realistic in his or her expectations, a new discussion is necessary. Go over the options as outlined above. Include pros and cons for each choice. Review how the different lens designs work. Find out what distances are most important to the patient. Sometimes you can achieve success by giving the patient good vision at that particular distance and adequate vision at the others.

Reassess

Do not forget to look at the fit of the lens on the eye. Soft multifocal lenses need to center to work properly. If the lens is not centering well, try a different design. If none of the soft contact lens options center adequately, consider a GP multifocal. Corneal GP multifocal contact lenses are available in aspheric, concentric, and translating designs. These can deliver superior vision, and adaptation is relatively easy.

Consider the physiology of patients’ eyes. Do they have good lid-to-globe apposition? This could have bearing on proper translation of a GP lens. Is the tear film plentiful or lacking? A problem here could decrease vision because of a poor or uneven tear/ocular surface interface.

What size are the pupils in average room light, bright light, and dim light? Illumination is important to good vision, especially at near. Also, excessively large pupils could go beyond the contact lens optic zone, leading to flare and glare, particularly at night.

Are there cataracts present? If so, what type are they? Nuclear sclerosis can decrease distance vision. Posterior sub-capsular cataracts can impact near vision. Cortical changes could affect both distance and near clarity.

Remedies

If something is amiss when you have reassessed the patient and the lens choice you made, you still have a chance to improve the outcome.

A different multifocal contact lens design may give patients the clarity and function they desire. That is the easier scenario. But, if all of the various components are optimal and a patient is still not happy, what do you do? A frank discussion with the patient is a must. Sometimes, no matter what contact lens you choose, it will not perform as you and the patient want it to. That is when the hard decisions have to be made.

Is a patient willing to use readers over the multifocal contact lenses if necessary? Would the patient be OK with using glasses at work and contact lenses for less visually demanding tasks? Every patient will have his or her own threshold of compromise acceptance. And, after all, we can all agree that presbyopia is a compromise! CLS