Millions of presbyopes want to wear contact lenses. Despite the acknowledged shortcomings of multifocal lenses, several common-sense strategies can make them a success for both patients and practice.
Multifocal lenses may be the biggest missed opportunity in soft contact lenses today. While multifocals may require more chair time than spherical or even toric lenses, and there are more challenges with multifocals, they can still be very profitable and contribute significantly to practice growth. Success with multifocals requires a positive attitude, an efficient fitting process that focuses on the patient’s most important visual tasks, and a fee structure that compensates the practice appropriately whether or not the multifocal modality is successful.
The demand for contact lenses among presbyopes is enormous, creating a huge opportunity for practitioners. Contact lens patients love their lenses. When they drop out of lens wear, it is almost always because they feel they have to (due to discomfort, dryness, inadequate vision, expense, etc)—not because they want to. This loyalty to contact lenses does not diminish when patients turn 45.
If contact lenses for presbyopes worked as well as spheres and torics, their growth would be exponential. Despite the limitations of multifocal contact lenses, many patients can find satisfaction in them—they must simply be allowed the chance to try. Herein lies the opportunity and the challenge for practices to make multifocal contact lenses work.
Presbyopes who want to wear contact lenses face a double challenge: vision and comfort. It is widely agreed that dryness-related discomfort is a chief reason why patients drop out of contact lens wear. While presbyopes’ eyes are drier due to age-related changes, the real challenge for them is vision. The complex visual needs of presbyopes can only be met by lenses with complex optics, giving rise to a more complex—though not impossible—fitting process.
Success with multifocal lenses requires first of all that the fitter believe in them. Patients read our levels of enthusiasm, and our positive attitudes give them confidence. Confidence in the possibility of success is important for doctor and patient, since they will likely need to work together during a brief period of trial and error.
Fee structure is also critical. Because fitting takes time and success is not guaranteed, it is important to create a fee structure that ensures adequate compensation whether or not patients ultimately succeed with multifocal lenses.
A key to success in presbyopic contact lens fitting is to know the patient’s needs and make sure the critical ones are met. I let patients know there may have to be some compromise, and I ask: “Should we emphasize good reading vision, or good distance vision?” With luck, a patient will say: “I really have to see my phone,” or “I want to be able to drive safely, and I don’t mind reading glasses for fine print.” I aim to meet their most important needs with the least possible compromise, and this tells me where to start.
Of course, uncovering a patient’s vision priorities is not always so straightforward. Often patients do not know what they want until they try. Many patients will say: “I really want to be able to read.” When I put them in multifocals optimized for near vision, some will come back and say, “I can read, but now I don’t feel confident driving.” Then we adjust the prescription and try again.
Fitting multifocals is a joint effort of the doctor and patient. We may not hit the bull’s eye on the first try, but with teamwork and a small amount of trial and error, we should be able to zero in on it quickly.
Know When to Quit
To a very large degree, fitting contact lenses in presbyopes is an empirical process. Theory has not advanced to the point where we can predict with certainty what will work for a particular patient, so we try options until we either succeed or agree that nothing available will work. Since trial and error is built into the procedure, success as a fitter of multifocal contact lenses relies on a fitting process in which it is possible to reach a point of decision quickly, with minimal wasted effort.
With experience comes a sense of which patients are likely to succeed in multifocal contact lenses. I virtually never bring a patient back more than three times for a multifocal fitting—in my experience, if by that point we cannot find lenses that will work, we have typically reached the point of diminishing returns. If both doctor and patient feel they’ve given presbyopic contact lenses their best shot, failure today does not close the door on future possibilities.
Monovision or Multifocal?
All other things being equal, I have strong preference for multifocals over monovision contact lenses, because multifocals preserve binocularity. In fact, I also have better overall success with multifocals, and I find that using advanced technology lenses reflects well on our practice. But monovision can and does work, and when patients feel most comfortable with this option, I am happy to prescribe it.
For new patients, I like to start with the latest and best technology, and that means a multifocal. It creates a better impression to begin with multifocals and work down to monovision, rather than the other way around. And since there is no significant reduction in chair time with monovision compared to multifocals, I find little reason to start there. Monovision is always an available fallback, if needed.
Today’s soft multifocals are vastly better than previous designs; but they do take longer to fit and are less successful than soft spheres or torics. Success in soft multifocals is seldom a matter of achieving 20/20, as it typically is with soft spheres or torics. Rather, many multifocal patients are content with “20/happy.” Even when the Snellen acuity is not what it would be in spectacles, multifocal contact lenses allow patients to function well without having to wear glasses, which makes them happy.
One vital key to successful fitting is to use the manufacturers’ fitting guides. Manufacturers have invested tens of millions of dollars developing soft multifocals, and they have an enormous amount at stake in our success. They create their fitting guides with care and a great deal of input, and using these can help tremendously when selecting lenses, making changes, and tweaking “almost there” fits.
When Patients Don’t Adapt
Inadequate acuity is by far the biggest reason that presbyopes fail in soft multifocal lenses. Patients who begin the fitting process with appropriate expectations will not be unduly upset at failure—indeed, they are typically grateful for the effort.
This attitude makes it feasible to bring up the multifocal option at future visits, when new technology becomes available. Patients appreciate our keeping a lookout for what’s new on the market and what may work for them. Success or failure is not the criteria for patient happiness—it is our honesty and clear effort to find a solution that earns their respect and loyalty.
I succeed with multifocals between 60% and 70% of the time, and I attribute this success, in part, to my care in patient selection. Looked at another way, I can afford a 30% to 40% failure rate in multifocal lenses because not only have I been paid appropriately, but patients leave happy knowing that I have tried. It’s a win-win, whether the patient leaves in multifocal contact lenses or another presbyopic correction modality.
Acuity in multifocal soft contact lenses may not match acuity in glasses or even soft spheres; and patients must expect that. If the fitter has made sure that there is good vision for the patient’s important tasks, most patients can accept the reduced acuity in other situations in return for spectacle freedom. It’s not for everybody, but for many patients “20/happy” vision in multifocals is the solution of choice.
THE BOTTOM LINE
Although multifocal contact lenses may not provide the success rates of spherical or even toric lenses, they can be a boon to patients and practice. The keys to success with these lenses include learning the patient’s most critical vision needs; creating an efficient fitting process; having a fee structure that keeps fitting profitable even if the patient doesn’t leave with multifocal lenses; and seeking other solutions quickly once it becomes clear that additional multifocal fitting is unlikely to succeed.
Glenda B. Secor, OD, FAAO, practices in Huntington Beach, CA. Refractive Eyecare editorial director David Kellner assisted in the preparation of this manuscript.