Multifocal contact lenses can provide presbyopes with unprecedented freedom from spectacle correction. Depending upon patients’ visual needs and lifestyle demands, eye care providers now have a variety of multifocal (MF) lens designs to choose from––including several daily disposable and toric options.
However, many practitioners experience some level of frustration or inherent difficulty during the fitting process that may, in fact, dissuade them from even offering multifocal lenses to their patients. Some of the most frequently cited obstacles include: poor ocular surface health, unrealistic patient expectations, a lengthy follow-up period and/or an outright failure to fit the lens effectively.
In an effort to ease your fears about prescribing MF contacts, we orchestrated a roundtable discussion between three of the leading multifocal experts in optometry––David Kading, OD, Mile Brujic, OD, and Jason Miller, OD, MBA. Drawing upon years of clinical experience, countless success stories and even a few failures, they will help assuage your concerns about some of the most ubiquitous challenges associated with multifocal contact lens wear.
1. Ocular Surface Considerations
Many contact lens patients struggle to maintain good ocular surface health—and then mistakenly attribute their discomfort to lens wear. If the problem isn’t addressed initially, improving vision and increasing comfort with a multifocal lens can be very complicated.
• Dr. Kading: We assess ocular surface health very carefully in patients who are either new to contact lenses or are struggling with lens wear. One thing we used to routinely overlook was meibomian gland function. Today, however, we express patients’ glands to assess overall functionality, as well as evaluate the quality of the meibum.
Evaporative dry eye disease is a tremendous problem for many of today’s contact lens patients. Clearly, we see this as the major obstacle to overcome in order to make our patients more successful with lens wear. So, we closely examine the patient and then treat any ocular surface conditions—either before or in conjunction with our contact lens fitting—to improve the likelihood of success.
• Dr. Brujic: Optimizing ocular surface health is an essential element of successful multifocal contact lens wear. If ocular surface integrity appears compromised—e.g., corneal staining, lissamine green staining, lid wiper epitheliopathy, decreased tear film break-up time, positive InflammaDry (Rapid Pathogen Screening) findings, low phenol red thread test—patients need to be educated about their underlying condition and then treated accordingly. The severity of these clinical signs and symptoms will largely dictate the appropriate management course.
Often, patients who are prematurely fit into lenses without a healthy ocular surface will not be as comfortable as they could be. Fortunately, many of the contemporary lens technologies are able to overcome some of the constraints associated with poor ocular surface health. Nevertheless, it is difficult to fully appreciate all the benefits of the MF lens technology without a robust tear film and clear anterior segment.
• Dr. Miller: I 100% agree that assessing the ocular surface and successfully treating any underlying ocular surface condition is critical to success with multifocal contact lenses. But, for me, it all starts with proper education.
Many of these patients do not believe that they have any issues and just want new contact lenses or something more comfortable. It is important to start by discussing how an underlying ocular surface condition affects their visual acuity and overall comfort during contact lens wear. Your treatment plan will vary based on the severity of their condition, but addressing it up front will improve your overall success rate.
2. Meeting Patients’ Expectations
More often than not, patients want better vision than an MF contact lens can provide. Over the years, many practitioners have abandoned multifocals because they do not meet patient demands. How do you adequately address and/or potentially temper expectations when your patient base has such a wide variety of visual demands?
• Dr. Miller: Expectations are everything. It can mean the difference between success and failure––particularly when fitting MF lenses. So, be sure to develop a system for orienting and clarifying expectations with each patient.
This starts with listening to your patients and identifying their occupation(s), hobbies and daily visual requirements so you can most effectively educate them on all the available options. It may even benefit both parties to use a written checklist, which will detail the most important considerations. This does not mean that 100% of your patients’ demands can be met with multifocal contact lenses. But, an improved understanding of their visual requirements likely will enable you to address the most important needs and improve their success rates.
• Dr. Kading: It can be said that the best way to meet an expectation is to set it. We have hundreds of patients who’d say that their MF lenses meet the necessary visual demands. In other instances, however, many new MF wearers simply have to learn how to use their lenses more effectively to achieve the same level of success.
Often, it takes time to grow accustomed to the lens—a process we call “cortical adaptation.” Patients must understand that MF lenses can provide things that glasses cannot, and glasses can provide things that contact lenses cannot. Also, such visual expectations are never the same from one patient to another.
Without question, however, any discussion of expectations needs to be individualized to the patient and his or her visual needs.
• Dr. Brujic: Soft MF contact lenses are based on the principle of simultaneous vision––meaning both the distance and near optics of the lens simultaneously focus light on the retina, which necessarily compromises visual acuity at either focal length as the eye generates two images rather than one. This inefficient use of the refractive process can become particularly troublesome to patients in low-light conditions. As Dave noted, a cortical adaptation period is required with the MF lenses while the patient adjusts to this newly altered optical system. Also, remind patients that when compared to traditional, monofocal systems (such as contact lenses designed with a single power, rather than multiple corrections), their best-corrected visual acuity will be slightly worse.
But, when these minor inconveniences are weighed against the tremendous visual benefits and freedoms that MF lenses offer, most patients will be highly satisfied with the wearing experience.
They immediately acquire a wider field of view that’s not limited by any frame edge. Also, most MF contact designs place the near optics in the center of the lens, which enables easy computer viewing without the need tilt your head backwards (as some patients require when wearing a traditional progressive addition lens). Finally, MF contacts grant patients the flexibility to wear plano sunglasses overtop their lenses.
3. Meeting Patients’ Needs
When patients try different lenses in the office, they frequently complain that no modalities effectively address all their visual needs.
• Dr. Kading: This can be a major concern for doctors and patients alike. A patient who presents for a contact lens evaluation likely has one primary visual need.
For example, we have a tendency to test patients’ distance vision as soon as they insert a multifocal––even if the chief complaint was poor near vision. Instead, we should immediately “give them a win” and show them how great their near vision is by instructing them to look at their cell phones.
In our offices, we have seen that once patients realize that their primary visual need has been met, the perceptual changes to the other aspects of their vision are not as significant or noticeable.
• Dr. Brujic: We seriously need to reconsider the way we approach our multifocal contact lens fittings. Patients typically opt for MF contacts when they experience difficulty with near focus. Thus, it would make the most sense for patients to practice near viewing immediately after placing multifocal lenses in their eyes. So, yes––letting them experiencing “a win” in the exam chair often will psychologically set the stage for a better initial assessment.
Typically, it is advantageous to allow the lenses time to settle before assessing visual acuity. But the ultimate test of MF lens functionality is to allow patients the opportunity to wear them out of the office and test them in a “real world” environment. Only then will patients truly know whether the lenses will be the best option for them.
• Dr. Miller: The manner in which we approach a multifocal contact lens fit potentially can be our greatest downfall. A patient who does not perceive good vision immediately will be more apt to complain. Then, many of us will hastily reach for a different lens design in an effort to make the patient happy. This particular method is a recipe for failure.
I make certain to educate my patients about the fitting process, as well as the importance of their follow-up care. Even before we get started, they know it may take one or two follow-up visits to effectively balance their near/distance vision––and, I prefer to err on the side of a little additional distance to start. For that reason, I do not like to make many significant adjustments or even show them a near visual acuity card during the initial fit.
4. Product Availability
In the past, practitioners have experienced limited access to specific lens modalities or designs that would be most ideal for certain patients.
• Dr. Kading: This has been a major cause of frustration for us. At my practice, 83% of our patient population wears single-use lenses. We are very proud of this fact, because we believe that it is the safest modality for most patients.
If a daily disposable lens wearer slowly started to need a multifocal lens, we used to have very limited options to offer.
However, in 2014 alone, both Alcon and Sauflon introduced new, one-day MF lenses to the market (Dailies AquaComfort Plus and Clariti, respectively). Along with CooperVision’s Proclear 1-Day Multifocal, we now have three great options to keep our aging daily disposable patients in the modality. Daily replacement maintains ocular surface integrity in patients who may be starting to experience age-related dry eye. And because the three designs differ slightly from each other, we can prescribe the most suitable option to each individual.
• Dr. Brujic: At this point, lens options and modalities are plentiful. SpecialEyes, Alden Optical and a number of other specialty soft lens manufacturers produce multifocal options for patients with significant astigmatism. SynergEyes produces the Duette Multifocal that combines the benefits of a gas permeable lens’s superior optics with a soft silicone hydrogel skirt for comfort.
• Dr. Miller: Many of the latest modalities and designs have really helped minimize this situation. Now, my biggest challenge is trying to keep my one-day diagnostic multifocal lenses in stock.
5. Who to Fit?
How do you determine whether a patient is a good candidate for multifocal contact lenses?
• Dr. Miller: Eye care professionals need to look at presbyopia as an opportunity! It gives us a chance to help a patient and correct this frustrating visual process with contact lenses.
Many ODs perceive presbyopic contact lens fitting to be a challenging, time-consuming process that isn’t worth the effort. If you are familiar with the specific designs and understand the fitting guides, however, the process can be streamlined significantly. Although these patients can be challenging, many of them find the notion of wearing contact lenses to be liberating. Additionally, it’s worth considering that if you don’t present the option of MF contacts to your patients, another eye care provider will!
For those reasons, we present contact lenses to every patient in our office––unless they have some underlying ocular health concerns that may limit their wearing ability. Even in that instance, such patients may be fitted with lenses once their condition has been treated effectively.
• Dr. Kading: I agree with Jason’s suggestion that multifocal contact lenses should be provided as a potential option for all appropriate patients. There’s essentially a lens for everyone––even patients who are only interested in part-time or occasional wear. For example, single-use MF lenses provide the patient with tremendous convenience, and easily may be worn when desired or needed.
• Dr. Brujic: Simply put––every patient who is a candidate for MF contacts should be educated about the opportunity to wear them. Certainly, there will be patients who do not want to wear contacts. Nevertheless, it is your responsibility to make them aware that they are indeed appropriate candidates if they ever change their minds.
6. Follow-up Care with MF Contact Lenses
How important is the adaptation period to MF lens wear, and how long should you wait to bring the patient back to check on his or her progress?
• Dr. Miller: Follow-up care shortly after the initial fitting is essential for successful, long-term multifocal contact lens wear. Just a small change in the prescription can make a marked improvement in the patient’s visual abilities and range of vision.
Typically, I like to wait about one week to bring the patient back for a follow-up appointment. I believe that it affords the patient enough time to adapt, but isn’t too long for the individual to potentially become frustrated and/or stop wearing their diagnostic lenses.
At that visit, be sure to involve your patients in the final decision. I often will let them know that their best-available correction rests between two lenses––one with a little more near vision, and another with a little more distance. Ultimately, I need to know which they prefer. When patients make that final call, they are signing on to the compromise inherent in multifocal wear, and will thus adapt to it far better than they would to a correction imposed on them by their doctor.
• Dr. Brujic: I prefer to see patients back two to three weeks after the initial lens fit. An adaptation period of approximately 10 to 14 days is required with any simultaneous-vision multifocal lens design. At this point, you can make any necessary final adjustments to the patient’s prescription.
• Dr. Kading: We like to let our patients know that they eventually will see clearly with MF lenses; their brain simply needs time to adapt. As mentioned previously, I’ve seen the cortical adaption process unfold time and time again in my practice.
In this instance, patients may see relatively clearly on the eye chart before they leave, but they often will complain about the overall quality of their vision. When they return for follow-up, however, they frequently report better vision. I like to schedule the initial follow-up at least one to two weeks after the fitting, largely depending on the patient’s attitude and visual status.
7. Unsuccessful Multifocal Patients
Ideally, 100% of our patients will be able to wear multifocal lenses successfully. But, in reality, we all know that isn’t going to happen. So, how do you manage the patient who is not successful with an MF lens fitting?
• Dr. Miller: Although some of the newer multifocal lenses will help reduce the number of necessary follow-up appointments, it is difficult to admit defeat and abandon the MF fitting process in an unsuccessful patient.
When the patient has unrealistic expectations and continues to have difficulty adapting to multifocal lenses after a couple of changes, I take a step back and explain what we have tried and which options we can consider in the future. Again, involve them in the decision-making process––but don’t be afraid to give them a little push, as well.
• Dr. Kading: It is important to incorporate the patient’s needs and expectations into the fitting process. Keep in mind that not all of our patients can successfully wear multifocal lenses as the manufacturer intended.
Instead, it is up to us to meet as many patient expectations and visual demands as possible. This may mean mixing and matching different companies’ lenses or fitting one eye with an MF lens suitable for distance enhancement and the other with an MF lens intended for near viewing. These unconventional MF fitting practices still offer several advantages over monovision lens wear, especially because they help preserve some binocularity.
At the end of the day, however, we will try to fit a patient until they are happy or they give up.
• Dr. Brujic: The key here is establishing proper expectations. Although there are a number of ways to discuss this, here is an example of how to communicate with patients to effectively temper visual expectations with regard to multifocal contact lenses:
“The great thing about multifocal contacts is that they provide more functional vision that minimizes your dependence on supplementary spectacle use. Most people who are successful in this modality really like it. But, it is important to know that the vision is somewhat different from what you may be accustomed to in your current contacts or glasses. Really, the only way to determine how successful you will be with multifocal lenses is to undergo a fitting, and then let you test them in your regular, day-to-day environment.”
Another challenge is to know when “enough is enough” for any patient who does poorly during a multifocal fitting. To help ensure a better fitting experience, I perform topographies on all of my contact lens fits. Our topographer automatically measures the distance from the geometric center of the pupil to the patient’s line of sight.
Additionally, I also perform topography over the contact lens. That way, I can determine whether the lens is lined up over the patient’s visual axis. In clinical experience, I’ve noticed that those patients who are unsuccessful with multifocal contact lenses often have a large discrepancy between their line of sight and the optical center of the pupil. Knowing this helps initially establish more realistic expectations and also reduces the number of follow-up appointments necessary for a patient who isn’t doing well during the multifocal fitting process.
8. The MF Lens Fitting Process
Because the process often takes too long and disrupts patient flow, can we ever actually devote enough time to fit multifocal contact lenses properly?
• Dr. Brujic: The key to successfully fitting any multifocal design is to follow the steps outlined in the accompanying lens guide. This helps standardize and, most importantly, streamline the process. By following the guide, you’ll dramatically increase the likelihood of a prompt and successful initial fit.
Additionally, if you find that working with multifocal contact lens wearers does, in fact, take more time than fitting other patients, consider adjusting your fee schedule accordingly to compensate for the additional time and expertise required.
• Dr. Miller: Understanding the patient’s visual needs, and documenting his or her dominant eye status, will help streamline the overall fitting process. If your patients spend 12 hours a day on the computer or drive long distances to their jobs, you’ll have a better idea where you need to make that extra push during the fitting. For example, a mechanical engineer with highly intensive visual demands may require an over-distance or over-near prescription to complete certain tasks.
And, yes, I absolutely agree with Mile––multifocal contact lens fits are customized processes that command higher fitting premiums than single-vision lens fits.
• Dr. Kading: Both Mile and Jason raise some great points. I think it’s imperative to understand that MF contact lenses are not just a small change over their spherical counterparts––but rather, a whole new way of seeing.
As such, we need to inform our patients that it is going to take time to adapt and time to work through the process of getting the right prescription that fits their visual needs. I also agree that, because of the increased amount of time required to perform the fit, it is important to charge appropriately.
9. Cost Considerations
Will patients be hesitant to pay the additional cost for multifocal lenses, when they could simply wear spectacles over top of their current monovision contacts?
• Dr. Brujic: It’s remarkable what people pay for creams, spa treatments and other cosmetic enhancements––simply in an effort to marginalize the effects of aging. Interestingly, however, none of those truly improve functionality.
But, with multifocal contact lenses, the patient is able to not only avoid a telltale manifestation of aging they consider aesthetically unpleasant—the dreaded reading glasses—but also increase functional acuity with a single corrective modality. For most patients, paying slightly more for a simplified, premium visual experience is worth every penny.
• Dr. Miller: Patients come to us for our quality of care, medical treatments and––above all else––our recommendations for their specific visual needs. If patients are appropriate candidates for multifocal contact lens wear, don’t limit your recommendations to only the corrective options you think they can afford and/or are willing to pay. Many individuals are more than willing to pay a higher fee for increased convenience and improved visual acuity.
• Dr. Kading: In our office, we do not have much pricing-related pushback, likely because we explain the technology and the fitting process up front, and then outline the visual and lifestyle advantages the patient will gain. Generally, I believe that our most interested patients understand that higher prices naturally are associated with premium vision care devices.
10. Deciding Not to Offer MF Lenses
What is the effect on your practice if you decide not to offer multifocal contact lenses to your presbyopic patients?
• Dr. Brujic: Not providing patients with this opportunity may cost you more than you think. Presbyopes are severely inconvenienced by spectacle dependence throughout the day when attempting tasks as common as reading a magazine or using a smart phone.
In many instances, patients simply start wearing glasses because they aren’t aware that contact lens options exist for presbyopia correction. But, imagine that same patient leaving your practice and then talking to a friend who currently wears multifocal contacts. Certainly, that patient might be upset with you for not discussing every available modality. And, in this day and age of social media, the last thing you want is an unsatisfied or displeased patient.
So remember––always educate your presbyopic patients about all their potential options. Then, even if the patient expresses disinterest in multifocal contact lenses and instead wishes to continue wearing glasses, you’ve at least covered all your bases. This approach ensures that your patient won’t first learn about advanced presbyopic correction options from their pals at the gym.
• Dr. Miller: That’s a great point, Mile. If you do not offer multifocal contact lenses as an option, your patients may seek out another eye care provider who will. The potential ramifications could be detrimental to your bottom line.
• Dr. Kading: Agreed––but also remember that there is a trickle-down effect. Often, entire families come to see you. If one family member leaves and sees another eye care provider who offers “newer” or “more advanced” technology, you could lose the entire family to the other practice. Of course, not all patients are going to head for hills over this consideration, but it is still something to consider.
From a larger perspective, however, intentionally neglecting the additional revenue stream and customer satisfaction generated via offering multifocal contact lenses simply isn’t good business.
Dr. Kading owns Specialty Eyecare Group, a Seattle-based practice with multiple locations.
Dr. Brujic is a partner of Premier Vision Group, a four-location optometric practice in northwest Ohio.
Dr. Miller is a partner at EyeCare Professionals of Powell, Ohio.
