Published in Contact Lens

Managing Messy Multifocal Fits

This is editorially independent content
6 min read

Learn how to communicate with presbyopic patients about finding the right multifocal lens for their visual needs.

Managing Messy Multifocal Fits
Have you ever encountered a presbyopic contact lens wearer that claims they have “tried everything” when it comes to presbyopic contact lenses—monovision, monthlies, dailies, new multifocal designs, and old designs? Sometimes, when you look at their chart, you realize they might actually be right. You see multiple iterations of various brands, powers, and add powers moving up and down the power scale, along with a wide variety of complaints that include discomfort, poor distance, and near vision.
It can feel overwhelming to think about approaching these cases. One might assume that these patients are uniquely picky or entering with unrealistic expectations. In most of these multifocal sagas, however, a fresh start and reset can establish the vision and comfort that the patient and fitter set out to achieve.

Start with fresh data

For every presbyopic contact lens wearer, but especially for those who have struggled to find a good lens power and brand combination, make sure you are starting with fresh refractive data. Don’t simply duplicate manifest refractions or contact lens powers from years past. Instead, take your own measurements.

Presbyopia not only influences add power, but distance prescription magnitude can fluctuate as patients progress through presbyopia as well. It is common for early presbyopes to be over-minused or for older presbyopes to show changes in hyperopia and/or astigmatism as the eye and intraocular lens age.

When fitting multifocal contact lenses, the initial lens power is based on the patient’s most-plus manifest refraction and add power. Make sure the numbers you are relying on are as current as possible to ensure you are starting with the lens most likely to address their visual needs.
Additionally, don’t rely only on age to help you determine what add power is best. Talk to your patient about their near visual needs and determine an add power based on where they need to see up close. This functional add power determination will help you choose the best initial lens with less need for troubleshooting.

Follow the fitting guide

Manufacturers develop fitting guides to ensure you choose the best lens combination initially and throughout the fitting process to maximize your chance of success. Fitting guides can admittedly seem somewhat elementary at times, which may lead you to think you can pull an initial lens pair on your own when you can’t seem to find that little booklet in your trial room.

Don’t ignore the fitting guide, even if you think you can guess the next best lens choice.

When the fitting guide suggests somewhat obvious choices for initial and subsequent lenses, there are almost always one or two guide suggestions that may not be so intuitive. These suggestions are based on the manufacturer’s unique understanding of and experience with that lens design.
Furthermore, these fitting guides are most likely to make you successful with the initial lens choice, troubleshooting in the least amount of time, and lens combinations. Most guides have digital versions that you can easily save to your desktop or phone. Take a few minutes to bookmark the guides you use most often so they are available to you when you need them most.

Start over with a new brand

When you look at a patient’s history and see that they have tried more than two versions of the same brand, or are in contact lens powers that are not close to their manifest refraction values, it is probably time to start over with a new lens brand. With modern multifocal designs, most patients should be able to achieve acceptable comfort and vision with the first or second lens iteration. If you need to troubleshoot past this, it is possible that the brand/design you are working with isn’t optimal for the patient.
Like many things we encounter as consumers, what works for one person doesn’t always work for another. When you feel like a particular design isn’t working for your patient after a few pair combinations, consider switching to a different design and starting over. Sometimes certain wearers may do better with one design over another based on their visual needs and preferences.

Consider design features like center-near versus center-distance and lens features like replacement modality to ensure you choose a design and lens type that is optimal for each unique patient.

Communicate and educate on expectations

Especially for patients who have previously experienced a frustrating fitting process, sometimes listening to their specific needs and complaints can guide you. You can’t solve a problem you aren’t aware of.
After making yourself familiar with the objective information in the chart, ask the patient what their experience has been so far with presbyopic contact lenses. Ask specifically what has worked and what hasn’t in order to get a sense of their goals and expectations. Once you understand what the patient’s goals are, you can make sure their expectations are in the right place. Multifocal contact lenses can correct vision well at most distances.
Specifically, in the early stages of adaptation, it is common for the patient to describe their vision as feeling “different,” “off,” or “strange.” Set proper expectations to let the patient know that the first step to success will be calibrating to this new optical system within the contact lens design.
As the adaptation phase begins to lock in, you can make more meaningful changes to refine vision at distance and/or near. Conveying confidence in the lenses and your ability to tailor them to the patient after the adaptation period will build mutual trust and lend credence to the fitting process as they continue adapting to the lenses.
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
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