Article

PRESCRIBING FOR PRESBYOPIA

CLINICAL PEARLS FOR IMPROVED OUTCOMES

A common complaint from eyecare practitioners about prescribing multifocal contact lenses is the amount of chair time it takes to reach a lens combination that satisfies their patients. They claim that it’s not worth their time and then resort to monovision or keep patients out of presbyopic contact lens options altogether. Multifocals are a great practice-building tool, and more patients deserve the opportunity to try them. Hopefully, the following practice pearls can pave a path to efficient, successful fitting experiences.

Motivation

First, be sure to understand patients’ motivation for the fitting. A patient desiring contact lenses to see a scorecard while golfing has a significantly different end goal compared to one who needs multifocals for working on a tablet all day.

Start with lenses that give patients the vision that motivates them the most, then work on the other distances. For example, I would push plus power for those who really want to see their phones during the day. Then, add small amounts of minus—mostly in the dominant eye—to improve their distance vision until they find the satisfactory balance. For patients who want their best all-around vision, I tend to start with good distance vision first, then push a little plus in both eyes to improve near vision, and finally a little more plus in the nondominant eye, if needed.

When adjusting lens powers, using the phoropter for an over-refraction is usually slower. In my experience, patients are more likely to want more minus power than they need. Instead, work outside of the phoropter with loose lenses, and present them in 0.50D steps to make it easier for patients to judge a noticeable difference.

Also, keeping the sphere power of the lens within 1.00D of the patients’ spherical equivalent refractive error will help with both lens selection and efficiency. With this technique, I have found that most patients can tolerate a little plus in the nondominant eye to achieve a wider depth of field, even those who have previously failed in monovision.

Real-World Vision

Another “real-life” practice pearl is to use everyday items as acuity measures. Consider keeping a golf card, a business card, or even a take-out menu handy so patients can look at these items. Also, ask patients to have their cellphone in hand, or sit them at a computer, to best judge their vision rather than using acuity charts. Nothing emphasizes aberrations more than the good-old black-and-white acuity charts!

After the final lens has been selected, I will collect a binocular distance and near acuity for medical-legal documentation purposes, but they are rarely used during the actual fitting process.

Schedule Time

Finally, it’s important to have the appropriate amount of time needed to properly educate and fit a first-time multifocal wearer. To ensure this, reassess your service fees and time slots for an initial multifocal contact lens fitting. I include my time for the initial assessment and two follow-up visits, with 15 to 20 minute time slots to make sure that the lens can be adequately assessed in office.

By scheduling (and billing) these patients appropriately, you can begin to view them as an asset and an opportunity for your practice rather than a burden. Once a smooth and efficient system has been developed, working with presbyopic contact lens patients can become not only successful, but enjoyable, too. CLS