Article

BUILDING A PRACTICE WITH MULTIFOCAL LENSES

Today’s presbyopes are just waiting for someone to give them freedom from reading glasses.

It is widely recognized that the greatest potential in contact lenses today lies with caring for presbyopes. In particular, as will be emphasized in this article, the most successful option for this population is the ever-evolving multifocal contact lens. You can build your practice by prescribing multifocal contact lenses to more of your presbyopes. Here’s how.

BE PROACTIVE

A study by Jones et al1 reported that when practitioners and staff were proactive in discussing contact lenses as an option, 46 out of 80 patients were fit into contact lenses, including 21 of 33 presbyopes. Conversely, when staff and practitioners were not proactive in recommending contact lenses, only 9 out of 80 patients were fit into lenses.

Contact lenses are 60% more profitable to a practice than spectacles alone are; this is a tremendous financial benefit to the practice.2 Patients benefit as well, enjoying freedom from spectacle wear, which is consistent with today’s presbyopes’ increasingly active lifestyle.

The problem is—whether it is the perception that fitting multifocal lenses is too complex or concerns about how patients will see, lens awareness, or expense—many eligible presbyopes are never presented this option. Make a difference by offering multifocal contact lenses to potential presbyopic contact lens wearers.

SELECT THE RIGHT CANDIDATES

Who are good candidates? Actually, the majority of presbyopes are good candidates, including:

  • Patients currently wearing single-vision contact lenses successfully without dryness or comfort issues. These patients do not want to discontinue contact lens wear. If they are emerging presbyopes, the transition into multifocal lenses is quite easy and successful.
  • New contact lens wearers motivated to remain free from glasses.
  • Patients willing to give up a bit of crispness (often very little) to gain freedom from spectacles for most or many daily activities.
  • The Generation X population, the majority of whom are now presbyopic. This is an ideal group for multifocal contact lenses, as they are typically happy, active, independent, open to new things, and—in many cases—already wearing contact lenses.

Who are not good candidates? A minority of presbyopes fit into this category. Certainly, rule out presbyopes who are resistant to this option when it is discussed and who appear to exhibit little-to-no motivation. Dry eyes can also represent a contraindication; however, with the increasing introduction of both daily disposable and scleral multifocals, this is less of a challenge than it was in the past.

RECOMMEND MULTIFOCALS WITH CONFIDENCE

Contact lens specialists are uniquely qualified to match the ideal contact lens option with a given patient’s visual needs. For presbyopes, more often than not, the best choice will be multifocal contact lenses. Recommend them with confidence! Research supports this recommendation. Multifocals can improve quality of vision and contrast sensitivity compared to monovision,3 and in studies in which subjects have worn both modalities, the overwhelming choice at the conclusion of each study was multifocals.4-8 The good news is that 75% of eyecare practitioners are recommending multifocals as their preferred choice (versus 59% in 2008),9 with both monovision and over-spectacles decreasing as the preferred option.10

COMMUNICATING MULTIFOCALS TO PATIENTS

While being proactive and talking with patients about multifocals, there are several questions that you can pose to help both educate presbyopic patients and also to help you in making the final decision. These questions can include the following:

  • Have you ever wanted to reduce your dependency on glasses?
  • Do you dislike putting on reading glasses every time you read something?
  • Did you know that there are contact lens options available that allow you to see at distance and near?

As patients may have some apprehension about wearing these lenses, the choice of words can mean the difference between success and failure. Use phrases such as “initial awareness,” “functional vision,” “freedom from glasses,” and “multifocal contact lenses can meet most of your visual needs most of the time” as opposed to “discomfort,” “blurry,” “compromise,” “less crisp,” and “glasses will always be better.”

Although words are powerful, providing potential wearers with the opportunity to actually experience multifocal contact lenses can be very impactful in helping them overcome any initial hesitation. An easy way to expose new wearers is to apply multifocal contact lenses prior to them selecting glasses in the office optical. Patients appreciate the improved vision, and the exposure can heighten patient interest in contact lenses.10 Another study indicated that this process led to a 20% increase in optical sales as well as a 2.5- to 3-times increase in contact lens fits or scheduled fits.11

AREN’T MULTIFOCALS DIFFICULT TO FIT?

Actually, multifocal contact lenses are relatively straightforward to fit and are becoming easier by the day. You can fit soft multifocal lenses out of an inventory and make any changes immediately in-office. Custom soft multifocal trial lenses can be ordered if necessary, and both hybrid and most GP multifocal lenses can be fit empirically, which often provides a very good initial visual experience with these lenses. Multifocal lenses often come with a simple, one-page fitting and troubleshooting guide. Each is designed to specifically address the nuances of that particular lens design. Some key fitting tips that have broad application include:

  • Use open-ended questions. After allowing lenses to settle, ask patients very open questions such as “How are you doing with the lenses?” This allows them to direct the conversation to areas of concern.
  • Keep happy patients happy. If patients respond that they are seeing well, document binocular vision at distance and near, but don’t make any changes. This may upset the balance and create a problem.
  • Use text-based testing for near acuity. Patients don’t normally read acuity charts. Most do read text on mobile phones. So encourage patients to pull out their mobile phone and ask them to open their text or email function. Success at performing common tasks such as these can be very motivating to a new wearer. Then follow up by having patients read from a text acuity card (Figure 1) under binocular conditions so that you can record their reading level in their clinic chart.

    Figure 1. An example of a text-based near acuity chart.

  • Isolate 20/40 for distance acuity. Many of us keep a full chart displayed in our examination lanes, with a bottom line of 20/20 or 20/15. New multifocal wearers may function quite well in the real world, but they may be discouraged if they are unable to read the small print on the distance acuity chart. Isolating the 20/40 line during initial acuity assessment ensures that patients are seeing well enough to drive legally, and it gives them the opportunity to feel successful. Once patients read the 20/40 line, advance to the 20/30 line, then to the 20/25 line and so forth. The initial taste of success can change the visual acuity measurement from a negative experience to a positive experience.
  • Avoid making too many changes on day 1. If at the initial fitting patients are not seeing as well as desired, prior to making any changes to add power, perform a careful loose lens over-refraction with room lights up and both eyes open. If a change in distance power is determined for a patient, dispense new diagnostic lenses and release the patient for a week. If the over-refraction does not help, modify the add as directed by the fitting guide and, again, release the patient for a week rather than reassessing vision at that visit. This approach gives patients time to adapt and time to experience multifocal vision in their natural environment, and it keeps the office schedule flow moving forward.

PREPARE PATIENTS FOR ADAPTATION AND THE VISUAL EXPERIENCE

The following key messages can help improve the patient experience:

  • “These lenses are designed to work together.” Sometimes multifocal optics need to be adjusted so that one eye is biased slightly for distance and the other for near. This can be disconcerting to some patients. Reassure them that the key performance criteria is how they perform in the real world under natural conditions, which is with both eyes open.
  • “Light is your friend.” It is well recognized that the most challenging visual environment for multifocal contact lenses is near vision in dim light. Share this with patients at the outset, then provide them with the tools to manage it including small lights, magnifiers, or mobile phone apps that provide both.
  • “Give it time.” Reassure patients that their vision will become better with lens wear12 and that, although a lens change or two may be necessary, they very likely will be successful if they are patient and motivated.

CONCLUSION

Remember, many presbyopes are happy to wear contact lenses for some activities and glasses for others. It is not an all-or-nothing proposition. However, this growing population is increasingly active and benefits from the visual freedom of being spectacles-free for many of their activities. Change the dynamic and be part of the solution by proactively recommending and fitting multifocal contact lenses. Your patients will see the difference as you build your practice with this life-changing modality. CLS

Acknowledgements: The authors would like to thank Stephanie Woo, OD, and Brooke Messer, OD, for their contributions to this article.

REFERENCES

  1. Jones L, Jones D, Langley C, Houlford M. Reactive or proactive contact lens fitting – does it make a difference? J Br Contact Lens Assoc. 1996;19(2):41-43.
  2. Ritson M. Which patients are more profitable? Contact Lens Spectrum. 2006 Mar;21:38-40,42.
  3. Rajagopalan AS, Bennett ES, Lakshminarayanan V. Visual performance of subjects wearing presbyopic contact lenses. Optom Vis Sci. 2006 Aug;83:611-615.
  4. Benjamin W. Comparing multifocals and monovision. Contact Lens Spectrum. 2007 Jul;22:35-39.
  5. 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;83:266-273.
  6. Situ P, Du Toit R, Fonn D, Simpson T. Successful monovision contact lens wearers refitted with bifocal contact lenses. Eye Contact Lens. 2003 Jul;29:181-184.
  7. Johnson J, Bennett ES, Henry VA. Multivision™ versus monovision: a comparative study. Presented at the Annual Meeting of the Contact Lens Association of Ophthalmologists. Las Vegas, Feb. 2000.
  8. Nichols J. Contact Lenses 2008. Contact Lens Spectrum. 2009 Jan;24:26-34.
  9. Nichols J. Contact Lenses 2016. Contact Lens Spectrum. 2017 Jan;32:22-25,27,29,55.
  10. Atkins NP, Morgan SL, Morgan PB. Enhancing the approach to selecting eyewear (EASE): a multi-centre, practice-based study into the effect of applying contact lenses prior to spectacle dispensing. Cont Lens Anterior Eye. 2009 Jun;32:103-107.
  11. Bishop M, Allison S, Hasty S, et al. Improving your eyeglass patients in-office experience with contact lenses. American Academy of Optometry Annual Meeting, Poster #140, Chicago, Oct. 13, 2017.
  12. Fernandes PRB, Neves HIF, Lopes-Ferreira DP, Jorge JM, González-Méijome JM. Adaptation to multifocal and monovision contact lens correction. Optom Vis Sci. 2013 Mar;90:228-235.