Clinicians have been fitting presbyopic contact lenses for almost as long as contact lens wearers have been struggling with the loss of accommodation that comes with age. This uphill battle often culminates in patients choosing to stop wearing their lenses. Nonetheless, contact lens wear is attainable, especially with today’s lens improvements and patient education strategies. 

An eye care provider’s success rate depends on their ability to educate patients about both presbyopia and contact lenses. Patients who have been properly informed about the condition and the advantages and disadvantages of the available correction options walk into the multifocal fitting process far more prepared and come out far more successful. These tips can help you become a better multifocal contact lens fitter, boosting your practice in the process. 

Communication is Key

Many presbyopic patients do not understand why they are struggling or why their vision continues to worsen, let alone what the root of the problem is, and may falsely assume that their eyes are getting worse because of the lenses or glasses they wear. To correct this misconception, a clinician’s first step has nothing to do with multifocal lenses; it is having a conversation with patients about presbyopia as an identifiable condition.

Only after the patient understands presbyopia should methods of correction be discussed, even with patients who have worn contact lenses for years and have already tried multifocals. Letting patients know that their vision will likely never return to what it was when they were 30 sets the foundation for the discussion about lens options. While possibly the most important step, this is also the one that is most often skipped. Ensuring that the patient and the provider are on the same page by setting realistic expectations is critical for success. 

When discussing the available corrective options, it is vital to a patient’s lens-wear success that a clinician covers both the advantages and disadvantages of multifocal contact lens wear. Despite the negative perception toward multifocal lenses in the past, they allow patients the opportunity to gain independence from glasses and acquire a full range of vision in all fields of gaze. In addition, prescription lenses have a non-glare coating that helps reduce visual problems patients often have while driving at night, looking at computer screens and using digital devices. Clinicians should also inform the patient that, while they have advantages, progressive and bifocal glasses also have limitations. Knowing alternative options present challenges as well helps patients realize they are gaining something by wearing lenses over glasses.

With today’s advances, soft multifocal lenses present many benefits to patients. Photo: Stephanie L. Woo, OD

Lens Options
The key to successfully fitting multifocal contact lenses is to follow the fitting guide. Even though it might be tempting for providers to take the fitting process into their own hands, the guide lays out exactly what to do if the initial lens fit is not successful. Following the fitting guide can help clinicians reach at least a 90% success rate with the second and third lens.

While most commercially available lenses are limited in that they do not correct for astigmatism, soft lens companies continue to innovate with new materials and designs, and spherical multifocal lenses usually help the vast majority of patients. The following lens options may be available for presbyopic patients depending on their circumstances:

Toric soft multifocal lenses. A substantial percentage of our practice’s patients has astigmatism and can only be fit with custom-ordered lenses. It is important to inform these patients that the fitting and their lenses will both cost more to accommodate the astigmatism. If a patient chooses to continue with the fitting process, clinicians should then provide their custom soft lens manufacturer with the patient’s sphere, toric, add power, keratometry readings, horizontal visible iris diameter and pupil size in photopic and scotopic lighting to ensure the most effective lens is created. 

Hybrid lenses. These lenses consist of a gas permeable center and a soft skirt and are designed for spherical and toric patients. To produce the best fit and calculate power measurements, clinicians should use a fitting set and do an over-refraction. If a provider has not fit a hybrid lens in the last couple of years, they should contact a colleague, attend a workshop at a conference or reach out to SynergEyes—the only manufacturer of hybrid contact lenses in the United States—to discuss the process and learn how to produce the best results. 

Gas permeable lenses. These are usually successfully fit because clinicians are able to modify the lenses until a patient’s vision is maximized. 

Scleral lenses. Although they have grown more popular over the last five years, some consider scleral lenses overkill for patients with normal corneas because of the larger size and increased cost of the lenses. Regardless, scleral lenses are fantastic options for presbyopic and toric patients. 

Fitting Challenges

For some patients with adequate pupil size who are fit in the right lens design, multifocal lenses provide a suitable depth-of-focus. For others, the combination of limited lens options and their anatomy and lifestyle may reduce their chance of success with lenses alone. In this case, clinicians often elect to prescribe over-glasses for either distance or near. Over-glasses can be presented as an alternate choice for completing specific visual tasks. Most patients do not need them, but those who do usually find them to be a great option for the times they could use a boost in their distance or near vision. 

Patients fit with multifocal contact lenses may face different obstacles depending on their add power, cylinder amount, pupil size and visual demand. Because a patient with multifocal lenses looks through distance and near correction at all times, they will notice a difference in their vision. 

A patient’s initial lens experience is usually the most uncomfortable and unnatural because cortical adaptation needs to take place. Once the patient’s brain realizes what to focus on, it will likely ignore areas of vision that are not as important for visual tasks. While clinicians should work diligently to reduce the shadows and glare patients sometimes experience, they must also realize they may not be able to get rid of either entirely, even with careful lens selection. 

Presbyopic contact lenses should account for a majority of the lenses clinicians fit because all patients who wear contact lenses age, and the vast majority want to continue wearing their lenses. By having detailed conversations before lens fittings, understanding the various lens designs and being prepared to troubleshoot when patients struggle with adaptation and anatomical or lifestyle challenges, clinicians can help their patients find satisfaction through presbyopia correction.