MULTIFOCALS
Multifocals in Action
Test these tried-and-true contact lens fitting tips.

We're all aware that multifocal contact lenses are booming. The number of multifocal contact lenses dispensed in 2000 grew by 30%, according to Joe Barr, O.D., M.S., F.A.A.O., editor of Contact Lens Spectrum, the leading contact lens journal. The bifocal disposable category alone grew by more than 45%.

Each year, 4 million Americans become presbyopic, and multifocal contact lenses fit their needs. Multifocal soft lenses alone are expected to grow from a $16 million market in 1998 to a $184 million market in 2003.

To help you hone your skills with this modality, here are some helpful fitting tips from doctors all over the country.

Here are three quick tips you should always keep in mind when fitting multifocal lenses:

• When reaching for a rigid gas permeable (RGP) multifocal, always use an aspheric design first. They're easy to fit, have superior visual performance and are many times more comfortable.
• If you have an existing RGP wearer entering presbyopia, always prescribe an RGP multifocal. These patients are the closest thing to a perfect multifocal contact lens candidate.
• In my experience, the main area for failure with bifocal contact lenses is distance vision. This leads me to choose aspheric designs first and pick up poor reading with an auxiliary spectacle. Remember, wearing an auxiliary spectacle up to 20% of the time still signifies a successful fit.

-- Milton Hom, O.D., F.A.A.O.
Azusa, Calif.

When fitting RGP multifocal and bifocal designs, it's critical to make this experience as comfortable and natural as possible. The use of a topical anesthetic is important because the natural lens awareness they'll experience will occur gradually. In addition, use diagnostic lenses in combination with the predicted over-refraction in a trial frame so that vision will be optimum immediately after lens application.

-- Edward Bennett, O.D., M.S.Ed.
St. Louis, Mo.

One of the most important things you can do when fitting a patient with a bifocal contact lens is ask him about his computer use. If set up correctly, the computer is a different distance (over 20") than "normal" reading distance (16"), so be sure that whichever lens you supply covers that viewing distance as well. Most likely you'll choose an aspheric or concentric design.

-- Jeffrey Anshel, O.D.
Carlsbad, Calif.

Having successfully fit bifocal contact lenses for many years, I've developed two simple rules that have worked well in our seven-doctor practice:

1. Have a fair no-fault refund policy that you can explain up front to patients before they're fit with any bifocal contact lenses. In our office, we offer a 2-month full satisfaction guarantee. If for any reason a patient decides not to continue with his contact lenses, we'll refund the full cost of the lenses. Examination and fitting fees aren't refundable.
2. Never prejudge who's a candidate for bifocal contact lenses. Of course, it's imperative not to undertake cases that are medically contraindicated, and it's absolutely critical that you fully explain the lower likelihood of success in difficult cases. I can't tell you how much my contact lens practice has grown because of this simple philosophy. Many borderline patients have always wanted to try bifocal contact lenses but were discouraged by their previous practitioner. A fair up-front refund policy gives you the freedom to offer these services to most patients.

-- Robert Bauman, O.D.
Waterbury, Conn.

Keep in mind that monovision still has a place. In fact, about half of the successful soft multifocal fits utilize some degree of modified monovision. With the Acuvue Bifocal, this often means unequal adds (using a lower add for the "distance" eye), and with other designs it can mean over-plusing the "near" eye.

Locking in on the idea that both eyes need to be equal cuts success rates in half. And, locking in on the "dominant" eye is another way to be wrong half the time. Patients who are successful with monovision or modified monovision are switch-hitters, and determining whether or not a patient has this flexibility is key to using these techniques.

-- Peter Bergenske, O.D., F.A.A.O.
Middleton Branch, Wis.

The best way I've found to increase our success with bifocal lenses is to let the patient try the lens. What I do is spend a little time and talk to the patient about bifocal contact lenses. I explain our fees and contact lens fitting policies. I also tell him that he can try the lens for free. I do this by first placing a pair of lenses on the patient. I then have him sit in the waiting room for 15 to 20 minutes to allow the lens to settle. Then, I call him back into my room to check the fit and visual acuity. That's when the patient must decide if he wants to continue. If he says no, then he isn't charged for the fit. If he says the lenses are okay but not perfect, I tell him that it's part of the fitting process. Depending on his vision, it may get better. But, if he wants to continue, then he'll be charged.

-- Deepak Gupta, O.D.,
Stamford, Conn.

In an imperfect world, multifocal contact lenses are somewhat of a compromise in the category of outstanding visual acuity. Therefore, in our practice, where a larger number of our patients participate in recreational activities, I always design multifocal contact lenses to suit the specific needs of my athletic patients. For example, a golfer must be able to locate his shot when it lands. My inclination is to slightly increase the distance prescription and underplay the near component of the lens. By doing this, the golfer can watch his tee shot in progress, read the green accurately and see the ball clearly at impact. The only compromise is not being able to read the scorecard as clearly. With the way many of us play golf, this may actually be an advantage!

-- Don Teig, O.D., F.A.A.O.
Ridgefield, Conn.

When fitting a bifocal contact lens patient, trial frame with loose spectacle lenses. This allows the patient to grasp the concept, while you determine if it's a viable alternative. Remind the patient that he may need over-correction for driving, computer use and long-term reading. Also explain why the lenses may not be appropriate. Honesty and skill make your patient more receptive to your recommendations.

--Pamela J. Miller, O.D., J.D., F.A.A.O.
Highland, Calif.