Milton Hom, O.D., F.A.A.O.: Years ago, in the realm of soft lenses, the options were few and far between for presbyopes. We had venerable monovision, but multifocal soft lenses were not that great.

Now, we have lots of great lenses from which to choose. How do we pick the right one? Unfortunately, much of the education surrounding multifocals is sponsor biased — in other words, contact lens companies talk about using their lenses alone. We know in clinical practice that, that is not true at all. In the real world, you have to use lenses from many manufacturers.

It seems like all the multifocals work for the low add. The kicker for me is the +2.50D add. This is a failure area for me and where my big headache lies.

Ben Gaddie, O.D., F.A.A.O.: Great point on the +2.50D add patients. In addition, I find low to moderate myopes do much better than their hyperopia counterparts for low- to medium-add demands.

But think about this: Most patients requiring the higher add powers also are in the demographic most likely to suffer from dry eye disease. I find a significant correlation between ocular surface integrity and overall visual performance with soft multifocal contact lenses. Ditto for patients with any amount of macular pucker or ERM. It also depends on the patients’ ability to neuro-adapt to the diffractive optics of these lenses. I find the 3D ghosting-like effect at near much more frequently with higher adds, and sometimes just switching to a different optics system-based multifocal contact lens does wonders.

While we’re on the subject, I think a significant market gap exists with options for daily disposable multifocal contact lenses. While a few are available, they revert back to designs of “years ago,” while their contemporary biweekly or monthly lens counterparts employ the latest designs. Why bring a daily disposable to market with optic designs from 20 years ago? I don’t get it. In fact, I would estimate an almost equal share of daily disposable multifocal contact lenses as single vision daily disposables.

M.H.: I agree wholeheartedly with your philosophy. Some patients just can’t get used to simultaneous vision. Others prefer monovision-like vision or binocular vision.

A patient having difficulty with a center near may prosper with two center distance lenses or a monovision-like system, or vice versa. When power tweaks don’t do the trick, changing optical systems may be the difference between success and failure. OM