Dr. DeKinder is an associate clinical professor at University of Missouri St. Louis College of Optometry. She is director of academic programs and director of residencies, and chief of contact lens services. She is a fellow of The Scleral Lens Education S
Dr. Henry is clinical professor, director of clinical operations and co-instructor in contact lens courses. She has also served as director of residencies, program coordinator for the cornea and contact lens residency, and chief of the contact lens servic
Becoming an experienced multifocal contact lens fitter allows ODs to address visual needs for two patient populations: presbyopes (and emerging presbyopes) and myopic children. Knowing when to choose a soft multifocal vs. a gas permeable or specialty design will increase fitting success for the OD as well as patient satisfaction.
Multifocal contact lenses have become the center of attention for two widely different markets: presbyopes and young myopic children.
In the next decade, we will see an increased number of contact lens wearers turning age 50 or older.1 Of those who are already contact lens wearers, the majority have worn them for their adult lives. This population desires to continue contact lens wear, reinforcing the need for successful multifocal contact lens designs and optometrists willing to fit them.
In addition, an estimated 100 million people in the U.S. are myopic and this number is increasing in prevalence each year.2 Multifocal soft contact lenses have been found to be a viable means of slowing the progression of myopia in children. A proactive optometrist can easily incorporate the practice of fitting soft multifocal contact lenses to our young patients to deter the myopic progression.
Fitting a patient in a multifocal lens is a multi-step process.
Setting expectations and determining the most critical visual demands for each presbyopic patient are important steps before selecting a lens material or design. By exploring the patient’s visual environment, hobbies, occupation, and everyday tasks, lens selection can be narrowed down to the best lens design for that patient.
A thorough slit lamp examination evaluating the cornea, lids, tears, and anterior segment health will determine if the patient is better suited for a gas permeable (GP) presbyopic lens, a specialty design, or a soft multifocal lens with variable lens replacement schedules.
Related: New correction option for presbyopes
For example, a patient who has been a long-time soft contact lens wearer would be a great candidate for a soft multifocal design. If the same patient also suffers from dryness symptoms, a daily disposable soft multifocal would be a great option. Similarly, if the patient currently wears a hybrid design or a spherical GP lens, the transition to a multifocal design can be smooth by staying in the same lens material and incorporating multifocal optics.
After the patient’s needs have been assessed, the next step is to obtain an up-to-date refraction with add power, keratometry, and dominant eye. Using this information, the initial lenses can be selected from the appropriate fitting guide.
Fitting guides are extremely helpful and must be used when working with multifocal lenses. The manufacturer has produced the fitting guide based on many patient encounters with its product, so deviating from the guide may result in an unnecessary failure.
While the initial lenses are settling, it is a good idea to discuss lens adaptation with the patient.
Encourage patients to consistently wear the lenses every day for at least two weeks to allow their eyes to adapt to the new lens design. Unfortunately, many multifocal contact lens dropouts may be avoided if patients were better educated about the adaption period.
This is a good time to use “real-world” examples to encourage the patient that success is obtainable with patience, persistence, and small adjustments to the lens. Reinforce that success is highly likely, but it may take adaptation to the lens and more than one office visit. Thorough education and discussion of the adaptation process helps prevent the patient who discontinues lens wear after four hours of wear.
Perform initial visual acuity measurements to enhance the patient’s perception of his vision in the lenses. Take all measurements binocularly in normal room illumination. Use an additional light source when checking near vision.
Perform binocular over-refraction in a phoropter-free environment. Low power plus and minus lens flippers are a great way to over-refract a patient with multifocal lenses.
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If a patient has acceptable vision with the first set of multifocal lenses, we dispense the lenses without making power changes. We find that inexperienced practitioners tend to make too many lens power changes at the dispensing visit. We prefer to have the patient wear the lenses for week or longer before making power changes, especially if the patient is seeing 20/30 or better binocularly at both distance and near.
A 45-year-old myopic female with an add power of +1.50 D and mild dry eye is currently wearing soft spherical distance-only lenses. Her most critical visual demands are at distance. A center-distance design might be a good option for this patient. This patient is a great candidate for a center-distance multifocal lens. With her complaints of mild dryness, a good lens option would be Oasys for Presbyopia (Johnson & Johnson Vision) or Biofinity Multifocal (CooperVision).
A 53-year-old male currently wears a 30-day continuous wear lens with great success. He would like to transition into a soft multifocal, but he does not want to give up continuous wear. This patient could be transitioned into PureVision 2 for Presbyopia (Bausch + Lomb). It is a center-near design with FDA approval for 30-day continuous wear.
A 51-year-old female currently wears monovision Air Optix Aqua (Alcon) and notices that her near vision is not as sharp as she would like. She also likes to wear daily disposable lenses when she is traveling and wants a lens that will work for both monthly and daily replacement. This patient is the perfect candidate for Air Optix Multifocal (Alcon) and either Dailies Total 1 Multifocal (Alcon) or Dailies Aqua Comfort Plus Multifocal (Alcon). Both lenses utilize the same center-near design and are interchangeable for patients desiring both lens replacement modalities.
A new presbyopic contact lens wearer may present with an interest in wearing a multifocal lens design on a part-time basis. Part-time multifocal lens wear can sometimes yield poor visual results secondary to poor adaption to the lens design.
To combat this, we encourage our patient to initially wear the lenses full time for a week or two to fully adapt. Several daily disposable multifocal lens designs can be used in this case. 1-Day Acuvue Moist for Presbyopia (Johnson & Johnson Vision), clariti 1 Day Multifocal (CooperVision), Biotrue for Presbyopia (Bausch + Lomb), Proclear 1 Day Multifocal (CooperVision), Dailies Total 1 Multifocal (Alcon) and Dailies Aqua Comfort Plus Multifocal are center-near daily disposable lenses.
Lid anatomy is the key to successful GP multifocal lens fitting.
Any presbyopic patient who is a current GP lens wearer is a good candidate for a multifocal GP lens. An aspheric multifocal GP contact lens should center well on the eye and be fit steeper than the flatter keratometry value.
A translating lens design is better suited for a patient with a tight lower lid that is located at or above the lower corneal limbus and has critical vision demands. The lens will be prism-ballasted and have a near segment that needs to translate upward into the visual axis for near tasks.
A 60-year-old long-time successful GP patient presented with the desire to limit her use of over-the-counter readers for near work. She has a lower lid 2 mm below the inferior corneal limbus and has a weak tonicity. She does not have critical near demands. This patient could be transitioned into an aspheric multifocal GP lens. The lower lid tonicity and anatomy will be better suited for an aspheric design, as will the noncritical near vision demands.
A patient who is currently wearing a specialty lens design has a few multifocal options. If the patient is a current scleral lens wearer, several scleral lenses are available with a front surface multifocal addition. Typically, the add power available in the scleral lens is limited to +1.50 D. Hybrid contact lens wearers can be fit with SynergEyes Progressive (SynergEyes). This is also a great option for patient with higher amounts of corneal cylinder, it but will not work well for patients with lenticular astigmatism.
Young myopes with advancing myopia are ideal candidates for soft multifocal contact lenses. Rules of thumb for fitting lenses for myopia control is to fit a center-distance lens design with the highest add power that will not decrease the distance vision.
Biofinity Multifocal “D” lens or Oasys for Presbyopia are both center-distance lenses that can be used. If the child also has a significant amount of astigmatism, Proclear Toric Multifocal “D” (CooperVision) lens can be used.
An 8-year-old female presented with interest in lenses to be worn to control myopic progression. Over the past six months, her prescription has advanced from -1.00 D in each eye to -1.75 D in each eye. She was fit with Biofinity “D” lenses in both eyes with power of -1.75 D and +2.00 D add. She has had good success and good vision with this lens design. She was fit in 2012; as of January of 2017 she has had less myopic progression than predicted by more than 1.00D.
An 11-year-old female presented to clinic for her yearly exam. It was determined that she had progressed approximately 0.90 D per year in her right eye over the last two years and 0.75 D per year in her left eye. She refracted with over 1.50D of astigmatism in both eyes. We educated her parents about myopia control, and they opted to try soft multifocal lenses. Due to the patient’s high amount of astigmatism, she was fit in Proclear Multifocal Toric “D” lens in each eye with a +2.00 D add.
An 8-year-old female interested in orthokeratology for myopia control presented with a prescription of -7.25 D in both eyes. She was fit into Oasys for Presbyopia with high add in both eyes, and she is wearing the lenses with good success. Over the last two years, she has had no progression in her myopia.
In our experience, fitting multifocals has never been more rewarding or in greater demand. Newer lens designs are easier to fit and patient friendly in terms eye health and disposability.
Fitting multifocal contact lenses helps build the practice by keeping patients in contact lenses as they move into presbyopia and by offering myopia control to concerned parents of myopic children.
Practitioners will find that as they become more experienced with multifocal contact lens fitting, their confidence will increase and creative solutions to fitting the patient will become more straightforward.
1. Studebaker, JB. Soft Multifocals: Practice Growth Opportunity. CL Spectrum. 2009 Jun;24(6):40-43.
2. Vitale S, Sperduto RD, Ferris FL, 3rd. Increased prevalence of myopia in the United States between 1971-1972 and 1999-2004. Arch Ophthalmol. 2009 Dec;127(12):1632-9.