Article Date: 2/1/2010

Share The Love
contact lens focus

Share The Love

Create success in your practice by fitting multifocal contact lenses

RHONDA ROBINSON, O.D.

I love you doc!”

What if a multifocal contact lens could give you that kind of response from your patients?

In this article, I will discuss the benefits of prescribing multifocal contact lenses and describe the Bausch & Lomb Multi-Focal Fitting Assistant, or MFA, a tool which helped me jump start the fitting process in my practice.

Multifocal lenses provide excellent binocular vision for presbyopia, better patient retention, increased patient referrals, and increased profitability. But the most important reason to fit them is that patients love the way they see.

The opportunities with multifocal lenses are tremendous. There are almost 40 million contact lens wearers, and studies tell us 92% want to stay in contact lenses as they become presbyopic. So, let's get started and learn to create success through the fitting process.

Speak the “language”

When introducing multifocal contact lenses, it's important to speak the patient's “language.” For example, say “night vision” to truck drivers, “lens design” and “optics” to engineers, and “no restrictions of width of gaze for spreadsheets” to accountants and draftsmen. Discuss common problems inherent with spectacle wear that you can correct with MF CLs. Presbyopes love not having to look down through a “sweet spot” to read. The ability to see distance, near, and in between in all directions of gaze is an advantage of these CLs over glasses. Also, use more appealing descriptor words, such as “balanced” vision rather than “compromised” vision.

Fewer trial lens changes

The Multi-Focal Fitting Assistant helps to reduce chair time by allowing the O.D. to make fewer trial lens changes. It yields an “individualized” diagnostic lens by accounting for the patient's spectacle prescription, near add, dominant eye, age, greatest visual demand (near, intermediate, or distance), typical lighting and past experience with contact lenses. In my office, the process takes about 30 seconds on average. I've used it in a variety of settings: 1) working with the patient in the exam lane, 2) having my technician determine initial lenses using my refractive data, and 3) as a screening device to allow a tentative patient to try the lens before taking up chair time.

The Bausch & Lomb Multi-Focal Fitting Assistant (www.presbyopesinyourpractice.com) asks eight questions to calculate the recommended starting prescription.

One key fitting tip: Give the patient enough time to adapt to the MFA's selection. I compare this to progressive spectacles. Frequently, patients are told that adjusting to their new progressive spectacles may take a few days or weeks. Most patients adapt and do not require a change in their glasses. We wouldn't consider a re-make until at least two to four weeks of “sensory adaptation.” Most multifocal contact lens patients understand that adapting can take time.

Resist evaluating the lens performance until the patient has had the lenses on for at least 15 minutes. If the acuity is acceptable but not yet perfect, instruct the patient to go home, wear them, adapt to them (with MF lenses, capability comes before clarity). Any refinements (tweaking), if necessary, will be accomplished at their follow-up visit. It's not uncommon for a patient with 20/25 acuity who complains of a bit of ghosting or intermittent blur to return with 20/20 acuity at their checkup visit. Be confident that the patient has the correct prescription and will adapt in time. A positive attitude increases success.

Following up

If there are distance vision complaints. Before adding minus or lowering the add power to the patient's dominant eye, ensure that adding plus blurs the distance image. Take the patient into natural light and instruct them to look out a window or across the room at a distant object, then add a +0.25D loose lens to the dominant eye to see if distance is more blurred. This accomplishes two things. First, if distance is indeed more blurry, you can be confident that you are at your endpoint for distance. Second, sometimes adding a bit of plus will make distance vision better, which will obviously improve near. If you jump to adding minus first, distance will not improve and you may think the patient is not an able candidate for multifocal contact lenses.

Next, do the same for the non-dominant eye independently of the dominant eye and lastly, together. However, always keep both eyes open and check visual acuity binocularly. If distance is not improved with plus, then try a bit more minus over the dominant eye or lower the add power. However, before changing the trial lenses, use the loose lenses to simulate the change at near. We don't want to sacrifice near vision to get more distance if we can help it.

If there are near complaints. Adding plus will certainly improve near vision, but how much plus can the patient accept before distance vision is affected? In this instance, take the patient out of the exam lane into the hall or an area with normal lighting to view distance. Add a +0.25D loose lens to the non-dominant eye to see if distance is affected. If no blur is noticed, then with the +0.25D in place over the non-dominant eye, add another +0.25D loose lens to the dominant eye. If distance is still o.k., continue to add more plus until distance is blurred. Now you know how much plus you can add. If adding plus to either in the non-dominant or dominant eye creates distance blur, then try increasing the add power, first to the non-dominant eye. If this blurs distance, you must have the conversation with your patient about what part of “balanced vision” is most important to them. Great distance and intermediate vision with a weak pair of readers is better than wearing readers for everything. Most patients understand the limitations of their spectacle progressive lenses, so it should be easy to discuss the limits of multifocal contact lenses.

A case in point

A 48-year-old mechanic presented complaining that he could “not do his job with his progressive glasses.” He often has to see at near and intermediate in the upward gaze underneath a car. I introduced the idea of multifocal contact lenses. He had never considered contact lenses but was willing to try them.

Spectacle prescription:
OD +0.75D sphere (dominant eye)
OS +1.00D sphere
Add +1.75D

Diagnostic lenses (using the MFA):
OD +0.50D Sphere (Bausch & Lomb)
OS +0.75D High Add Multi-focal (Bausch & Lomb)

After 20 minutes of adaptation, the patient saw distance 20/20 (OU) and near 20/25(OU).

Two weeks later, he provided his assessment: “I love you, doc!” He said he was now able to “do his job” and loves the independence from glasses. He had no distance complaints, but acknowledged reading could be better. So, after a loose lens check of adding plus over distance prescription:

New Trial OD +0.50D Low Add

Results: Distance and Near 20/20 (OU).

Fitting tip: Give your patients the best distance vision at the initial visit — reading can be “tweaked” at follow-up if necessary. If distance is blurry for the first week or so, the patient may give up or be frustrated.

The patient was so happy that he kept professing his love for his doc as he exited the office. You can imagine my other patients' thoughts: “I want what he has!” OM


DR. ROBINSON IS IN PRIVATE PRACTICE IN INDIANAPOLIS AT OSSIP ROBINSON OPTOMETRY. CONTACT DR. ROBINSON AT RROBINSON@OSSIP.COM.

Optometric Management, Issue: February 2010