A Guide To Multifocal Contact Lenses

It’s 4:45 PM at the end of a long day and in your mind you’re halfway out the door — until you see the chief complaint on your next chart. “55-year-old with decreased vision in their monovision contacts.” You picture your hands shaking as you hold loose lenses in front of an increasingly unimpressed patient. Sure, they can read the 20/20 line, but it’s a blurry 20/20 . . . Suddenly the end of the day doesn’t seem so near.

While I chose to pick on monovision wearers — they’re an easy target — all presbyopic contact lens wearers should be included in the discussion on multifocal contact lenses. By offering improved depth perception compared to monovision and eliminating the inconvenience of reading glasses over single-vision lenses, the advantages of multifocal contacts lenses are easy for the patient to recognize. In fact, more and more frequently, I find that patients are the first ones to broach the subject.

Don’t let them be. By being the one to present new technologies and anticipating their visual needs, we build patient confidence in our skills and in the lenses that we prescribe. That being said, it's difficult to recommend anything without a working knowledge of the product. What follows is a brief review of multifocal lens designs and the most popular lenses currently on the market.

Often I hear doctors describe multifocal contacts to their patients as “kind of like progressives." And I get it. It’s familiar to the patient, easy to explain, and close to the truth. As practitioners, though, we should know the design used in a given multifocal lens, if for no other reason than to avoid repeating similar designs after a failed trial.

Translating designs are common in RGP lenses and work by moving a near correction in front of the pupil when the patient shifts gaze.¹ Most soft contacts use simultaneous vision designs — termed such because multiple vision corrections are viewed at the same time. It is this viewing of multiple prescriptions at once which causes the mild visual compromise associated with multifocal lenses.

Of the lenses produced by the four major manufacturers (Johnson & Johnson, Alcon, Bausch & Lomb, and CooperVision) nearly all use some variation of a center-near, aspheric design. Acuvue® Oasys for Presbyopia, which utilizes a center-distance design combined with alternating, aspheric, concentric rings, is one of the few exceptions. Regardless of lens design, initial selection will begin by selecting a replacement schedule — monthly, biweekly, or daily.

Like many of you, I prescribe monthly-replacement lenses due to improved patient compliance over biweekly options and a lower price point than daily disposables. Alcon, Bausch & Lomb, and CooperVision offer multifocal lenses in this category.

The Air Optix® Aqua Multifocal is Alcon’s flagship monthly multifocal. Featuring a center-near, bi-aspheric design and low, medium, and high add powers, this multifocal is a logical transition for patients already wearing Air Optix® monthly lenses. Expect to see Alcon rollout the Air Optix® “plus Hydraglyde” Multifocal — promising increased comfort and reduced protein deposition — in the coming months.²

Ultra for Presbyopia is Bausch & Lomb’s premier monthly multifocal, largely supplanting both generations of the PureVision multifocal. The PureVision2 for Presbyopia shares a similar design with the Ultra for Presbyopia — center-near with a “3-Zone Progressive” to provide clear vision at far, intermediate, and near distances. The original PureVision Multifocal shares a center-near, front aspheric design with Bausch & Lomb’s biweekly Soflens Multifocal.

CooperVision bucks the trend of center-near lenses, if only slightly, by introducing separate designs for the dominant and non-dominant eye. In both the Biofinity Multifocal and the Proclear Multifocal, a center-distance lens is placed over the dominant eye* and a center-near lens is placed over the non-dominant eye. The Proclear Multifocal is also available in toric powers, unlike any of the other lenses presented here. While not a traditional multifocal, CooperVision also produces Biofinity Energys, which uses “Digital Zone Optics” to relieve accommodative stress associated with digital device use.

*The dominant eye is the eye which reports greater blur when alternating +1.50 or +2.00D lens between the best-corrected eyes.

Note: Round down if add power is between available adds. XR follows the same fitting guidelines.

Note: Round down if add power is between available adds

While biweekly lenses suffer a stigma of patient overwear, in some cases they represent the best option for transitioning patients into a multifocal lens (e.g. Acuvue® Oasys loyalists). Acuvue® and Bausch & Lomb both offer biweekly multifocal options.

Acuvue® Oasys for Presbyopia offers a unique, center-distance design with concentric, aspheric rings providing correction at intermediate and near distances — they call this “Stereo Precision Technology." Between the comfort provided by Hydraclear Plus and the familiarity of the brand, Acuvue® Oasys for Presbyopia can be a gentle transition for presbyopic patients looking to move into a multifocal lens.

The less said about the Soflens Multifocal, the better. With an abysmal Dk and the dated “NatraSight” design found in the original PureVision Multifocal, your patient will be better off in one of B&L’s monthly designs. If biweekly wear is a must, consider Acuvue® Oasys for Presbyopia.

Dailies, increasingly popular with active, young patients should not be overlooked when prescribing for presbyopic patients. Older patients will also appreciate the health benefits and convenience of this modality and are often more prepared to pay the higher price tag. All 4 major brands now produce daily disposable multifocal lenses.

While Johnson & Johnson’s 1-Day Acuvue® Moist Multifocal doesn’t offer an impressive Dk compared to some dailies, the addition of Lacreon technology provides improved patient comfort via an embedded wettability agent. The 1-Day Acuvue® Moist Multifocal is the only lens optimized for presbyopic pupil sizes and utilizes a center-near aspheric design to achieve clear vision at all distances. All of that, in addition to UV blocking materials, makes this lens a contender for any daily replacement multifocal wearer.

Alcon offers two daily replacement multifocal options — the Dailies AquaComfort Plus Multifocal and the Dailies Total 1 Multifocal. The AquaComfort Plus Multifocal is business as usual for Alcon, with the bi-aspheric, center-near design of the Air Optix® Aqua Multifocal, combined with the materials of Dailies AquaComfort Plus.

The Dailies Total 1 Multifocal doesn’t branch out from Alcon’s Precision Profile multifocal design, but its comfort and breathability are unparalleled compared to any lens on the market. Presbyopes with a history of dry eye or complaints of discomfort in their current lenses are prime candidates for the Dailies Total 1 Multifocal.

The BioTrue OneDay for Presbyopia is Bausch & Lomb’s only daily replacement multifocal. Marketed as part of the BioTrue OneDay line, B&L delivers a strong showing for comfort and ocular health with a 78% water content and a very respectable Dk/t, while maintaining the proven “3-Zone Progressive” optics of the Ultra for Presbyopia.

As a modern hydrogel lens, the BioTrue OneDay for Presbyopia is well-positioned for patients who are unsuccessful in silicone hydrogel lenses or are struggling with the comfort of older hydrogel materials.

In a change of form from their monthly lenses, CooperVision opted for fresh, center-near, aspheric designs for their daily replacement multifocals. The Proclear 1 Day Multifocal offers no traditional add powers and instead rely on the provider to prescribe a near boost in the non-dominant eye. Sounds like monovision, right? Yes and no.

Unlike traditional monovision, the Proclear 1 Day Multifocal is able to maintain binocular vision while providing clear vision at distance, intermediately, and near. The Clariti 1 Day Multifocal offers excellent breathability (it’s one of the only silicone hydrogel daily lenses reviewed here) and clear vision at all ranges thanks to its center-near spherical design. Hindered only by its complicated fitting guide, the Clariti 1 Day Multifocal should be close at hand when prescribing for patients who require the health benefits of silicone hydrogel at a fraction of the cost of Dailies Total 1.

There are a number of multifocal options available for soft contact wearers struggling to adjust to presbyopia. By being the one to present them, you can ensure that your patients are making informed decisions about their vision, rather than settling for what they think is available — this leads to happier patients with increased trust in their doctors.

I know what some of you are thinking, “That’s great and all, but multifocal fittings take forever.” And it’s true. Fitting a multifocal lens is going to take longer than other soft lenses. It can be easy to lose track of time trying to over-refract an unsatisfied multifocal wearer, but it doesn’t have to be that way.

Ignore your instincts to tackle a problem head-on and instead consult the lens’ fitting guides linked in this article. These companies have spent a lot of time and a lot of money figuring out the best path to a successful fitting. Don’t be too prideful to take the advice that they’ve written out for you. By managing patient expectations and then following the fitting guide provided by the manufacturer, multifocal fittings can be a simple, systematic process like any other part of your practice.