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The Art of Multifocal Contact Lens Fitting (2018)

2M in Australia | 0.5G in New Zealand | 5 June 2018

EXCLUSIVE TO LUXOTTICA

You’ve heard it all before, right? Every few years a contact lens company launches a new multifocal contact lens, and tells you how you should be fitting these lenses to everyone. So, you go ahead and try it. And guess what? Sometimes it works, sometimes it doesn’t. You’re not sure why, you can’t predict it, so you stop trying in fear of looking silly in front of your patients.
Ultimately before we go into the nitty gritty, we need to ask, why should I bother?

Why Should I Bother?

Below are the common complaints we hear around multifocal contact lenses;

  • I don’t have time!
  • They’re too fiddly
  • They don’t work
  • They’re too expensive
  • The fitting guide is confusing
  • What design works best?
  • Monovision is easier/better
  • It’s all too hard!
  • What’s in it for me?

Let’s try and address these.

What’s In It For Me?


Figure 1. Chart: Akerman DH. 40 is the new 20/20; presbyopia equals opportunity. Con Lens Spectrum. 2010:25:3

It isn’t fair right? Why should you even bother reading this article? What benefit can we as optometrists gain from fitting multifocal contact lenses, and how can they fit into the “All For You” customer journey?

The aging population in developed countries means that an increasing number of the patients walking into our practices are presbyopic. In Australia, 46 per cent of the population is aged over 40.1 However, the reality is that as contact lens wearers reach the age of 40 and beyond, and their refractive needs increase, their use of lenses declines.2

For those that require vision correction, 84 per cent wear spectacles as their main form of vision correction while only 9 per cent wear contact lenses.3 What is alarming is that 56 per cent of presbyopes are aware of contact lens alternatives, and 36 per cent are interested in trying them, but only 10 per cent are recommended them as an option!3

So, combining this unmet demand with the fact that baby boomers are projected to hold 70 per cent of the total disposable income,4 there is an obvious, huge opportunity to fit presbyopes with contact lenses. This will help increase your number of new contact lens fits and significantly grow your store. And what’s more, wearers of multifocal contact lenses are more likely to be loyal as they have a 95 per cent rate of satisfaction with their optometrist.3 Because presbyopes will inevitably need to purchase higher value spectacles such as multifocals as well, this loyalty may generate significant income for your store.

Who Are You?

Who are these presbyopic contact lens wearers? What do they want?

When a presbyope walks into your consulting room complaining of poor near vision or headaches or sore eyes or any of the numerous symptoms of presbyopia, what do they want? Reading glasses? Multifocals? Bifocals? Trifocals?

At the end of the day, they just want to see more clearly. All the options above have some sort of drawback to them and a significant failure rate, and yet we don’t hesitate to recommend them as frontline vision-correction options for our presbyopic patients. So why are we so reluctant to suggest multifocal contact lenses as an option? And who is an ideal candidate?

Presbyopic contact lens wearers are typically female (68 per cent), have a higher income and are in their 50s.3 They have busy lifestyles and want convenience.3 They are active, healthy, wealthy, concerned with their appearance and want to look younger.3

Communication Breakdown

When patients are in our consulting rooms, they often think that if they’re suitable for contact lenses, we’ll discuss it with them. Conversely, we as optometrists assume that if our patients are interested in contact lenses, they’ll ask about them.

There’s a huge disconnect here.

What are some of the other barriers that might prevent us from talking to our patients about multifocal contact lenses?

Cost

Did you know that 7Eleven sells coffee for AU$1? That’s at least 70 per cent cheaper than the fancy $3.50 coffee you get from your local heavily-bearded barista. But honestly, how many of us are willing to trade in our delicious roasted morning caffeine hit for something that’s possibly not as ‘artisan’ – just to save some money?

If that’s the case, why would we assume that a presbyope is not willing to pay more to have one of their most important senses function more effectively?

As optometrists, we happily recommend daily disposables due to their compliance and health benefits5 even though they’re more expensive than monthly lenses. We are also happy to recommend expensive multifocal spectacles because they have advantages over reading glasses. So why do we hesitate to recommend multifocal contact lenses?

One should never assume what priority or value a patient will place on their vision correction, however, when cost is a consideration, I always give my patient a choice. One of the advantages of Alcon’s range of multifocal contact lenses is that they all feature the Precision Profile Design and are available in daily disposable and monthly modalities. So, even if you trial a patient in Dailies Total1 Multifocal or Dailies AquaComfort Plus and price does become an issue, you can simply switch them to the AirOptix Aqua Multifocal without having to adjust any powers.

Convenience

We’ve all got lots of patients who find the thought of wearing glasses akin to their worst nightmare. Others are so busy they don’t have time to keep track of where their glasses are. Then there are the ones who have so many simultaneous visual demands that they need multiple pairs of glasses. These patients are the ideal candidates for fitting multifocal contact lenses… and yet only 10 per cent are recommended contact lenses as an option!3

Where I practice, a lot of my patients are busy office workers whose list of daily visual demands can look like this;

  • Two or three desktop screens
  • Laptop
  • Smart phone
  • Tablet
  • Large conference/meeting rooms with presentations
  • Driving
  • Reading in bed at night (usually on a smartphone)
  • Sport on the weekend

In my opinion, to satisfactorily meet all those demands, these patients need multiple pairs of glasses. Usually this entails a combination of a general purpose multifocal for when they’re out and about, an office multifocal to allow them to see their desktop screens without giving them neck issues from tipping their head back, some single-vision reading glasses for in bed, and maybe a single-vision distance pair for sports. Even then there are no guarantees due to the mixed adaptation to progressive lenses, and that’s before we even mention sunglasses.

Of course not everyone will go ahead and purchase all of those options. But even when I start to talk about what they ideally need, I can see their eyes start to roll back into their head at the thought of keeping track of all those pairs of glasses. I then discuss multifocal contact lenses as an option for the majority of their tasks and there’s a bit of a lightbulb moment…

“Multifocal contact lenses? Really? I never knew they existed! How do they work? Will I feel seasick or have to move my head all the time like I do when I’m wearing my multifocal glasses?”

This is where communication and messaging becomes incredibly important. How do we explain how multifocal contact lenses work and what to expect?

Firstly, it is important to be able to manage our patients’ expectations and explain the technology in simple terms. Explain that they should be able to manage 80–90 per cent of their visual needs with multifocal contact lenses, but may need some spectacles for an additional boost for very small print at near.

How to Explain How Multifocals Work

Alcon’s Precision Profile Design is a centre-near design and works on the basis of ‘Simultaneous Vision’. While that may be easy for us as optometrists to understand, explaining the concept to your patients may not be so simple. One easy way to explain simultaneous vision to is to use the example of hearing. We often hear multiple sounds and things at once, and yet we learn to only listen to one thing by focusing our attention on what’s important.

Explaining this to our patients is critical, especially when they are initially adapting to the lenses and their new vision. It’s important for them (and us) to remember that their vision may be a little softer after insertion and that it takes between 5–20 minutes to adapt. In fact, Kim and Mah6 found that with simultaneous vision both distance and near vision improved over a one-month follow up period.6 This adaptation period is an important part of the fitting process and we’ll go into this in more detail shortly.

But first, let’s talk about the perception that multifocal contact lenses are too difficult and take too much time.

Time

Multifocal contact lenses take more time to fit than spherical contact lenses, right? But how much?

The answer is not much. With Alcon’s centre-near Precision Profile Design, 51 per cent of multifocal contact lens wearers were fit in one visit, 84 per cent were fit in two visits7, and 97 per cent of patients were fit successfully with two lenses or fewer per eye.8

With multifocal contact lenses, a team approach to contact lenses is imperative to achieve successful outcomes, and the ‘All For You’ customer journey does exactly this – it incorporates the entire team into the contact lens experience for our patients. If possible, have a trusted and experienced member of your team trained to help discuss the vision experience with potential patients to give them an idea of what they might experience. This will put your patient at ease and may improve the chances of a successful fit and progress to purchase.

However, if you’re still concerned as to how you’re going to fit everything in to your limited consult time, here are some tips to help streamline your day;

  • Start your consultation with contact lenses in mind so that you’re looking at things from a contact-lens perspective
  • Ask your patient about contact lenses when taking their history and symptoms

    o          Do you wear contact lenses?

    o          Have you worn them in the past?

    o          Are there any times where you would like to be spectacle-free?

  • When doing your refraction, it’s important to take note of the maximum plus refraction before any adjustments are made for spectacle dispensing. This is incredibly important for initial contact lens selection.

  • When discussing vision correction options, include contact lenses as part of that discussion every time – remember patients often think we’ll mention contact lenses to them only if they’re suitable.

  • Check corneal staining, tear break-up time and under the patients’ lids during your routine slit lamp examination, as these factors can help determine the chances of future contact lens success.

Multifocal vs Monovision

Click here to enlarge.
Figure 2. Adapted from Adele Jefferies; Multifocal Contact Lenses, How?, Why? And Modern Designs. Mivision September 2016, p53–57.


 

Click here to enlarge.
Figure 3. Adapted from Woods J, Woods CA, Fonn D. Early Symptomatic Presbyopes – What Correction Works Best. Eye Contact Lens 2009;35:221-226.

But what’s wrong with good ol’ monovision you ask?

In the 1980s, controlled trials between early multifocal contact lens designs and monovision showed better or equal results with monovision.9 However, it’s not the 1980s anymore, and technology has advanced dramatically. That Commodore64 ain’t no iPhone and the improvement in multifocal contact lens technology now means that in multiple studies, multifocal contact lenses regularly outperform monovision.

I like to refer to our modern presbyopes as ‘individuals’ who require bespoke visual corrections for their own particular demands and workspaces. A study by Woods et al found multifocal contact lenses outperform monovision across a variety of visual demands and tasks.10

Simpler Fitting Process

We know our patients demand the latest technology, so why do some of us persist with prescribing monovision? Is it because it’s perceived as simpler?

I remember a few years ago when a number of new multifocal contact lens designs came out, I thought I’d give them all a try. After a number of attempts I’d had mixed success and wondered where I was going wrong. Often, I’d find I was needing to add lots and lots of extra plus, nothing was making sense and I was about to give up on them all thinking they were no better than the old designs. Then a funny thought popped into my head…

“Maybe I should actually read the fitting guide…”

So, I did just that and suddenly my success rate went from ~50 per cent to at least 90 per cent. In the conversations I’ve had with other optometrists, it’s interesting to note how many of us don’t read the fitting guides and just ‘wing it’. As mentioned above, when optometrists follow the Alcon Precision Profile Design fitting guide, 97 per cent of patients can be fit with two lenses or fewer and optometrists rate the design as 9.2/10 for ease of fit.8

When fitting Alcon’s Precision Profile Design, it’s important to remember that it has a negative peripheral power profile, which allows you to ‘push the plus’ through the distance power of the lens. This means you can keep the add power down to minimise aberrations and increase your chance of success.

Fitting multifocal contact lenses doesn’t have to be tricky or time consuming, we just need to be prepared and follow the steps.

Prior to Fitting

To minimise chair time for you and your patient, have the following ready and prepared prior to the fitting appointment. Of course, if your fitting follows on as part of your routine examination, ensure that you keep these in mind during the initial consult.

Up-to-Date Subjective Refraction

One of the most important but often neglected parts of successful multifocal contact lens fitting is having an up-to-date refraction. We discussed earlier that taking note of the most plus/least minus refraction result before any modification is made for spectacle dispensing and adaptation is incredibly important and this should form the basis for your initial lens selection. Presbyopes’ hypermetropic shifts can progress quickly and if we use an out of date spectacle prescription as the basis for our fitting, we often end up chasing our tails as more and more plus is revealed. We then find we’re having to use several lenses and often give up. I know I used to.

Dominance

There are two main ways to measure ocular dominance; sighting dominance or sensory dominance.

Sighting Dominance

We all know this one, where the dominant eye is chosen based on which eye is used to ‘sight’ a distant target.

Sensory Dominance

Otherwise known as the Swing Plus Test, this technique actually yields stronger results for multifocal contact lens fitting.11 A +1.50DS loose lens is placed over the patient’s distance correction one eye at a time while looking at the 6/9 or 6/12 line. The dominant eye is the one that reports more blur when covered with the loose lens.

Initial Lens Selection

With Alcon’s Precision Profile Design, it is recommended to select the initial lens power by adding +0.25 to the most plus/least minus refraction. Then, decide which add you need based on the table below;

Add Selection

Spectacle Add

Both Eyes

UP TO +1.25

LO

 

+1.50 TO +2.00

MED

+2.25 TO +2.50

HI

 

For Example:

Subjective Refraction

R: +1.00

L: +1.50

Add: +1.25

Initial Lens Selection

R: +1.25 (LO)

L: +1.75 (LO)

 

                                   

The Fitting Appointment

Now you’ve got everything ready, the fitting process is very simple.

Lens Insertion

Insert the lenses you selected prior to the appointment.

Settling and Adaptation

Once you’ve inserted the lenses, it is critical you allow the patient to adapt to their new vision. It is not unusual for patients to feel their vision isn’t overly clear or that they feel a bit ‘funny’ in the first few minutes of wear and now is a good time to discuss this with them. Assess vision initially only as a reference as it is likely that it will improve over the next five to15 minutes, and avoid making any changes to the lenses you have selected. Use this time to talk them through the hearing analogy discussed above, remind them that it takes time to adapt and that it’s normal for their vision to be a little ‘softer’ initially.

Vision Assessment and Over-Refraction

Only assess the patient’s vision after they have had a chance to adapt to the lenses.

With both eyes open, perform a distance over-refraction on each eye separately by adding plus in 0.25D steps until the patient reports a decline in distance vision. Use real-life targets such as a distant sign and their mobile phone, and don’t use a phoropter or occlude. I find flippers easiest as I’m clumsy, so when I’m trying to juggle three different loose trial lenses, one of them inevitably ends up in the patient’s lap.

Apply new contact lenses based on the over-refraction if needed, dispense trials and have your team arrange a review in three or four days. It can also be helpful for you or a member of your team to call them the next day to reassure them and to discuss their initial reaction.

When discussing vision expectations with your patient, be sure to include some information on how to influence their pupil size to ensure they are getting the best vision possible in each situation. With Alcon’s centre-near Precision Profile Design a smaller pupil will improve near vision and a larger pupil will improve distance vision. Hence, ensuring your patients have adequate light when looking at near objects will help keep the pupil small and conversely, using sunglasses when outside to keep the pupil large will help improve their overall visual experience.

Aftercare and Troubleshooting

You might be pleasantly surprised to see how many patients come back perfectly happy with their new contact lenses. But what about the ones that don’t? The following steps will help enhance their vision and can be used to tailor their correction to their individual needs.

Enhancements

As discussed above, our modern presbyopes are all ‘individuals’ and so often require a little more near or distance acuity, depending on their needs and preferences.

 The Alcon fitting guide suggests the following to enhance vision as needed.

Enhancements

Near

Distance

Increase Plus on Non-Dom Eye

Reduce Add in Dom Eye

 

Slit Lamp and Tear Film Assessment

It is important to remember that the incidence of dry eye increases with age and that tear film quality can have an impact on vision. Assessing this with your slit lamp or corneal topographer will allow you to decide whether the lens material is suitable. We know that the Water Gradient material and SmarTears technology in Dailies Total1 has excellent wettability12,13 and supports the tear film,14 which means it may be indicated in patients who have a poor quality tear film to not only improve lens comfort, but potentially also improve visual quality.15

Summary

Like multifocal spectacles, multifocal contact lenses are a vital tool in an optometrist’s belt to help combat the issues and inconvenience of presbyopia. By following this simple process, you’ll be surprised at how easy it is to fit and fit in multifocal contact lenses into your day.

Simon Allen graduated from UNSW with a Bachelor of Optometry (Hons) in 2003. He has worked in both Australia and the UK, most recently in a practice where he gained broad experience with unusual and complicated refractive cases, including contact lenses. He is a member of Alcon’s Professional Affairs team. 

References:
1. Australian Demographic Statistics September 2014. Available at www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3101.0Main+Features1Sep%202014
2. Akerman DH. 40 is the New 20/20 – Presbyopia Equals Opportunity. Con Lens Spectrum. 2010:25:3.
3. Multi-sponsor surveys_ 2013 Gallup Study of the US MF CL Market
4. www.marketingcharts.com/uncategorized/baby-boomers-control-70-of-us-disposable-income-22891/ (accessed Oct 2017)
5. Dumbleton K, Woods C, et al. Patient and practitioner compliance with silicone hydrogel and daily disposable lens replacement in the United States. Eye & Contact Lens. 2009;35(4):164-171.
6. Kim J, Mah K. Visual performance with simultaneous vision multifocal contact lenses for presbyopia. Contact Lens & Anterior Eye 2013; e16-46
7. Alcon Data on File 2011. In a single masked, randomised crossover study, n=25.
8. Bauman et al. Material effect on MFCL same design same fitting guide. Poster BCLA 2017
9. Jefferies, A. Multifocal Contact Lenses: Why? How? And Modern Designs. Mivision August 2016
10. Woods J, Woods CA, Fonn D. Early symptomatic presbyopes — What correction works best? Eye Contact Lens 2009;35:221-226.
11. Quinn, T. Prescribing for Presbyopia. Contact Lens Spectrum. 2015. https://www.clspectrum.com/issues/2015/november-2015/prescribing-for-presbyopia
12. Thekveli S, Qiu Y, Kapoor Y, Kumi A, Liang W, Pruitt J. Structure-property relationship of delefilcon A lenses. Cont Lens Anterior Eye. 2012;35(suppl 1):e14
13. Guillon M. Pre-Contact Lens Tear Film Kinetics Under Normal and Adverse Environmental Conditions. Poster ARVO 2017
14. Alcon DOF 2016. In a randomised, observer masked, crossover study. n=82
15. Robert Montes-Mico, Lurdes Belda-Salmeron, Teresa Ferrer-Blasco, Cesar Albarran-Diego and Santiago Garc?a-Lazaro. On-eye optical quality of daily disposable contact lenses for different wearing times. Ophthalmic & Physiological Optics 33 (2013) 581–591

' 56 per cent of presbyopes are aware of contact lens alternatives, and 36 per cent are interested in trying them, but only 10 per cent are recommended them as an option! '