A natural aging phenomenon, presbyopia typically starts around one’s mid-40s and causes progressive loss of the accommodative system. It has been reported that roughly a quarter of the world’s population is presbyopic, with 112 million of those people living in the United States.1
Not only is the population of presbyopes increasing, but the visual demands of this group are higher than ever. Today’s presbyopes seek contact lenses that provide adequate distance and near vision with all-day comfort as they face increased screen time and busier lifestyles.
Contact lens dropout in presbyopes
A 2020 literature review found that 21.7% of contact lens wearers drop out, with the most common reasons being inadequate vision issues and increased discomfort in new and established wearers, respectively.
It was reported that up to 75% of patients who drop out of contact lenses are able to successfully return to contact lens wear if adjustments are made for comfort or vision.2 These statistics emphasize the importance of appropriate lens selection, follow-up care, patient education, and dry eye management.
The connection between dry eye and contact lens dropout
Dry eye and anterior segment disease have been increasingly discussed as one of the main causes of contact lens dropout. These conditions become even more prevalent as we age and can make or break the success of a presbyopic contact lens wearer.
The Tear Film & Ocular Surface Society Dry Eye Workshop (TFOS DEWS) II study found dry eye syndrome, depending on definition, was found to be as prevalent as 50% in certain populations.3 It is important to have conversations with patients about dry eye management before fitting multifocal contact lenses.
Highlighting options like daily disposable lenses, artificial tears, meibomian gland management, and eyelid scrubs can increase a presbyope’s potential for success. Dry eye disease is not the only factor that can cause contact lens discomfort.
TFOS recognizes that contact lens discomfort (CLD) is the result of one of two main categories:4
- The contact lens itself, including the material, design, cleaning solution, fit, and wear time.
- The environment, which includes intrinsic patient factors like age and systemic/ocular disease, modifiable patient factors such as medication compliance, the quality of the ocular surface, and the external environment including factors like humidity and air quality.
A careful history of the presenting problem and discomfort is the first step in determining the root cause of CLD and allowing your patients to start or continue contact lens wear comfortably.
Multifocal contact lens design improvements
Modern soft multifocal contact lenses employ a simultaneous image or simultaneous vision design based on the brain’s ability to choose or interpret the clearest image when multiple images are presented. The majority of soft multifocals utilize two or more power zones over the pupil, meaning that multiple images are superimposed on the retina.
The brain subconsciously ignores the blurred image and chooses the one that is clearest for the task. It is this viewing of multiple images at once that causes the mild visual compromise associated with multifocal lenses.5
The majority of multifocal lenses on the market utilize aspheric optics, where the power gradually changes across the lens. The center of the lens can be near or distance focused with the power transitioning to be more minus or plus as the distance from the center increases.
There are some multifocals that use aspheric optics combined with concentric optics. Classic concentric designs have an abrupt change in power between the rings and can cause issues with halos, shadowing, and double vision. When combined with an aspheric design the lens has smoother transitions between zones and can alleviate some of those issues.6
Acuvue Oasys Max 1-Day Multifocal
Johnson and Johnson (J&J) released the Acuvue Oasys Max 1-Day Multifocal in the fall of 2022, designed with a combination of new technologies. One of the limitations of multifocal contact lens zone designs is variability among patients’ pupil size, especially in situations where lighting is insufficient.7
If a pupil is larger or smaller than expected for a given task, the patient may not see through the proper zone in the lens. J&J Vision addresses this optical issue with a Pupil Optimized Design. It’s widely understood that pupil size becomes more miotic with age. Studies have also shown that pupil size changes by up to 24% due to refraction alone with more hyperopic eyes having smaller pupil sizes.8
J&J uses this design in Acuvue Oasys Max 1-Day Multifocal, 1-Day Acuvue Moist Multifocal, and 2-week Oasys Multifocal lenses to provide the clearest vision at all ranges by considering the natural pupil variation that occurs depending on refractive error and patient’s age.9
Figure 1 highlights the relationship between pupil size changes, age, and refraction.10
Figure 1: Courtesy of J&J Vision.
Johnson and Johnson goes a step further in enhancing the optics of the Acuvue Oasys Max 1-Day Multifocal by incorporating an OptiBlue Light Filter. This filter specifically targets blue-violet light, which typically reduces the quality of vision by causing glare and halos. OptiBlue Light Filter filters 60% of blue-violet light—the highest level of any contact lens.12,13
TearStable Technology is another piece of technology found in J&J’s Acuvue Oasys Max 1-Day Multifocal. This feature combats comfort issues and dryness associated with contact lens wear as it spreads the wetting agent across the lens surface and throughout the lens.
In the trials reported by J&J, 94% of patients reported comfort throughout the day and 90% reported satisfactory comfort at the end of the day.11
Total 30 Multifocal
Released in fall 2023, Alcon’s Total 30 Multifocal includes the new CELLIGENT Technology with the goal of creating a contact lens surface that is most similar to the corneal surface. It mimics the cornea by being hydrophilic and lipophobic with antibacterial properties.14
The Total 30 line of contact lenses also incorporates a blue-violet filter that blocks 34% of light in this wavelength.15 This is another contact lens that can be a good option for those patients with some dryness and heavy screen use but who prefer a monthly replacement schedule.
MyDay Daily Disposable Multifocal
MyDay Daily Disposable Multifocal from Coopervision launched in the spring of 2023. It reports the incorporation of a “Binocular Progressive System'' optic design that aims to optimize vision at all distances with its unique fitting strategy.15
What makes this fitting guide different from other multifocals is that the dominant eye will always wear a low add power. Adjustments needed for distance or near enhancement are only made to the non-dominant eye. Coopervision reports an 83% success rate with the first fit and 98% success with two or fewer adjustments.16
Infuse One-Day Multifocal
The Bausch + Lomb Infuse One-Day Multifocal hit the market in the summer of 2023 and incorporates ProBalance Technology. The inclusion of electrolytes (potassium), osmoprotectants (erythritol and glycerin), and moisturizers (poloxamine 1107 and poloxamer 181) in Infuse contact lenses assist in maintaining tear film homeostasis.
These molecules were determined to be helpful based on the findings of the TFOS DEWS II report on tear film osmolarity and ocular surface homeostasis.17 Given the high rates of ocular surface disease (OSD) and dry eye in the presbyopic population, the Infuse One-Day Multifocal can be a great option for those patients who have experienced contact lens discomfort in the past.
BioTrue ONEday for Presbyopia
Although this lens has been on the market for over a decade, BioTrue ONEday for Presbyopia from Bausch + Lomb uses patented technology to provide an optimized multifocal lens design.
The seven biometric factors studied include:18
- Pupil size
- Anterior chamber depth
- Higher-order aberrations
- Axial length
- Corneal topography/diameter
- Residual accommodation
- Subjective refraction
These factors were gathered from a diverse sample of patients and a contact lens was designed from those data points to provide optimized vision in a wide range of presbyopes. In Bausch + Lomb patient surveys of BioTrue ONEday for Presbyopia wearers, over 90% of patients reported clear vision on their phone, computer, and when driving.18
Avoiding contact lens dropout in presbyopes
Meeting visual demands is a key component of fitting presbyopes in contact lenses. Expectations should be set before the fitting that the goal is to find a balance between the distance and intermediate/near vision.
It will take their brain and eyes some time to adapt to the design of multifocal contact lenses—and adjustments can be made if needed, once they have 7 to 10 days of trialing the contact lenses in their daily life. Having these discussions with patients on the front end of the fitting will prevent dropout during the trial period and allow them to feel comfortable and informed when discussing their multifocal contact lenses with you.
Dry eye, OSD, and CLD management are crucial for the success of presbyopic contact lens wearers. A thorough slit lamp examination can save chair time and prevent patient and prescriber frustration later on by diagnosing blepharitis, tear film insufficiency, meibomian gland dysfunction (MGD), and any other anterior segment disease before proceeding with the fitting.
Accounting for contact lens factors, like wear time and solution use, and environmental factors, like patient systemic disease and air quality, can also ensure that the root cause of any contact lens discomfort is diagnosed. Patients can typically be successful contact lens wearers with proper management of these conditions.
Final thoughts
Studies have also shown that patients prefer multifocal contact lenses over monovision.19 Multifocal wearers can maintain their binocular vision with little impact on their depth perception. Adequate vision at an intermediate or computer-distance is another advantage of multifocals over monovision.
Fitting a multifocal can feel overwhelming when you are trying to determine what lenses to start with or how to troubleshoot. Luckily, all modern multifocals come with a fitting guide or calculator (most can be easily accessed online) that tells you what lens to choose in any scenario.
Several studies have found that one to two trial contact lenses per eye is all that is needed for most multifocal fittings, provided the fitting guides or online calculators are followed.20 Patient education and setting expectations are crucial for success with new multifocal contact lens wearers.
Discuss the new technologies that are available in presbyopic contact lenses with your patients. The improved end-of-day comfort with TearStable Technology in the 1-Day Acuvue Oasys Max 1-Day Multifocal, Probalance Technology in the Infuse Multifocal, or CELLIGENT Technology in the Total 30 Multifocal can allow for patients who previously had issues with dryness in contact lenses to be successful.
In addition, the Binocular Progressive System optic design in the MyDay Daily Disposable Multifocal and the seven biometrics technology used to design Bausch + Lomb BioTrue ONEday for Presbyopia are new innovations designed to improve visual clarity in multifocals.
Fitting multifocal contact lenses is incredibly rewarding as a practitioner as it can give your presbyopic patients freedom from glasses and improved quality of life. The comfort and visual quality of soft multifocal contact lenses have been improving since their invention and surely will see continued advancements in the future.
