The Switch to Multifocals: Simple Fitting, Seamless Transition
By Bob Davis, OD
My philosophy over 40 years has always been to lead with contact lenses—an approach that has made us one of the largest contact lens practices in the state of Florida. With the multifocal lens technologies available today, I can continue to follow that approach as patients get older. Like other contact lens patients, they can see more naturally and enjoy activities, and multifocal lenses offer the same benefits to the practice, such as more frequent visits, more spending, and more word-of-mouth referrals.
Multifocal contacts are a good choice for many presbyopic patients, and a seamless transition for those who have long worn monofocal lenses. When we put contact lenses first, educate patients, and deliver comfort and clear vision, we have a patient for life.
With the range of comfortable multifocal lenses available today offering very good visual results, we’re able to please people we couldn’t please in the past and fit patients well into their 60s and beyond. In my practice, I have patients of all ages and see many of them through years of wearing contact lenses. Their transition to multifocal lenses is an easy one, particularly if they continue with the same wear schedule and brand, which will have the same feel. That said, I also suggest multifocal lenses to new patients of any age who are good candidates. The process is very straightforward, with some nuances.
- Start the discussion. In the chair, I tell patients that they’re good candidates for multifocal contact lenses and ask if they’re interested. More than 50% of my patients want to try them. (If I said nothing and relied on them to start that conversation, that number would be much lower.) I explain the fitting process and set the expectation that they will see clearly at distance and near, and we’ll hold their hand as they get used to the lenses. In my experience, 95% of patients who try this generation of multifocal contact lenses find the lenses are comfortable and meet their visual needs.
I recently fit a patient with multifocal lenses, and he raved about them to a friend at his gym. His friend was unhappily wearing a near monofocal lens and a distance lens, and he was dismayed that his doctor never mentioned multifocal lenses. I want patients to hear about multifocals from me, not from a friend.
- Get an accurate refraction. The refraction for multifocals is somewhat different than what we do for progressive eyeglasses, particularly with respect to the add power, which I find can usually be lower with multifocal lenses. For example, a common result for someone wearing a 2.25 add in glasses is 1.75 or 2.00 for multifocals. To determine the add, I put patients behind the phoropter and continuine to add plus at near point until they tell me they can see the J2 line.
I use the red-green test to make sure I’m not over-minusing the patient. I also test for sensory dominance rather than functional/sighting dominance because it simulates the act of creating disparity. In simple terms, we are intentionally causing positive blur to each eye and determining which eye has the greater sensitivity to this blur (the dominant eye). This shows how choosing the wrong dominant eye would cause the patient to have poor distance vision. Other tips: make sure to use a current refraction, and use ambient lighting rather than a darkened room to see the patient’s real-life vision.
- Choose the right lens. I use many brands of multifocal lenses, which gives me the flexibility to pick the lens that I think will be best for each case. The Acuvue Oasys Multifocal Lens with Pupil Optimized Design, which came out earlier this year, is my go-to lens because its aspheric center and spherical peripheral area help the lens center very well, and the Oasys lens is known for comfort. The 2-week lens has 183 different optic zone sizes to match the patient’s pupil size, depending on age and refractive error, and optimize vision correction. I also use Alcon Dailies and Alcon’s monthly lens, Air Optix. The lenses take a bit more time to fit, but they work well for my patients. The Ultra lens from Bausch + Lomb and the CooperVision Biofinity multifocal toric allow me to treat presbyopic patients with astigmatism.
- Use the fitting guide. No matter which multifocal lens you choose, each lens has a unique design and a different fit, and each has its own guide that does all the work for you. For example, although the Oasys lens has 183 different optic zone sizes, it is very easy to fit and requires minimal chair time compared to other multifocals. We enter the patient’s prescription, age, and add power into the fitting guide and find the right lens—it’s no harder than fitting an astigmatic lens.
- Fit diagnostic lenses. I place a pair of diagnostic multifocal lenses on the eye, let them settle for a few minutes, and then ask patients to take out their cell phones, so I can see real-world use. If they can see the phone nicely, I’m one step ahead. Next, I have them read the chart binocularly, from 20/30 to 20/20. If they’re comfortable and seeing well, I send them home in a pair of diagnostic lenses (5-10 single-use pairs or 1 pair of reusable lenses). I see them again virtually or in-person in a week to determine if they’re ready for the prescription. If an engineer wants to tweak the prescription, we can do so using the fitting guide to select a second pair of diagnostic lenses.
Give Patients More Natural Vision
Ultimately, contact lenses not only alleviate patients of some of the hassles of eyeglasses, but they also give them the freedom to use their eyes more naturally. Beyond the basic advantages of contact lenses, I ask patients what they’re looking for in a multifocal lens. Do they want to see the computer? Feel more comfortable driving at night? Once patients try diagnostic lenses, I ask if the lenses meet their goals. If they do, we’re home free. The lenses are accomplishing the important task of providing comfortable real-world visual clarity.
Bob Davis, OD, heads a team of optometrists and ophthalmologists at The Eye Center in Pembroke Pines, Florida, and serves as team doctor for the Miami Dolphins, Inter Miami CF and multiple college and university teams. He lectures internationally on contact lenses and ocular disease. He is a consultant for J&J Vision.