Article Date: 2/1/2008

The Presbyopes Are Coming!

The Presbyopes Are Coming!

The entire baby boom generation has reached middle age. Here's how to turn this challenge into an opportunity.

BY JAMES E. WINNICK, O.D.

We've all heard the baby boomer statistics many times. According to the National Center for Health Statistics, one-third of the U.S. population will be between 40 and 59 years old by the year 2010. With this trend comes the demand — and the opportunity — to meet the visual needs of the over-40 population.

Fortunately, the contact lens industry took note of this trend and has developed innovative new products to answer the challenge. Advances in manufacturing, materials and designs have given us many more options for our presbyopic patients. Here and in the pages that follow, Jason Miller, O.D., M.B.A., Earl Sandler, O.D., and I describe typical patient encounters and the products we use to satisfy our patients' needs and exceed their expectations.

Recognize This Patient?

You probably see a patient like Elizabeth almost every day. At age 50, she's raised her children and now helps manage the family business. She enjoys gardening and traveling. Her general and ocular health are unremarkable. Her only medication is hormone replacement therapy.

When I asked [Elizabeth] if she'd ever considered multifocal contact lenses, her surprised response was, "I didn't even know they existed. Nobody ever gave me that option before."

Elizabeth always had good distance vision, but she started using over-the-counter (OTC) readers about 8 years ago. Her previous doctor prescribed progressive addition lenses (PALs) after Elizabeth noticed the quality of her near vision decreasing. However, she doesn't like to wear eyeglasses full time, so she tends to use her PALs as glorified reading glasses. When I asked if she'd ever considered multifocal contact lenses, her surprised response was, "I didn't even know they existed. Nobody ever gave me that option before."

Unfortunately, this scenario isn't unusual. Regardless of their history, presbyopic patients need to know about all of their options, including multifocal contact lenses. I continued my discussion with Elizabeth, keeping in mind the keys to multifocal contact lens success.

Confirm Motivation

The first key to success is motivation. This includes the patient's willingness to accept the time and cost of a proper multifocal fitting, as well as motivation to make contact lenses part of his or her daily routine. This is particularly important for patients who've never worn contact lenses. Remember that motivation has to come from the patient, not you.

Set Proper Expectations

I've learned that presbyopes are a demanding group. They know what they want, and they expect results. However, they also understand the need for compromise to achieve a goal. As their doctor, you must describe the pros and cons of any potential compromises they may face to achieve their goal of spectacles-free vision.

Unlike presbyopia-correcting eyeglasses, where patients look through one power at a time, soft multifocal contact lenses are designed to provide simultaneous vision. Patients need to understand this difference. Emmetropes and low ametropes, especially, need to know that multifocal contact lenses will improve their near vision, but their distance vision with them may not be as crisp as their uncorrected distance vision.

I like to use the analogy of a screen door to explain this. If you're inside looking through a screen door at the kids playing in the yard, you can see everything that's happening. However, if you open the door, you see everything more clearly. Patients seem to understand this analogy; and it's very important to explain it beforethey leave your office with their first pair of lenses.

Have a Full Armamentarium

Now that you've prepared a motivated patient with proper expectations, what lens design do you start with? Having a large practice, I'm fortunate to have just about every soft and gas permeable lens design available to me. I almost always start with a CooperVision product. In my experience, I can meet most patients' prescription requirements with Biomedics EP, Proclear Multifocal, Proclear Multifocal XR or Proclear Multifocal Toric lenses. I can choose from multiple base curves, ensuring stable lenses even with difficult-to-fit corneas. All of CooperVision's multifocals are made with PC Hydrogel material, so they offer excellent ocular health and extended comfort compared to other hydrogel materials.

I started Elizabeth's fitting with the Proclear Multifocal system. This system's design — one lens for the dominant eye (center distance, intermediate and near in periphery) and one lens for the nondominant eye (center near, intermediate and distance in periphery) — is one of the reasons why it works well for so many patients (Fig. 1).

Each lens incorporates distance, intermediate and near vision. You can alter the distance or add power of either the distance or near lens independently to meet your patient's specific visual needs. This allows for subtle but powerful changes that affect the depth of field for the patient.

Prescribing for Elizabeth

When fitting the Proclear Multifocal, I first establish eye dominance, using the "hole in hand" and the "plus blur tolerance" techniques. Elizabeth is right eye dominant.

Next, I use my manifest refraction to choose the first diagnostic lenses. Elizabeth's manifest refraction was:
OD: +0.50 –0.25 × 90 OS: +0.50 –0.25 × 90
Add +2.00

I chose the following first diagnostic lenses:

Proclear Multifocal 8.7/14.4
OD: +0.50/+2.00 D Lens (dominant eye)
OS: +0.50/+2.00 N Lens (non-dominant eye)

This combination gave the following initial visual acuities:
OD: 20/25+2 OS: 20/40–1
OU: 20/25+2 Near OU: J2+

After receiving instruction on lens care, application and removal, Elizabeth returned home to wear the diagnostic lenses in the real world. At her 1-week and 1-month progress visits, she was very happy with her new visual freedom. Over time and with no lens parameter changes, her vision improved to:
OD: 20/20–2 OS: 20/40
OU: 20/20–1 Near OU: J1

Elizabeth reported good overall visual performance at distance and near throughout the day. She carried a pair of +1.00 OTC readers in her purse to improve her reading as needed in dark environments, such as restaurants. She still can't believe that no one offered her this option before, and she has referred several patients to my practice for multifocal consultations.

New Powerful Tools

Manufacturers like CooperVision are providing new, powerful tools that will help us meet the demands of most of our presbyopic patients. By educating your patients, following a fitting protocol and learning techniques for problem-solving, you and your patients will benefit from this rewarding experience.


Dr. Winnick has a private group practice in Livermore, Calif. He is a diplomate in the Cornea & Contact Lens Section of the American Academy of Optometry.

10 Tips for Streamlining Your Fitting Process

Use these clinical pearls for successful fitting and follow-up of Proclear Multifocal patients:
  1. Establish proper motivation and realistic expectations.
  2. Understand the patient's visual needs, particularly occupational demands and recreational activities.
  3. Have patients prioritize their distance, intermediate and near tasks to guide your recommendation.
  4. Start with a fresh, accurate manifest refraction.
  5. Start with new topography, keratometry and iris diameter measurements to predict potential fitting challenges.
  6. Perform all testing with normal room illumination. Simulate real world surroundings and observe how patients use their visual system.
  7. Use individual diagnostic lenses or flippers to over-refract. Avoid the phoropter unless it's needed to determine cylinder, because it creates an artificial viewing environment.
  8. Be sure to over-refract monocularly if the expected binocular acuity is not achieved. Since both the D lens and the N lens incorporate distance, intermediate and near vision, a problem with distance vision, for example, is not necessarily due to the D lens. The only way to determine this is to check vision monocularly.
  9. Make only small diagnostic lens power changes and have patients experience the changes in the real world. The exam room is an artificial environment and visual perception with these lenses changes over time.
  10. Charge appropriately for your time and skills. These are rarely one-visit fittings.


Optometric Management, Issue: February 2008