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How to succeed with multifocal contact lenses

Course code: C-15605 O/CL
Dr Cameron Hudson BSc (Hons), PhD MCOptom The prescribing of first generation multifocal contact lenses a decade ago was often a frustrating process, yielding low success rates amongst patients. Even today, many practitioners are reluctant to fit multifocal lenses despite significant improvements in materials, designs and parameter ranges, which provide
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Figure 1 Schematic to indicate the generic design principle of a centre near multifocal contact lens
throughout the UK and Europe have begun to show favour towards multifocal lenses.6 is growing at a rate of approximately 5,000 new wearers per quarter.6 Despite these new fitting behaviours there is still a long way to go before multifocal contact lenses to correct presbyopia becomes the norm. In the UK alone, this segment of the industry

better visual outcomes and more satisfied patients. This article reviews the
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current status of multifocal contact lenses and guides practitioners on how to reliably achieve high levels of success and satisfaction amongst wearers.
In the UK, the presbyopic population A huge disparity exists between the desire amongst presbyopes

represents the largest growing, yet least common

developed, segment of the contact lens for reduced spectacle dependence and market.3 Contact lens options available the actual use of contact lenses in this for presbyopes include multifocal contact population.4 As a result, manufacturers lenses, monovision, or a combination of have applied a range of optical principles single vision distance contact lenses with to produce different multifocal contact reading spectacles. In light of the potential lens corrections, which can be applied to both increase the number of patients to suit the individual eye or functional who can benefit from contact lenses and to requirement, of the patient. Similarly, generate additional revenue, it is interesting contact lens materials have evolved to to consider the lingering factors that prevent improve oxygen transmission (eg, silicone practitioners from tackling the presbyopic hydrogels), reduce wetting angles, and challenge. For many practitioners, it resist deposition and dehydration, in may be that a previous bad experience order to minimise the impact of dry eye. limits their enthusiasm for multifocal The visual environment of the typical lenses. For others, it may be a fear of presbyope has also evolved at a rapid failure to achieve promised outcomes, or pace, with less emphasis on near work at an uncertainty regarding what to expect a relatively close distance (40cm or closer) over the short-, medium- and long-term. in down gaze and greater emphasis on Ever-increasingly, presbyopes enjoy better visual display units (VDU) and mobile health and increased vitality during the phones at a range of distances from middle years of life. The range of activities 40cm (and closer) to 80cm (and beyond). carried out and attitudes towards physical There is a common view amongst appearance have changed substantially over practitioners that correcting presbyopia the past 20 years. These factors, along with with monovision requires less chair time other social trends, are likely to make visual and yields higher success rates compared correction options that are uninhibiting with multifocal contact lenses. However,
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What are the principles of current multifocal contact lenses?

The latest generation of soft multifocal contact lenses are based on the principle of simultaneous vision whereby multiple powers are placed within the pupil at the same time. Therefore, light both from the distant and near portions of the lens is focused onto the retina simultaneously. This description, however, tends to overcomplicate the reality, which is that when a patient views a distant object the image quality will be affected by the area of relative positive power (near zone). The reverse is true when viewing near objects. Thus, for any given simultaneous lens design, the amount to which the image is affected depends on a careful balance of the following factors: Relative size of the distance and near optic zones Blending, or non-blending, of the distance/near zone junction Rate of blending of the distance/near zone junction Relative position of the near optic zone (centre-near vs. centre-distance and/or concentric design)

and burden-free increasingly attractive. over the past two years, practitioners

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Pupil size and ambient light Near add power Aspheric optics Centration and stability of the lens on the eye The performance and advantages of

clear vision (p<0.05) than monovision.7 Amongst early presbyopes, Woods et al.2 found superior subjective performance with the Air Optix Aqua Multifocal lens when compared with monovision. Their most notable findings were the improvement in subjective ability to change focus (p<0.001), watch television (p<0.001) and drive during the day (p<0.05) and at night (p<0.001) whilst wearing the multifocal lenses. Overall satisfaction with the lenses was also significantly better with multifocal than monovision correction (p<0.01), leading the investigators to conclude that incorporation of subjective vision metrics into the fitting assessment improves the predictability of success.
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emerging presbyopes. For many of these individuals, contact lenses have been the refractive correction of choice. They are also far more aware of contact lenses and have far more varied visual needs than established presbyopes. Unlike baby boomers, these individuals are more likely to embrace technology eg, using the Internet and mobile phones. Accordingly, these individuals are more likely to be motivated to preserve their functional visual ability as well as their appearance. Historically many practitioners may resist correcting presbyopia until as late a stage as possible. However, the key to multifocal contact lens success is tackling the emerging presbyopic changes before becoming overtly manifest. The ideal time is when patients report that their ability to change focus is reducing/slowing down.1 Irrespective of the patients age, good candidates for multifocal contact lenses possess some level of dissatisfaction with their current correction in at least part of their day-to-day life. Most importantly, practitioners must first identify, and then seek to quantify, this level of dissatisfaction, as it will form the benchmark against which all alternative corrections are compared.

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one lens type over another cannot be simply attributed to, for example, whether a lens is centre distance vs. centre near or whether a lens has a higher or lower add power. There are two commercially available centre-near silicone hydrogel multifocal contact lenses with aspheric optics (Figure 1), namely the PureVision

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Multi-Focal (Bausch & Lomb) and the Air Optix Aqua Multifocal (CIBA Vision). Such lenses achieve a different balance between distance and near vision due to differences in the specific lens design. For example, the Acuvue Oasys for presbyopia (Johnson and Johnson Vision Care) ring offer uses design, control a centre-near which of to is the concentric believed to

A broad conclusion that can be drawn from the literature is that multifocal contact lenses are capable of providing a superior level of subjective vision, whilst monovision wearers obtain relative sparing of near VA under high and low contrast conditions.
2,7-11

distance/near ambient light.

One proposed reason for

balance

according

the subjective preference of multifocal lenses is the minimal disruption to binocular vision due to preservation of stereoacuity and range of near vision.7,10,12

What do patients think about multifocal contact lenses?

Several studies have investigated the objective and subjective visual performance of multifocal contact lenses, specifically by comparing (VA) them to monovision. sensitivity Objective assessments included visual acuity and contrast (CS)7,8 whilst subjective assessments have centred on intent to purchase, satisfaction, and questionnaire of responses.2,9-11 and the When comparing the objective visual performance PureVision monovision Multi-Focal lens, Gupta

Which patients are best suited to multifocal contact lenses?

The success of multifocal contact lenses is largely dependent upon identifying candidates who stand to gain tangible benefits from being less dependent on their spectacles. Presbyopes aged between 50 and 64 years are commonly referred to as baby boomers, few of whom entered into contact lens wear at a young age. Thus many of this group may not possess the motivation to commence wearing contact lenses. This is not to say, however, that they cannot succeed if given the opportunity. The greatest potential for success lies with those individuals within generation X. These are people born after the postworld war II baby boom (typically between 1960-1970) and are the current

Communicating effectively and establishing realistic expectations

Failure with multifocal contact lenses is often due to poor communication rather than the lens technology. The practitioners ability to establish realistic expectations

et al.7 found significant differences in the performance of the two modalities. Most whilst notable wearing was the improvement (p<0.05), in high contrast distance and near VA monovision although they also found that the low addition multifocal lenses achieved better stereoacuity (p<0.01) and near range of

Figure 2 Binocular over-refraction using handheld trial lenses

at the initial fitting stage is commonly cited by lens manufacturers as one of the key milestones in achieving success. However, this should not constitute an opportunity for the practitioner to repudiate all responsibility for what is about to happen. The practitioners choice of language can have a large impact on the success/uptake of multifocal lenses once fitted. Describing the visual outcomes with terms such as slightly compromised vision or vision that is not as good as spectacles does not provide the patient with either a positive or necessarily realistic outlook on what might be achieved. It is far better to describe the visual outcomes using terms such as functional all-round vision or achieving a better balance between distance and near vision. In the broadest terms, practitioners should describe what the patient stands to gain rather than what they stand to lose (Table 1). This approach will improve the likelihood of success and offer patients a compelling reason to proceed; the approach should be akin to recommending varifocal spectacles to a new wearer by being realistic about expectations and having a positive outlook.

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Figure 3 Example case summary of a presbyopic multifocal contact lens fitting

chair time. In the same way that not all patients will adapt to varifocal spectacles, it would be unrealistic to expect every patient to adapt to multifocal contact lenses. However, by following the manufacturers fitting guidelines, practitioners
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in two stages; short-term (20-30 minutes) an ideal situation a practitioner would be able to assess the best possible visual performance achievable shortly after initial lens application, giving an indication of success or failure, but in practice this is not the case. Short-term adaptation A period of 20-30 minutes is usually required for the lenses to stabilise and for any initial physiological reaction (eg, lacrimation) to pass. During this time is it advisable that the patient leaves the consulting room and be given opportunity to perform a mixture of visual tasks eg, looking into the distance, reading the time on their watch, viewing their mobile phone, alternating between distance and near vision tasks etc. in a real world environment. Upon their return, patients should be encouraged to subjectively score their distance and near vision eg, on a scale of 1-10, to provide the practitioner with a relative indication of their satisfaction. This is the recommended clinical standard2 and provides the practitioner with a benchmark to work against in order to obtain the optimal balance of distance and near vision when refining the lens power. Furthermore, subjective grading of vision may be sensitive to small changes in lens power that cannot be identified using objective methods; equally, it has been shown that

can The are

expect success rates of 72-79%. manufacturers fitting

guidelines

derived from experience gained during lens development, often involving hundreds, if not thousands, of patients. Following
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the manufacturers fitting guidelines also serves as an important indicator of the point at which no further adjustments to lens power should be made, for example, in the relatively small percentage of instances where the patient doesnt achieve the visual outcome they require.

How do I know which lens power to select initially?

There is no one size fits all approach to multifocal contact lenses. Each lens has its own manufacturer approved set of fitting guidelines, which should be followed for every new patient. Following the manufacturers guidelines will increase the rate of success and reduce unnecessary

Adaptation
Unlike most other types of contact lenses, multifocal lenses require a period of adaptation in order for the practitioner to obtain a true sense of the visual performance.13 Adaptation is best thought of

Words/phrases to avoid
Compromise Trade-off Not perfect Not as good as spectacles Loss of crispness/slightly hazy/foggy

Words/phrases to use
Functional vision Balance between distance and near Re-prioritisation of vision Reduced dependence on reading glasses Likely to use your reading glasses 60-90% less

Table 1 Guidance on communication when discussing multifocal contact lenses

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and long-term (1 week and beyond). In

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where objective vision appears reduced or improved there may be no correlation with a patients subjective opinion.13 Long-term adaptation As for first time varifocal spectacle wearers,

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patients who are new to multifocal contact lenses commonly require a longer period of adaptation to get used to their new vision. This is where the real trial of the lens begins. It is important to fulfil this part of the lens fitting process as subjective performance of the lenses can change significantly from the initial findings.13 near vision is not close to an acceptable level consider adding a small amount of positive power to the distance component in the non-dominant eye (eg, +0.50D).1 the overwhelming majority (78%) chose to use both to combine the benefits of each.15

Figure 4 Example case summary of an emerging presbyopic multifocal contact lens fitting

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Summary
Multifocal contact lenses have evolved significantly over the past decade and increasingly practitioners are fitting them. However, the presbyopic population remains the least developed segment of the contact lens market and thus presents a very real opportunity to the industry. Emerging presbyopes stand to gain the most from multifocal contact lenses, as they have greater familiarity with contact lenses and possess a wider variety of visual requirements than more established presbyopes. Adopting a fitting strategy that conforms to the manufacturers fitting guidelines will improve the success rate and reduce unnecessary chair time. Practitioner communication, particularly during the pre-fitting discussion, also plays a significant role in the outcome achieved. It takes practice to achieve high and reliable success rates with multifocal lenses. Practitioners should seek guidance from experienced peers or consult with contact lens manufacturers for fitting guidance and education.

Improving outcomes
Guidance note 1 It is important to check that the distance vision is optimised. In general, this process involves measuring the objective VA and subjective opinion binocularly; add as much plus power to the distance prescription as the patient will accept, up to the point where further plus power causes a reduction in VA.14 This will enable the add power to be kept to a minimum. The process should be done in good illumination. Begin with the dominant eye and increase plus power in 0.25D steps. Repeat this process for the non-dominant eye. Use handheld trial lenses to carry out the over-refraction and avoid using a phoropter or trial frame (Figure 2). If minus lenses are required to improve distance vision act cautiously. Only reduce the plus power if there is a distinct improvement in subjective vision. Practitioners should be wary of chasing contrast improvements when overrefracting with minus powered lenses. Guidance note 2 Only when the distance power is optimised should near vision be assessed, since small changes to the distance power can have a profound effect on near vision.
1,14

Guidance note 3 Follow the manufacturers fitting guidelines, even if a patient isnt achieving high scores subjectively. Provided that the patient is willing and that they objectively achieve a standard of vision that from a medico-legal perspective is deemed acceptable, encourage an extended trial (4-7 days) and re-assess the visual performance after this time. If, at the end of the extended trial, there are no further adjustments to the lens power, formulate a succinct way to summarise what you have achieved (Figures 3 and 4). This will allow the patient to formulate in their own mind about whether the vision achieved justifies the lenses being dispensed.

Which method of correction do presbyopes prefer?

Given that there is no single correction that suits all presbyopes for all activities it is important that clinicians consider all options to satisfy an individuals lifestyle and visual demands. This may involve combining the benefits of several correction options in order that the relative advantages and disadvantages can be maximised and minimised, respectively. It has been demonstrated that when spectacle-wearing presbyopes are given the opportunity to try multifocal contact lenses,

About the author

Dr Cameron Hudson is the professional services manager for CIBA Vision, UK.

References
See http://www.optometry.co.uk/clinical/ index. Click on the article title and then download references

Aim to keep the near add

power as low as possible. If subjective

Module questions
Course code: C-15561 O

PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight on March 14 2011 - You will be unable to submit exams after this date answers to the module will be published on www.optometry.co.uk. CET points for these exams will be uploaded to Vantage on March 21 2011.

Course code: C-15605 O/CL

1. Which age group of patients is LEAST represented within the contact lens industry? a. 20-27 years b. 28-35 years c. 35-45 years d. 45 years and above 2. The performance of a simultaneous design multifocal contact lens is dependent upon which of the following factors? a. Relative size of the distance and near optic zones b. Relative position of the near optic zones on the lens c. Pupil size and ambient light d. All of the above 3. According to Woods et al. which of the following statements reflects patient opinion on multifocal contact lenses? a. Patients generally prefer monovision over multifocal contact lenses b. Patients generally prefer multifocal contact lenses over monovision c. Multifocal contact lenses and monovision are liked equally d. Neither multifocal contact lenses nor monovision are liked by patients 4. Which of the following terms would be MOST appropriate to use when describing the visual outcome with multifocal contact lenses? a. They provide a slight loss of crispness b. They provide functional vision for distance and near c. They provide a compromise between distance and near d. They provide vision which is not as clear as with spectacles 5. When refining the multifocal contact lens power, practitioners should: a. Aim to provide the most plus distance refraction b. Preferably use a phoropter c. Assess vision monocularly d. Assess vision in low room illumination 6. When given the opportunity to experience multifocal contact lenses, what proportion of varifocal wearers preferred to combine the benefits of both spectacles and contact lenses? a. 35% b. 78% c. 54% d. 63%

1. Which of the following statements is FALSE? a) Currently an estimated 700,000 people in the UK have dementia b) Two thirds of people with dementia have Alzheimers disease c) 90% of people with Alzheimers disease have visual function decline d) Visual system disturbances can pre-date manifestations of dementia 2. Which of the following is a typical visual symptom of Alzheimers disease? a) Difficulty with reading at near b) Blurred vision, not due to refractive error or eye disease c) Difficulty picking out objects in a group d) All of the above 3. Alzheimers disease does NOT affect which of the following? a) Tear ducts b) Crystalline lens c) Optic nerve d) Retina 4. Motion processing is NOT associated with which of the following? a) Dysfunction of magno- and konio-cellular processing b) Dysfunction of form identification c) Difficulty interpreting patterns d) Mental confusions 5. Which of the following statements about assessing visual function in Alzheimers disease is FALSE? a) The Vistech chart reveals loss of high spatial frequency contrast sensitivity b) Frequency doubling technology is preferred for testing visual fields c) The City University test is preferred for assessing colour vision d) Threshold visual fields are more suitable for monitoring co-morbidity with glaucoma 6. Which of the following conditions requires an individual possessing a driving licence to notify the DVLA? a) Alzheimers disease b) Parkinsons disease c) Glaucoma d) All of the above

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