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The Pesky Presbyope

Patients wearing multifocals are just as apt to experience problems as those wearing single vision lenses. But the solutions they need are entirely different.
By Mile Brujic, OD, and Jason Miller, OD, MBA

6/15/2015

In our attempts to derail contact lens dropouts, we often focus on alleviating certain risk factors that may interfere with successful contact lens wear. These factors may present in different combinations in particular patient subpopulations—for example, in presbyopes we must not only address the decreased quality of the tear film, but also provide them with multiple points of focus. 

While challenging, successfully integrating each factor into the approach is no less important. The following three cases demonstrate several non-traditional options to help presbyopic patients function better.

Case 1: The Multifocal Gas Permeable Wearer
A 54-year-old patient came in to our office for the first time. He was wearing single vision rigid gas permeable (RGP) contact lenses and was using reading glasses over his RGPs to see things at near. He reported this method was cumbersome because he even had to put the reading glasses on to see his smartphone, which he looked at several times an hour. He said that he had tried monovision contacts in the past, but was unsuccessful, and was wondering if simply transitioning to glasses full time with a progressive addition lens would be a better, more convenient option for him. 

We discussed vision correction options, including multifocal contact lenses, and the patient elected to proceed with the fitting. 

He was fit with a front surface aspheric multifocal RGP with the distance optics located in the center of the lens progressing to the near optics towards the periphery. The initial lens fit well and gave the patient excellent distance and near vision; however, the patient complained that his distance vision in low light levels, specifically night driving, was significantly compromised compared to his previous single vision RGPs. This decrease in distance vision was attributed to pupil dilation: in scotopic conditions, the patient was asked to cover one eye and look at the 20/25 line with the other while wearing his multifocal lenses. The patient noted during this task that his visual acuity was worse, but with a light shone into his non-viewing eye, he reported an improvement in visual acuity.

We ordered new multifocal RGPs (GoldenEye AFM, Valley Contax) with a slightly larger central distance optic zone in the center of the lens in an attempt to reduce the effects of pupil dilation on his distance vision in the evening. The lenses were dispensed and the patient noted an immediate improvement in his night driving. However, because access to the near optics had been moved further out in the lens with the increased diameter of the distance optics in the center of the lens, the patient had a harder time with his near vision. So, while we had improved one problem, we had also created another one.

We discussed the advantages and limitations to both lens designs, and the patient said that he was still considering moving to glasses full time in either case. So, we came up with an additional option: the use of topical brimonidine in a non-FDA approved manner to help control pupil size in the evening. Topical brimonidine is available commercially in concentrations of 0.1%, 0.15% and 0.2%. 

We provided the patient with a sample of 0.1% brimonidine to instill 15 minutes prior to night driving. Note, some studies show drops should be instilled 30 minutes prior to night driving for maximum effect.1 Because the RGP material doesn’t absorb the medication, the drops can be used while the lenses are being worn. 

The patient reported experiencing a remarkable difference after the first night of use and affirmed that he wanted to proceed with the drops. He uses the drops more frequently in the winter due to the significantly shorter days and more rarely in the spring, summer and fall because of the increased daylight hours in northwest Ohio. 

Case 2: The Weekend Warrior
A 49-year-old male who is a computer programmer wears a monthly disposable multifocal contact lens. He loves the comfort of the lens and understands the balance between his distance and near vision that is required when wearing multifocals. He particularly enjoys the ability to work well at his computer screen while having functional distance vision. However, he recently started playing golf and while he loves his contacts for day-to-day work, he reported finding them difficult to wear while golfing because he has a hard time following the ball. For this reason, he has been wearing his glasses while playing golf.

We discussed single vision contact lens options and he conveyed that he didn’t like the idea of having difficulty seeing the scorecard with single vision lenses. We discussed other options, including sunglasses with a low set bifocal, but he expressed that he does not like to golf while wearing sunglasses. So, we fit this patient with a single vision lens set for his best corrected distance prescription for his dominant eye—in this case, the right eye—and we corrected his non-dominant eye with a multifocal lens in the lowest add power available. 

The patient was fit into a daily disposable lens and reported he liked the flexibility of having this as an option for critical distant-dependent activities such as golf. He ordered a 90-pack of daily disposable lenses for each eye.

Case 3: Monovision—Don’t Rule It Out
A 53-year-old female is a +2.00D presbyope and has a distance refractive correction of -2.00D in both the right and left eye. She wears reading glasses over her distance vision contact lenses in order to see up close, and expressed interest in contact lens options that would reduce her dependence on reading glasses. Of note was a history of significant seasonal allergies that present in the spring and fall; she was also developing a mild case of contact lens-induced dry eye.

We decided to fit her with multifocal contact lenses; however, after trying two separate designs, she felt that her distance vision wasn’t acceptable in either case. We discussed monovision lenses as another option and the patient elected to try it. Because her right eye was dominant, the lens was removed from the left eye to leave her -2.00D myopic eye uncorrected. She reported that while her distance vision wasn’t as good as with two single vision lenses in her eyes, she felt her vision was clearer than with either of the other two multifocal lens designs she tried. 

Initially, she wore a monthly disposable lens, but she experienced comfort issues during the first allergy season after she began wearing this lens, so she was refit into a daily disposable lens instead. She reported feeling much more comfortable throughout the day with the daily disposable lens than with monthly replacement, but even with proper topical anti-allergy therapy, she found it difficult to wear her lenses during allergy season.

We discussed orthokeratology as an alternative option and the patient was successfully fit with an ortho-k lens to be worn in her right eye overnight. She reported experiencing excellent distance vision during the day, without the comfort issues she had while wearing her contact lenses. 

All three of these examples represent a challenging scenario in which a presbyope was prevented from dropping out of contact lens wear in a non-traditional manner. While not always the case, thinking outside the box to help this patient population function better in their contact lenses will prevent dissatisfaction and derail contact lens dropouts, thus ultimately helping your practice.   

1. McDonald JE, El-Moatassem Kotb AM, Decker BB. Effect of brimonidine tartrate ophthalmic solution 0.2% on pupil size in normal eyes under different luminance conditions. J Cataract Refract Surg. 2001 Apr:27(4):560-4.



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