Published in Contact Lens

Guide to Fitting Contact Lenses for the Presbyopic Population

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9 min read

Fitting contact lenses in presbyopes can be very challenging. Here are several things to keep in mind when you face this challenge in practice.

Guide to Fitting Contact Lenses for the Presbyopic Population

Fitting contact lenses in the presbyopic population can be challenging in today’s environment.

Today’s patient expects instant gratification. Unfortunately, for most presbyopes there is going to be a learning curve when wearing contacts, especially for the first time.
The right expectations need to be set without discouraging the patient from trying contacts.
Having success fitting your over-forty patients starts from the time you discuss those expectations at the first visit. You must tailor the contact lens fit to each patient. Each and every patient will have different needs so don’t attempt a cookie-cutter approach and try to put everyone in the same lens!
Talk to your patients.
Dig deep and find out why they are interested in contact lenses.
  • “I want to use them only when I go out for special occasions”
  • or “I work in front of a computer all day and I don’t like wearing my glasses”
  • or “I am a nurse and need to be able to look at charts, as well as seeing the monitors five feet away”
Once you have determined the patient’s needs, you can offer options that are best for the patient.
I offer all viable options to my patients and we discuss together what the best option will be.
Unfortunately, all too often, I hear from patients, “the doctor said this is what I had to wear.”
If you feel that your patient is not a good candidate for contact lenses, it is okay to let he or she know that they are not. Don't feel pressured to put every patient in contact lenses. As the doctor, it is your role to determine who is a good candidate and who is not.

Contact Lens Options Available

When discussing contact lens options with my over 40 patients, they will usually fall into one of the following categories.
  • Distance Only with readers (All spherical and toric lenses)
  • Monovision (All spherical and toric lenses)
  • Multifocal Lenses (Biofinity MF, Air Optix MF, Acuvue Oasys for Presbyopia etc.)

My Approach

The first thing to remember is to Keep It Simple. Don’t complicate the fitting process. The following is a list of rules that I keep in mind when fitting presbyopes.

1) Perform an accurate refraction.

It is important that the starting point is correct. If the refraction is not accurate, then you will be “chasing your tail” so to speak.

2) Read the fitting guides when fitting multifocal contact lenses.

These fitting guides are designed to help the clinician with best practices. Unfortunately, these guides tend to be underutilized and, therefore, many practitioners can experience low success rates. Always start with EQUAL ADDS. Unequal adds or using a spherical lens in the dominant eye and a multifocal in the non-dominant eye should be an endpoint…not a starting point.

3) DO NOT make multiple changes on the first visit.

This can create information overload and confusion.

4) DO NOT offer patients the “Pepsi Challenge” when fitting contact lenses.

I believe when you put one brand in one eye and another brand in the other eye, or tell a patient to try these all out, this just causes confusion and is counter-productive. Be confident in the lenses that you prescribe. Patients view this like throwing spaghetti against the wall and seeing what sticks.

5) Aim to under-promise and over-deliver.

I’m realistic with my patients without being negative. When fitting multifocals and monovision, I explain to the patient that they will be able to see well for about 95% of their normal activities. I discuss with them that on occasion they made need to use some low power magnifiers. Patients are okay with this.
Trying to fix the “other” 5% will most likely lead to failure. As clinicians, we should not expect perfection and we need to convey this to our patients. Something to remember is “Perfection is the enemy of good.” If they want perfection, this is not for them.

6) Remember 20/Happy.

This is a term that was used quite often years ago when fitting contact lenses. Why did optometry get away from this term? What does it mean? The patient may not be seeing 20/20, 20/25 or even 20/30 but overall, they are happy. Remember, it will not be perfect and we shouldn’t expect or promise perfection.

7) ALWAYS test eye dominance when fitting monovision or multifocals.

Once again, keep it simple.
The easiest way to check eye dominance is to have the patient extend their hands in front of them. I usually put a single large “E” on the chart. I have them overlap their hands and thumbs leaving a little space between the hands. I have them center the “E” and bring their hands back towards their eyes. Simple.

8) Be consistent with every patient and take control.

Do not allow the patient to dictate every change. If you set the right expectations, you should not have an issue with this.

9) Be confident.

Patients know when the clinician is having difficulty and the patient will lose confidence in you if they sense it. Don't let this happen!
Now let’s investigate all the different modalities of contact lens wear in these patients.

Distance Only

Obviously, the easiest contact lens option to fit in presbyopes is distance only correction.
So…why don’t we do it?
Sounds like a slam dunk.
And it is.
This is a great option for truck drivers or those patients that may want to use contact lenses at a sporting event, or primarily only for distance viewing tasks. This also gives you the option of prescribing other spectacle lens options like plano sunglasses for them, or a back up pair of progressives that has transitions (which is what I use)!


I started fitting lenses when monovision was probably the most prescribed lens option for this demographic.
Bifocal or multifocal contacts were not as advanced as they are today. So when you fit monovision everyday, you get pretty good at it.
Monovision does have it’s limitations but is a great option for younger presbyopes.
Remember, I let patients know that this will not be perfect but will accommodate 95% of their needs. When evaluating the lenses in the room, I perform the over-refraction outside of the phoropter with both eyes open.
I use hand-held lenses or flippers over the dominant eye first to see if there is any improvement to the distance vision. I will do the same for reading. I don’t like to make too many changes at the initial visit. Remember, if my refraction is on target, I shouldn’t have to make a change.
I will usually discuss with the patient that I tend to be a little conservative when prescribing plus for near. I will usually let the patient experience the lenses in the real world when they are at work and home. Adjustments can be made at the follow-up if needed.
Do not add additional minus to the distance to help far away vision and then add plus to the near to help near work. It is not needed.

Multifocal Contact Lenses

Multifocal lenses are relatively easy to fit although clinicians tend to complicate the process.
As I previously stated, read the fitting guides for each lens that you fit.
Always start off with equal adds. Remember, unequal adds should be an endpoint not a starting point.
I tend to use the lowest add to start off with. More plus can be added to the near if needed but I tend to be somewhat conservative with the plus. Once again, check acuities outside of the phoropter and use hand-held lenses for over-refraction. Patients with a -0.75 cylinder in the dominant eye I tend to put in monovision. Remember to account for the spherical equivalent with the cylinder power as low as a -0.25. As stated earlier, I let my patient know we can accommodate for about 95% of their needs but may need the help of magnifiers occasionally.

Final Tips For Success

We, as clinicians, must think outside the phoropter.
I believe that as technology has increased, our creativity with contact lenses has decreased.
In summary, these are a few quick things to always keep in mind:
  1. First and foremost, determine if your patient is a good contact lens candidate.
  2. Second, discuss the viable options with the patient and set the right expectations.
  3. Finally, check acuities outside the phoropter and perform an over-refraction.
  4. Refrain from making multiple changes on the first visit.
Fitting presbyopes successfully in contact lenses can be a great practice builder. You can build your practice from generating word-of-mouth leads from satisfied patients which will also lead to increased revenue for your business.
Michael Hay, OD
About Michael Hay, OD

I graduated from Southern College of Optometry in Memphis, TN. Since graduating, I have worked in all modes of practice including a military setting, corporate and private practice. Currently, I work at Crystal Clear Eye Associates of Florida, PA., a large commercial group practice in Jacksonville, Florida. I enjoy writing and mentoring young doctors. I am a member of the American Optometric Association and NE Florida Optometric Society. In my free time, I enjoy spending time with my 3 sons

Michael Hay, OD
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