It surprises me in 2017 how many new patients show up wearing monovision contact lens correction or distance contact lenses along with readers around their neck. According to these patients, they have never been presented with a multifocal contact lens option.
In the early 2000s that was certainly understandable. The designs were primitive, offering limited success despite a cumbersome fitting process. We have seen significant advances in the multifocal arena over the past two decades—advances that deserve our attention and utilization.
When it comes to rigid gas permeable or scleral lens fitting, many doctors tend to shy away. Some ODs think it’s not something one can “dabble” in. You either invest in the equipment and training to dive in, or you avoid it—at all costs.
Previously from Dr. Brimer: Sizing up daily disposable contact lenses
Whether that’s true or not, you shouldn’t be intimidated by multifocal lens fitting. After seeing my multifocal fitting success increase significantly over the past several years, I became compelled to consider the source for the momentum. Below are nine habits that may have had the biggest impact.
1. Pick your battles
As ODs, we may get caught up thinking that if we just try harder and spend more time with the patient, we can make it work. Even if that ends up being true in a few cases, realize that this is not necessarily a healthy approach for the practice.
If you’re new to multifocal contact lens fitting, choose patients who are easy to work with. Consider pupil size, visual demands, and personality when presenting multifocal contact lenses as an option.
Even when the patient is not a good candidate, you should make him aware of multifocal contact lenses and the reasoning for your recommendation against them. This prevents him from hearing about multifocal contact lenses from someone else and assuming you are behind the times.
2. Require acknowledgement of limitations
After the refraction, I sit face to face with the patient and ask how he spends his day visually. I then provide three contact lens fitting options as a presbyope. I explain the positive and negative of each, and we quickly review which option seems to best match his goals. Though I make a recommendation, and nine times out of 10 it will be for multifocal contact lenses, I force the patient to make the actual choice.
In essence, I make him ask for the fit and agree to the imperfections of the contact lens before we start. I do this by reiterating any potential negatives, and then I gain his acknowledgement.
“You understand that neither your distance nor near vision will be perfect? But our goal is for you to do most tasks most of the time without readers.”
“We may have to go through a couple sets of trials, which will require at least one additional visit, sometimes more. This is a process. Are you okay with all this?”
In no way do I avoid multifocal contact lens fits or represent them negatively. I believe strongly in recommending multifocal contact lenses, even to patients who come in only for glasses. I want them to clearly understand the limits of the design, our relative goals, and the journey to achieve them.
The biggest benefit I have found is that patients are happier on their return. We don’t have multiple lens changes and visits because they have a better understanding of their optimal vision. The majority of my multifocal contact lens fits are completed with only one follow-up visit after the initial fit—which makes the extra three-minute discussion worth it.
3. Match design to demands
Find out how your patient uses his eyes throughout the day and if distance or near vision is more important. Use this information when considering a center-near design, center-distance design, or one of each. I have one go-to brand that I always start with, but I also have a backup brand in each of those categories for the one-sided demands, such as a truck driver or accountant.
For each multifocal contact lens you use, learn it well. Always follow the fitting guide for the brand you choose.
Related: Top multifocal contact lens tips
4. Celebrate the functionality
Once we have decided to move forward with the multifocal fit, I no longer discuss negatives. The last thing you want is for the patient to leave your office looking for what may be wrong with his vision.
Emphasize what he can see. Get the patient excited about being able to read without his spectacles, and reiterate what an enhancement this will be to his functionality and quality of life. I tell the patient it’s going to get even better.
I explain that because of the dim light in the exam room, this is probably the worst vision he will experience. With better light and time for his brain to adapt, it will get even better, day by day. I say this, not as an appeasement or hope in the face of dissatisfaction, but as a way to build excitement.
I’m also careful not to derail his momentum by dilating at this visit. When he is able, I walk the patient out so I can continue to celebrate and watch him experience his vision in the natural light.
5. Don’t overwork the lenses
Whether you’re working with hair gel, paint, bread dough, or multifocal contact lenses, don’t over work it. Sometimes the best results come when you stop yourself and walk away.
Multifocal contact lens fitting is no different.
6. Procedures with both eyes open
I use flippers to see if changing one lens will improve the patient’s binocular vision. I over-refract one eye at a time, but I do not occlude. If the answer is ambiguous, leave it as is—even if the acuity is not perfect.
It may be difficult for the multifocal patient to identify improvements with a lens change, so it’s best to avoid switching the lens unless he is consistent in reporting potential improvement with over-refraction.
7. Real-world targets
The two most important things a patient wants to see is her phone and the road. Oculus has developed a multifunctional and impressive digital chart, called Vissard 3D, that tests dynamic vision by showing a license plate as the car drives away.1
Short of that, we must head to a window or the parking lot. This may not be practical in every office, but it’s certainly a miss if we don’t ask every patient to pull his phone out and check the clarity. It’s no help to either of us if he finds out later he can’t see what’s most important to him.
8. Acknowledge the impact of the tear film
Considering the complex optics of a multifocal design, the tear film is more important than ever to maintain clarity and consistency. For a contact lens wearer, tear film becomes divided. Patients over age 40 may already have underlying tear film deficiencies.
Any build-up on the lens will further decrease its wettability, inducing visual disturbance and frequent blinking. For these reasons, use daily disposable multifocal contact lenses whenever possible.
Explain to patients the potential consequence to their comfort, vision, and ocular surface and be firm in your recommendation of daily disposables. If that’s not possible, be adamant about recommending a peroxide system for daily use.
Always be aggressive in implementing treatment for underlying ocular surface problems before fitting a patient with multifocal contact lenses, and see him more frequently to monitor for changes and ensure compliance.
Don’t overthink the complexity of a multifocal contact lens fit. If you are considerate and direct in your presentation on the first visit, it will establish realistic expectations and have a dynamic impact in improving patient satisfaction in a timely manner.
Don’t overthink the lens choice. Choose a successful go-to lens and learn the fitting nuances well.
Don’t ignore the impact of tear film. Treat first, then proceed in a watchful manner.
Finally, don’t underestimate the influence satisfied multifocal contact lens patients can have on your practice. These patients will be incredibly loyal and can be a great referral source.
1. Oculus. Oculus Vissard 3D. Available at: http://www.oculus.de/de/produkte/refraktion/vissard-3d/highlights/. Accessed 8/21/17.