With presbyopes representing a 25% of the world’s population and 112 million presbyopic individuals living in the United States, alone, multifocal contact lenses provide the possibility to both meet growing patient needs while growing practice revenue.1
Studies have also shown that patients prefer multifocal contact lenses over monovision, meaning you can decrease dropout and increase satisfaction by prescribing premium lenses to spectacle-dependent patients ready for a change as well as those currently in monofocal contacts.2
However, though other studies suggest that over 50% of the presbyopic population are open to wearing contact lenses, only 3% are fitted for multifocals.3 Therefore, finding their vision needs unmet, 62% of contact lens wearers over 45% will drop out.3 These statistics indicate the optometric community is missing a tremendous opportunity.
Multifocals meet changing demands
Multifocus lenses and soft lenses are a growing percentage of our contact lens practice. Soft, multifocal contact fits make up 15% of my overall fits, which is up from 5% just 3 years ago. I attribute this proliferation to having an aging but active patient population who desire lenses that can meet their variable distance demands.
I am seeing an increasing demand for variable vision. Our lifestyles are so active, single vision only has become an issue. Multifocal lenses are ideal for patients with a diverse lifestyle whose routine involves a constant fluctuation of vision from near to intermediate to distant.
These individuals may start their day with a morning workout or walk, then spend the next 8 hours in front of a screen at their job, followed up by an evening out watching a ballgame, playing pickleball, or visiting a restaurant for dinner. Each activity has different visual demands; this is the patient multifocal technology was selected and made for.
Addressing multifocal len dropout
A study, sponsored by Johnson & Johnson, revealed that approximately 50% of your practice is 40 and above and at the age of 40, over 90% think they're going to continue to wear their contact lenses.4 By the age of 45, 50% of that demographic have dropped out, so we're not identifying a real issue that exists for our patients.
Four factors seem to be paramount in contact lens drop-out among these patients:
- Ocular surface changes: By the age of 50, our tear films become dramatically different than they were when we were younger, compromising the ocular surface and leading to dry eye discomfort.
- Onset of cataract development: At middle age, we will see a decline in lens opacities, and this aggregation of proteins will eventually become cataracts.
- Presbyopia: This change in near vision leads to more complex and varied solutions.
- Decreased interest in physical appearance: Though not always the case, vanity seems to decline as individuals age, making them less averse to wearing glasses.
7 pearls for fitting multifocal lenses for new practitioners
For new practitioners fitting multifocal lenses, I suggest following these seven guidelines.
1. Start with a clean distance refraction.
2. Make sure you don't over minus the patient.
Personally, I'm a big fan of using the duochrome test.
3. Do not overprescribe the add.
I think we want to get every patient seeing 20/20 at near, and that's not the real world. Make them functional at near, so they can see their cell phone and laptop
4. Address any ocular surface issues.
As providers, we have to get better at identifying and addressing dry eye disease. For optimal results with multifocal contact lenses, or any lenses for that matter, you must maximize the ocular surface.
In the initial general exam, we always ask questions around dry eye. Though we occasionally use the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, I feel you can get more information from a conversation than a form. It is key to have well-trained staff who know how to elicit the pertinent information.
Some of the questions I find most useful are:
- Does your vision fluctuate?
- Do your eyes feel tired and heavy?
- Do your eyes become red during the course of the day, especially with computer use?
- Do you have any foreign body sensation or gritty feeling in your eyes?
- At what time of day are you taking out your contacts? And why?
Following the dry eye discussion, I put in fluorescein and/or lisamine for all of my contact lens wearers. Depending on these results, if I see a reason, I will schedule them for a full and thorough dry eye workup.
To learn how to effectively check contact lens patients for dry eye disease, check out The Dry Eye Workup in Contact Lens Patients!
5. Never make assumptions.
One key component of successful fitting is to be proactive; do not become lackadaisical with prescribing and assume that just because a patient isn’t actively complaining, they are completely satisfied. Always inquire and look for ways to improve vision and comfort, even if the patient has not voiced a concern.
This may require patience and perseverance. Do not discount a new lens after trying it on one patient, one time. Try it out on 10 of the best possible candidates, and then analyze who it worked best for and why.
6. Match the product to the patient.
If we don't want to be replaced by vending machines and mail order, don't act like vending machines and mail order, meaning don't base every decision on profitability—base it on the patient needs and the best possible outcomes.
To get the best possible contact lens experience, it is imperative to figure in all the variables surrounding economy, comfort, and vision. It's our job to be able to tailor and address their needs and concerns with both the lens material and the lens design while employing technologies, such as pupil-optimized design.
When you look at the intricacies of a concentric ring design and factor in the pupil varying in size from distance, from myope to hyperope, this is a crucial element in making sure the optics are correct for the right lighting and distance demands.
Three of my go-to lenses are:
- Acuvue OASYS MAX 1-Day (Johnson & Johnson)
- Infuse (Bausch + Lomb)
- MyDay (CooperVision)
7. Educate yourself and your patients
With continuous innovations and new products entering the ophthalmic space, it is vital that you keep abreast of new solutions. Though manufacturers offer a wealth of information, it is important to remember that there may naturally be some bias in their literature. Do a deep dive into the associated studies and scour different sources to find compatible statistics.
Contact lens representatives are also an invaluable source of information and underutilized. Take time to discuss what they see as the ideal patients and the benefits of their specific lens in regard to meeting common complaints.
Patient education on multifocal lenses
The emergence of online companies and big box stores offering deals for the cheapest lenses around, patients are prone to value economy over all else. Because they do not realize the visual benefits of premium products, they focus only on costs.
It is our job as eyecare professionals to remind them that contact lenses are medical devices that interact with the tear film, conjunctiva, cornea, and lid, and must be treated with caution. We must educate them on the advantages of choosing the right product for their specific sight and schedule requirements, and that paying more will be worth it in the long run.
The second biggest misconception I see in my practice is in regard to wear schedule. Many patients do not grasp the concept that wear schedules cannot be completely random and will greatly influence the performance and comfort of the lens.
Therefore, encourage them to be completely honest about when and how they are planning to utilize the lens, so you can find the best possible solution based on this information.
Sample patient conversation for prescribing multifocal lenses
“In looking at your prescription, we see you don’t have a lot of astigmatism. However, you do have a somewhat compromised tear film. That's very normal at this point in your journey through life. From talking with you, I know you want to continue to be in contacts and that your day has a varying set of visual demands. So, I'm going to select the Acuvue OASYS MAX multifocal lens for you today.
In addition, we discussed your screen time, and the Acuvue OASYS MAX has a blue light filter, which will improve comfort. The material is designed to enhance the tear film and help your eyes hold their moisture all day. Also, I really liked the pupil-optimized design.
This lens is made to be with your prescription; it’s like getting a tailor-made suit off the rack. Now, as you wear this lens, you will neuroadapt and you're going to see your vision get more and more comfortable.
Visually, it’s not quite like being a 20-year-old again, but it's going to make your vision much better. For really small type, you may need to throw your readers on, but if you're doing that once in a while, for a few minutes a day, and still optimizing all of your other vision, that's a win.”
Final thoughts
As we’ve established, multifocal lenses offer an immense opportunity, especially considering that the number one reason non-contact lens wearers reported never having tried lenses was because they had never been offered them as an option.5
Multifocal contact lenses can provide our presbyopic patients with a superior solution to achieve vision at all distances while maintaining an active lifestyle and avoiding cumbersome reading glasses. The key to success is taking advantage of all the existing lens technologies and customizing lens selection to each patient's very specific needs.
