Optometry Times Editorial Advisory Board member Milton Hom, OD, FAAO, shared his top 10 multifocal contact lens tips during a session at the American Optometric Association’s Optometry’s Meeting.
Seattle-Optometry Times Editorial Advisory Board member Milton Hom, OD, FAAO, shared his top 10 multifocal contact lens tips during a session at the American Optometric Association’s Optometry’s Meeting.
“When it comes to fitting a presbyope with contact lenses, we’ve really come a long way,” he says. “I think that nowadays that with the number and the quality of multifocals that we have on the market, I’ve completely shifted away from monovision-we really don’t use it anymore."
Dr. Hom says it’s impossible to overemphasize how important communicating with a patient is when it comes to fitting a multifocal contact lens. You’ll have to spend a lot of time with these patients to find out what their needs are.
“Not all presbyopes are alike. Each one of them are different,” he says. “More so than any other type of lens we use, it is a customized fit because you really have to know the patients’ lifestyle, what their needs are, the lighting conditions are, so you really have to spend a lot of time finding out their needs and finding the right fit.”
Patient history also plays a strong role in multifocal success. You have to find out more on their past history with contact lenses and what their vision needs entail.
Dr. Hom says that ODs tend to use negative language when discussing multifocals, with phrases such as compromise, trade off, not perfect, etc. Instead, you should focus on putting a positive spin on the patient’s expectations.
“What can you do now that you weren’t able to do before in your glasses or your single-vision contact lenses? Let’s summarize these things,” he says.
“Instead of saying ‘compromise,’ talk about function vision. Instead of ‘trade off,’ talk about a balance between distance and near. I always say, ‘It’s not going to be perfect,’ but you can teach them how to prioritize their vision,” Dr. Hom says.
Dr. Hom says that failure with multifocal contact lenses has more to do with a lack of doctor-patient communication than it has to do with lens technology.
“I’ll be honest with you, it took me a lot of failures to learn this particular lesson,” he says. “When you look at multifocal problems, there are distance problems, there are near problems, or you have problems with both distance and near.”
Dr. Hom says that when you look at the fitting guides for most of the major contact lens manufacturers, they’re all basically the same.
“If a patient has difficulty seeing distance with her multifocal lens, you lower the add. Now what’s interesting, if she really can’t see, another alternative would be going to a single-vision distance in one eye, so that you turn it into a modified monovision, or a modified multifocal,” he says.
“If a patient has difficulty seeing near, you increase the add. Or, another thing that you can do is increase the plus, usually on then on-dominant eye,” he says.
But these are non-dramatic changes.
Dr. Hom says that when you have the distance power optimized, the near vision should be assessed. Small changes to the distance power can have a profound effect on near vision. Aim to keep the near add power as low as possible.
“It’s really hard to get used to a high add-that’s just basic optics,” he says. “Low adds, however, are easy to get used to.”
“I think that manufacturers would like you to stay within one particular type of lens, but that is so far from what you do in clinical practice. You can’t get away with getting one set,” says Dr. Hom. “There’s not one size that fits all, and there’s not one manufacturer that fits all.”
You’ll need to determine whether the patient will be biased toward near, intermediate, or distance vision. Then, you’ll have to determine the add-for a +2.50 D add, you’ll have to try every single trick in the book, says Dr. Hom. Those are the patients who will give you sleepless nights, he says.
Related: 3 correction options for presbyopes
• It is a fact of life that some patients will adapt to monocular vision
• Other patients never will
• Make all of your power changes first
• When you make a change, make it significant
Smartphones have become one of the most important aspects of your patients’ lives. Take these devices into account during the exam.
“Smartphones are very important, so what I have my patients do is look at their smartphone. After we have them all tuned up for distance, we have check to see if they can see their smartphones,” Dr. Hom says.
“A lot of times when we do follow up, they say ‘I can’t see this. I can’t drive. I can’t drive at night. I can’t see my smartphone. I can’t do this. I can’t do that.’ If you have your patients bring their smartphone, you can point out to them that they could not see their phone without reading glasses before, and now they can,” he says.
Lighting can make all the difference in the world for presbyopes.
Dr. Hom recommends the app MagLight, which uses the phone’s camera to magnify text and the camera’s flash to illuminate. The app allows the user to control the degree of magnification, brightness of the light, and the contrast.
It is available on both iOS and Android systems.
“I used to be afraid of prescribing spectacles-it was like a measure of failure on your part,” says Dr. Hom.
Dr. Hom also says that the demographic who needs multifocal contact lenses also generally has significant disposable income, so purchasing spectacles in addition to the lenses is not a problem.
“I never really get pushback on price at all with these presbyopic patients. If I get pushback, it’s because they can’t see,” he says. “It’s all about the vision.”
If patients can use the multifocal contact lenses alone for 75 to 80 percent of the time, that is considered a success, says Dr. Hom.
“It took me a while to learn this lesson, but it is one of the most significant lessons I’ve learned over the years,” Dr. Hom says. “Just think: if you fit your emerging presbyopes into multifocals, will it be harder or easier when they hit the +2.50 D add? It will be so much easier.”
By the time they hit that point, they will be accustomed to multifocal vision, and you can just make little tweaks along the way, he says.
“Start them as early as you can,” he says. “It’s going to benefit them in the long run.”
Dr. Hom says work from fellow Optometry Times Editorial Advisory Board member Mile Brujic, OD, has opened his eyes to the angle kappa and unlocked the door for a lot of problem fits.
Pupil size is important, especially in the extremes.
“We usually assume that the center of the pupil is at the center of the line of sight. But there are patients out there in which they are not lined up. In fact, there are patients out there in which there is a large gap between the center of the pupil and line of sight, where the angle kappa is large,” says Dr. Hom.
“You have these patients that will come in and say that they’re using the distance portion, but they can’t really see distance, but they see near and vice versa,” he says. “Those are signs that you have a large angle kappa, and that lens is decentering, and they’re not using the proper area that the lens is designed for.”
Dr. Hom says it’s important to treat the ocular surface disease, which can be a major factor in discomfort and, in turn, drop out.
“For a lot of patients in multifocals, you get so involved in trying to get the vision right, and the powers right, and changing this lens and that lens, that comfort and ocular dryness gets pushed aside,” he says. “Nowadays, you have to pay attention to these discomfort problems.”
Related: Why do you choose that contact lens?
Dr. Hom recommends billing on the vision plan for the contact lens fitting, and then bringing back the patient back for an ocularsurface disease workup on a medical plan.
In order to manage discomfort, Dr. Hom also recommends:
• Switching to a daily disposable
• Using rewetters
• Trying a different material
• Changing solutions