contact lens management

A Focus on Those Who can't

Four sure fire tips to successfully fit multifocal lenses

Mile Brujic, O.D.

It's no secret that presbyopic patients are notoriously hard to please with contact lens wear. Thankfully, contact lens manufacturers have produced lens materials, care systems and an array of multifocal designs to help meet these patients' needs.

That said, for these patients to achieve success in multifocal products, we must follow these four steps.

1. Assess the ocular surface

Presbyopic patients tend to be predisposed to ocular surface disease by virtue of their age, increased medication use and hormonal changes — all of which compromise ocular surface health. Therefore, in addition to performing a standard slit lamp exam, evaluate the presbyopic patient's ocular surface with vital dyes (both fluorescein and lissamine green), which allow for the determination of tear film break-up time, corneal staining and the presence of lid wiper epitheliopathy. Also, assess the quality of the meibum by applying pressure to the outside of the eyelid, and, at times, with the assistance of a Mastrota paddle. A Mastrota paddle allows you to leverage the lid against the paddle to express and view the quality of meibum from stagnated glands. This may also provide some therapeutic benefit.

Should you identify underlying ocular surface disease, treat accordingly to promote a healthy tear film. This improves the patient's odds for successful wear.

2. Set realistic expectations

Always explain to patients that these lenses will provide vision that is "different" than their spectacle vision. Although some will describe their vision through eyeglasses as being clearer than through multifocal contacts lenses, educate patients of the major advantage of multifocal lenses: visual freedom from glasses for most, if not all tasks. Also, educate these patients that they may still require single vision spectacles or readers for certain tasks, such as viewing fine-print reading material.

Armed with this education, a patient can then decide whether he wants to try multifocal contact lenses. Should he decide to try multifocal lenses, he won't be surprised, and, therefore, dissatisfied, with the lenses, should he experience any of the aforementioned issues. A patient dissatisfied with a product you've dispensed because of misperceptions regarding what the product will deliver is a patient dissatisfied with you.

3. Demonstrate near vision immediately

Offer to fit the patient in a trial pair, so she can see for herself what to expect from multifocal contact lens wear. Once you've fit the patient, have her focus first on a near target, such as her cell phone. (This is likely something that was difficult, if not near impossible, for the patient to view without her reading glasses prior to being fit with the multifocal lenses.) (Demonstrating the benefit of the lens' near vision capabilities makes the explanation of the difference in distance vision among ophthalmic multifocal lenses and traditional single vision lenses much more acceptable to these patients.)

Next, measure the distance visual acuities binocularly starting with the isolated 20/40 line, and slowly lead the patient to her best binocular visual acuity.

4. Always follow the fitting guides

As tempting as it may be to do what seems "intuitive" when fitting multifocal lenses, following the fitting guidelines maximizes success with multifocal wearers. For instance, a multifocal design is available that requires us to reduce the add power in the non-dominant eye at high add powers if the patient reports dissatisfaction with his near vision. This fitting guide strategy is extremely successful with this specific design, yet appears somewhat counterintuitive.

Meibomian gland expression using a mastrota paddle.

In addition, dominant and non-dominant designs exist with the dominant lens' distance optics located in the center of the lens and the non-dominant lens' near optics located in the center of the lens. Intuitively, we may want to increase the power in the non-dominant lens to deliver more near power if needed, but in fact, we may need to modify the dominant lens (depending on the over refraction results) to maximize near vision. Again, this may initially seem counterintuitive, but it yields extremely successful results.

Great technology is only one piece of the successful wear puzzle. The other piece is the eyecare practitioner's level of commitment to fitting presbyopes. As a result, be sure to follow these four tips to maximize success when fitting multifocal lenses. OM