Published in Contact Lens

Establishing a Multifocal Mindset

This is editorially independent content
8 min read
Successfully fitting multifocal contact lenses requires the right mindset. Learn how to overcome internal and external challenges to get you and your patient on the same page of the fitting guide.
Establishing a Multifocal Mindset
If you’ve ever fitted a multifocal contact lens, you’ve spent at least a little time educating on the perceived negative sensations the patient might experience like compromised overall vision or glare. How much time, however, did you spend telling your patient about the positive outcomes they might enjoy?
Did you tell them that after a short adaptation period, they will likely prefer their vision with the multifocal contact lenses? Did you mention that they will be able to enjoy depth perception and clear vision at a range of distances instead of just a couple? It’s easy to warn of the negative side effects, but forget to emphasize the reasons you are pursuing this lens modality in the first place.

Multifocal lenses have come a long way

Multifocal contact lenses are the best vision correction option for presbyopes seeking to be spectacle-free for all activities. Unfortunately, multifocals are under-utilized by eyecare providers (ECP’s).1,2 This underutilization is probably an understandable hold-over from negative experiences ECP’s had with older lens designs or even due to perceptions that multifocal options don’t exist for certain refractive errors or astigmats.1,2
The truth is, however, that most modern multifocal contact lens designs have excellent visual and comfort performance. In addition, the current contact lens market includes parameter options for almost every myope, hyperope, and astigmat you will encounter.
Resources to help achieve success with each multifocal brand are also very accessible today. Manufacturers have developed easy-to-follow, extensively researched fitting guides that help you select both the right patient type and initial lens power to lead to a successful fit.

Keys to successful multifocals’ fitting

When fitting multifocals, it’s important that everyone involved—patient and practitioner—have the appropriate mindset. For the ECP, this means changing how you define “success.” When a presbyopic patient presents with high visual demands and a personality that demands precision, some ECPs might lean toward a monovision modality in order to provide the “best” visual acuity at distance and near without the perceived compromise of a multifocal.
That mindset, however, isn’t particularly helpful when fitting the presbyopic contact lens wearer.
Our world isn’t separated into one far and one near focusing distance only. We experience a range of distances where we need clear, functional vision. For the same reasons we don’t see patients prefer flat-top bifocals to progressive addition lenses in their spectacles, presbyopic contact lens wearers do not prefer monovision over multifocals.
The downsides we used to accept from monovision (lack of depth perception, poor intermediate vision) are no longer acceptable now that we have multifocal lens designs that perform so well.
In studies that compare monovision to multifocals, it has been reported that even when objective vision test results (like reading the exam room acuity chart) were “better” with monovision, presbyopic contact lens wearers subjectively preferred multifocal modalities.3,4
The visual experience a multifocal provides is better than monovision, even if the acuity value you record in your chart doesn’t reflect that. The fact that multifocals allow for depth perception and clear vision at intermediate distances makes the multifocal experience superior to monovision. While distance visual acuity may be similar, it’s been reported that multifocals provide improved near range of vision and contrast sensitivity compared to monovision.5
As ECP’s change how they define success with presbyopic vision correction and focus more on patient preference and perception, they will find that multifocals consistently deliver a patient-preferred outcome.

Establishing the appropriate patient mindset

Once the ECP is confident in the multifocal modality, establishing the appropriate patient mindset is arguably the most important part of the fitting process. While it’s necessary to establish appropriate expectations about what the lenses can and cannot accomplish, avoid dwelling on the negatives.
The adaptation period with multifocal contact lenses can be frustrating for some, but we know that most patients experience improved vision with multifocals after adaptation. Over the course of about 2 weeks, it has been shown that, compared to monovision, multifocals perform better on both subjective and objective visual measurements.6 Importantly, vision with the multifocal at both distance and near improves over time.5
While it’s important to acknowledge the sensations a patient will experience while they adapt to the new visual design, it’s more impactful to reassure them that vision almost always gets better with adaptation. In those first few minutes with the multifocal, instead of over-analyzing negative or new visual sensations, emphasize that the adaptation process is necessary to get to the appropriate endpoint.

Ensure that adjustments to lens power can be made after adaptation to refine vision and exude confidence in your ability to troubleshoot the lenses.

Make the patient part of the fitting process. Let them in on what you know about how these lenses work. Taking an extra 30 seconds to describe the lens design in easy-to-understand terms will result in more acceptance of any negative sensations experienced during the adaptation period.
I usually say something like, “These lenses focus multiple images on your eye at the same time. Your brain will take a few days to figure out how to find the sweet spot depending on what you are looking at.” This will result in them being more accepting of the adaptation process and, therefore, have a better overall experience with the lenses.

Final thoughts on multifocal contact lenses

While visual acuity at all distances and physical comfort are important parts of any contact lens fitting process, establishing the appropriate mindset is uniquely important when fitting multifocal contact lenses.
Abandoning past perceptions that you, as the eyecare provider, have about multifocals is a necessary starting point. Then, educate your patient on how the lenses work and what they can expect during adaptation.
Ensure their visual experience will only get better over time and exude confidence in your ability to troubleshoot any subjective visual issues that might remain after adaptation. When both the doctor and patient have aligned attitudes about what a multifocal contact lens can achieve, success is just an adaptation period away.

References

  1. Morgan PB, Efron N, Woods CA, International Contact Lens Prescribing Survey C. An International Survey of Contact Lens Prescribing for Presbyopia. Clin Exp Optom 2011;94:87-92.
  2. Morgan PB. International Contact Lens Prescribing in 2020. Contact Lens Spectrum 2021.
  3. Woods J, Woods C, Fonn D. Visual Performance of a Multifocal Contact Lens Versus Monovision in Established Presbyopes. Optom Vis Sci 2015;92:175-82.
  4. Gupta N, Naroo SA, Wolffsohn JS. Visual Comparison of Multifocal Contact Lens to Monovision. Optom Vis Sci 2009;86:E98-105.
  5. Fernandes PR, Neves HI, Lopes-Ferreira DP, et al. Adaptation to Multifocal and Monovision Contact Lens Correction. Optom Vis Sci 2013;90:228-35.
  6. Fernandes P, Amorim-de-Sousa A, Queiros A, et al. Light Disturbance with Multifocal Contact Lens and Monovision for Presbyopia. Cont Lens Anterior Eye 2018;41:393-9.
Erin Rueff, OD, PhD, FAAO
About Erin Rueff, OD, PhD, FAAO

Dr. Erin Rueff received her Doctor of Optometry degree from The Ohio State University (OSU) College of Optometry. Upon graduation, she completed the Cornea and Contact Lens Advanced Practice Fellowship at OSU. After fellowship, she continued at OSU as a clinical instructor and completed a PhD in Vision Science. In 2018, she joined the faculty at the Southern California College of Optometry at Marshall B. Ketchum University. Dr. Rueff’s research interests include contact lens discomfort and compliance. She enjoys teaching students in the clinic and classroom on contact lens and general optometry topics. Her clinical interests include multifocals, gas permeable and scleral contact lenses, keratoconus, and dry eye.

Erin Rueff, OD, PhD, FAAO
💙 Our Sponsors
EssilorLuxottica LogoJohnson & Johnson Vision Logo