Humans are naturally resistant to change. Whether it’s simply switching to a new brand of product or moving to a different country, the majority of us experience some level of discomfort when our circumstances change, in part due to perceived loss of control and uncertainty regarding the future. 

Contact lens patients affected by presbyopia face such uneasiness. Often for years, these patients see beautifully using the same contact lens product line. But as age and time catch up with them, contentment with their contact lenses diminishes as the advance of presbyopia intrudes upon their daily lives. Patients often become caught between an inertia of habit that keeps them committed to the lenses they are familiar with and the frustration of presbyopia’s inevitable effects. 

As practitioners, our ability to address patients’ concerns regarding new modalities is a unique opportunity to assuage disenfranchised patients and smooth their transition to multifocal lenses. The words we use are powerful and our enthusiasm for new products enhances our ability to successfully address or avoid pitfalls. Factors such as price, visual compromise, adaptation period and presbyopic progression over time are all triggers that can lead to patient dropout. Having a good strategy to help keep these valuable patients involved in the practice is key.

	Contact lens wear declines as refractive need begins to dramatically increase. The red line shows a projection of the potential contact lens wearing population if dropouts could be eliminated.

If the Price is Right
Many of us are guilty of jumping to conclusions about the contents of our patients’ pocketbooks, and how they choose to spend it. Multifocal lenses are premium products and the professional skill needed to get the best outcome requires a fee commensurate with the service provided. The offer of a “free” trial pair usually includes a comprehensive eye examination and the potential for a “fitting and follow-up” fee if the decision is made to move forward with the modality. 

An up-front discussion can help reduce any misunderstanding if fees appear unexpectedly at the conclusion of a fitting process. Presbyopic patients are usually the most financially stable portion of our patient population, as they’re typically at the peak of their career earnings, and are usually willing to pay the additional expense when the outcome results in increased convenience and less visual compromise. If needed, however, part-time use, especially with daily disposable multifocal lenses, addresses the convenience issues and high material costs associated with premium lenses.

No Compromise
Visual compromise is a huge issue for patients as they become presbyopic. Dryness and associated discomfort, redness and inconvenience are just some of the reasons patients drop out of using contact lenses, and these factors often worsen as patients grow older. 

It is critical to listen to your patient’s needs and concerns when fitting multifocal contact lenses. In addition to setting realistic expectations, identifying individual preferences, whether occupational or social, helps patients understand the rewards and limitations of multifocal lenses. 

All current soft multifocal contact lenses are based on simultaneous vision designs—when both distant and near images are seen at the same time. In this case, the brain must learn to suppress the image that is out of focus for the desired task. While this ability is not innate, it can improve with adaptation. Cortical adaptation may occur in a few days to a few weeks, depending on the patient. Knowing the dominant eye and emphasizing the vision for the preferred task will enhance the experience and reduce compromise. However, dominance does not always dictate a preferred distance. Listening again to the individual needs of patient expectations can guide your adjustments.

It is easiest to start with good distance acuity and adjust the near as needed. This builds enthusiasm and confidence in the modality for patients and allows for easier adjustments at future follow-up visits. Avoid adding extra minus power anywhere, as any additional distance power often compromises the near vision. 

Small incremental alterations in the parameters of multifocal contact lenses can make enormous changes in function for patients. This is especially true with aspheric designs—a 0.25D change in plus power can have a profound effect in near acuity. Hyperopic presbyopes are incredibly grateful for multifocal designs, as their age-related vision loss is catastrophic for various distances. Binocular acuity testing and real world targets such as cell phones serve as good markers when deciding how to adjust parameters. Encouraging full blink excursion is critical with prolonged use of digital devices. This keeps the meibomian glands “pumping” efficiently.

The visual compromise that occurs with presbyopia can be addressed simply by allowing patients to experience multifocal contact lenses in their world and adjusting the parameters as needed to improve their experience.

The Art of Lens Fitting 
The successful fitting of contact lenses employs a combination of knowledge and clinical experience with various lenses and the ability to respond quickly when change is required. Understanding a patient’s needs and behaviors can reduce the adaptation period because your initial lens choice may improve your odds for success. And with a variety of wearing schedules and lens design choices now available, our toolbox of multifocal contact lenses has never been better. 

Most manufacturers use lens designs based on some form of asphericity, with the majority having a center-near approach. Center-distant lenses and “lens system” approaches are also excellent choices for the right patient. Lens System designs use different corrections for each eye by incorporating different power rings for distance and near. Traditionally, the dominant eye is fitted with the distance-centered design and the non-dominant eye is fitted with the near-centered design. Early or emerging presbyopes may adapt quicker to the center distance design or  two distance centered designs when using the lens system approach. Needing more near vision help is often easier to achieve with the center near/higher add powers. For those in the middle of their presbyopic experience, having multiple add powers allows flexibility to personalize their visual experience by biasing one eye for their preferred distance.

Centration with any contact lens is critical, but it is imperative with multifocals. Since we are rarely able to modify curvature, changing the design is extremely helpful when needed. Additionally, extreme pupil size—either too large or too small—is likely to cause problems.

As a side note, many manufacturers offer fitting guides to assist you with starting points and problem solving. While you may have your own bias about ways to enhance vision, these guides can be great reference points to direct your decision-making process to reduce the adaptation period.

While visual acuity is important to success, it is not always the tipping point for patients. In fact, motivation is probably the most critical variable in the fitting process. Motivated patients are more willing to try the recommended designs, return for follow-up care and pay the financial cost of a new modality.

It’s important to note that insufficient adaptation time may prevent a patient from adjusting to new technology when they otherwise would have succeeded. Waiting a minimum of 10 to 15 minutes prior to checking initial acuities allows settling time. Typical adaptation times vary from one to three weeks, with changes made at appropriate visits. Changing one variable at a time simplifies the process and makes judging the impact easier. The patient’s vision will almost always improve when given adequate time for adaptation; not rushing this process will help prevent early abandonment.

However, if you have used all your clinical expertise, made appropriate lens changes and the patient is still less than “wowed” by the lens performance, be willing to abandon multifocals for their old modality. Though many patients will want to stay with the new lenses when they perceive the benefit of binocularity and improved function, some may prefer their old ones. Often, unsuccessful patients will comment that they appreciate the chance to try something new and know that we will have new products next year to address more of their unmet needs.

Presbyopic Progression 
Age is unkind to ocular health. As our ability to accommodate decreases with age, so does our tear production, which can lead to ocular surface disorders such as dry eye. Addressing these issues prior to any contact lens trial enhances success exponentially, as contact lenses can exacerbate certain symptoms. 

The newest generation of presbyopes, Generation X, are those born between the early 1960s and early 1980s. Their needs and expectations are unique to their generation and life experiences. They have always known technology as a tool to enhance their lives and their self-reliance and independence sometimes makes change even more difficult. Regardless, they resist being or looking old, and don’t want to “become their parents” too quickly. So, this population is generally amenable to addressing their presbyopic needs using newer methods like multifocal contact lenses when the reality of compromise is not working. Additionally, early presbyopes require lower reading options and often can adapt easier than more mature presbyopes who are entering the multifocal lens market. 

Flexibility and creativity with mature presbyopes is key to their success. Being willing to wear the lenses part-time, mix different brands or use additional over-spectacles for specific tasks enhances options. Additionally, this population has future opportunities for new options when available and unlimited referral potential when their experience is optimized.

Achieving freedom from glasses for both aesthetics and function will motivate many presbyopic contact lens patients to succeed with multifocals. However, for those that may have concerns regarding making the change, many options exist to cater to their specific needs. It is our responsibility as multifocal contact lens experts to allow patients the ability to try lenses; meeting their needs is both professionally and financially rewarding. 

Dr. Secor is in private practice in Huntington Beach, Calif. She is also a Fellow of the American Academy of Optometry, a Diplomate and past Chair of the Section on Cornea and Contact Lens and Refractive Technology. Dr. Secor has also been active with the American Optometric Association, most recently serving as  Past Chair of the Contact Lens and Cornea Section. 

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