SOFT MULTIFOCALS

Soft Multifocals: Practice Growth Opportunity

Here's how you can multiply opportunities for practice growth with soft multifocals.

By Joseph B. Studebaker, OD, FAAO

Dr. Studebaker is a clinical assistant professor at The Ohio State University College of Optometry. He is a past president of the Ohio Optometric Association and a Fellow of the American Academy of Optometry. He practices at Northwest Optometry, LLC in Englewood, Ohio. He is also an independent contractor for Bausch & Lomb.

Like many of you in the trenches of patient care, I was once guilty of being a "soldier of caution" with regard to recommending multifocal contact lenses to those seeking presbyopic correction. A decade ago, the prescribing of early iterations of these lenses was, too often, a frustrating and prohibitively time-consuming clinical adventure. Materials, design options, and parameter availability were all limited and frequently produced disappointing vision results for patients. This served to reinforce prescribing patterns for many practitioners that, unfortunately, persist even today.

If the "three R" (refit, refit, refund) philosophy of multifocal prescribing is still hindering the growth of your practice, it's time to reevaluate this philosophy.

Demographic Considerations

Change is an inevitable constant in all of our practices, especially with regard to patient demographics. A 2008 study, conducted by the Gallup Organization, projected that the number of prospective U.S. contact lens wearers was expected to increase to almost 34 million over the next decade — a percentage increase (9.2 percent) greater than the overall projected national population growth rate (8.4 percent). Most notably, the 50 and older segment of this projected group of potential contact lens candidates comprises its largest single age component — projected to be 28 percent of all potential wearers by 2018. That's more than 13.5 million people! In addition to this "baby boomer" group, "Gen-X" patients (born between 1964 and 1971) represent the next generation of new and emerging presbyopes. Technology is a key component to these patients. Not surprisingly the mindset, visual requirements, and lifestyle demands of early presbyopic Gen-Xers are different (Table 1). This generation is highly motivated to preserve both vision function and youthful appearance.

Clearly, as our patients live longer, more active lives, growth in the presbyopic market segment will remain robust for many years. Patient interest in multifocal correction will substantially increase. In fact, 82 percent of emerging presbyopes now search for health information online. To meet the demands and satisfy the increasing curiosity of all contact lens candidates who seek out quality presbyopic correction, practitioners need to be ready to help their patients and their practices reap the benefits of new and emerging contact lens technologies. Fortunately, there are lens designs that meet the vision needs of all your presbyopic patients.

Patient Preferences, Practitioner Perceptions

In delivering eye and vision care to our patients, we like to think that we have a good handle on assessing and meeting their needs for individualized, high quality vision correction. Most of the time, this is the case. But are we doing a good job of educating our patients with regard to presbyopia and the available contact lens alternatives for its correction?

Recent Bausch & Lomb-sponsored eyecare practitioner and patient surveys suggest that, despite the fact that eyecare practitioners feel they are meeting this need, patients may have a different perspective. Seventy-six percent of 151 practitioners reported that they first recommend soft multifocal contact lenses to current presbyopic soft contact lens wearers. And, of those that offer soft contact lenses for presbyopic vision correction, 50 percent recommend multifocal contact lenses first. However, in a survey of 500 presbyopic patients, only 8 percent of current contact lens wearers reported being told about multifocal contact lenses when they complained to their practitioners about initial near vision problems. The same study indicated that once regular contact lens wearers and monovision patients were informed about multifocal contact lenses, one-third of each group were likely to try them. Moreover, one-third of respondents said they would likely seek out the services of another practitioner if their existing one didn't inform them about multifocal options.

Still not convinced you should be taking a second look at multifocals and their place in your contact lens practice? Researchers — as well as your patients — might just feel otherwise. Vision scientists are uncovering evidence that points to high patient preference for multifocal correction over monovision among presbyopic patients. A randomized, crossover study of 38 presbyopic patients by Richdale (2005) at The Ohio State University College of Optometry compared the visual performance and overall satisfaction of patients wearing soft multifocal contact lenses (B&L SofLens Multi-Focal) versus monovision wear (B&L SofLens 59). The study enrollees had no previous history of multifocal or monovision lens wear, normal binocularity, and near add requirements of at least +0.75D. The B&L fitting guide was followed for each of these new soft multifocal fits. At the end of the two-month study, 76 percent preferred bifocal contact lens wear versus 24 percent who preferred monovision wear — a statistically significant difference (chi-square, p=0.001). A survey was mailed to all participants six months to one year after the study conclusion (depending on their enrollment date). The survey indicated that three times more multifocal patients than monovision patients were still wearing their chosen lenses at least three days a week. No monovision patients considered contact lenses as their preferred form of vision correction.

Multifocals Versus Monovision

The results of the Richdale study are of practical significance to clinicians considering the prescribing option of multifocal contact lenses versus a monovision-based modality for patients who are heavily involved in near vision tasks.

There is continuing debate relative to the negative impact of monovision-produced stereoacuity reduction upon distance depth perception where monocular visual cues such as motion parallax, aerial perspective, or overlap may be more significant factors. However, findings from several studies highlight the unique importance of stereoacuity and binocular summation to the performance of near vision tasks such as eye-hand coordination. Such studies, also referenced by Richdale and her colleagues, established that unsuccessful monovision contact lens wearers were more likely to be those who experienced a greater degree of monovision-induced reduction in stereoacuity.

In light of the apparent importance of near stereopsis to patients' overall success with presbyopic contact lens correction, one Richdale study finding, that there was only one test in which multifocal contact lenses were significantly superior to monovision: stereoacuity, is key. Multifocal contact lens wearers in the study exhibited statistically superior near stereoacuity (126 ± 137 sec arc) versus monovision wearers (205 ± 214 sec arc) and versus the patients' habitual (baseline) vision correction (158 ± 220 sec arc). According to the study, average stereoacuity was 79-sec arc better with the multifocal compared with monovision contact lenses. Considering the long-accepted importance of near stereoacuity to patient satisfaction with their overall contact lens correction — especially in this era when an increasing number of our patients work in fields such as information technologies and other vocations that require high quality near correction — it is obvious that multifocals offer substantial benefits to many presbyopic patients over those provided via monovision contact lens wear. However, if you remain skeptical about multifocal advantages, consider this additional, corroborating, real-world evidence.

Recently published research by Gupta (2009), Aston University, compared the visual performance of multifocal lenses (B&L PureVision Multi-Focal) to monovision with single vision lenses (B&L PureVision). This study of 20 presbyopic patients, 17 of whom had no previous contact lens wear history, found that multifocal contact lens wear provided significantly better stereoacuity at near (174.0 ± 95.2 sec arc) versus monovision (273.0 ± 102.0 sec arc) (Z=–2.6, p<0.01). The study also found that multifocal wearers exhibited a significantly better (p<0.05) subjective near range of clear vision with little difference in contrast sensitivity function (1.59 ± 0.70D) compared to the monovision wearing study participants (1.21 ± 0.77D). Thus, one important practical conclusion from the study was that multifocal wear provides a "better balance of real-world visual function…due to minimal binocular disruption."

So, with all of this evidence in support of multifocal correction, why the apparent disconnect between research findings, practitioners, and patients? Perhaps it's because some of us stubbornly cling to established prescribing habits and default to a seemingly simplistic "if it ain't broke don't fix it — or minimize the risk (monovision)" approach to patient management. Some patients are equally culpable in their resistant mindsets to new lens modalities. Maybe it's because we incorrectly assume that because our patients don't ask about multifocal lenses, that they aren't interested in wearing them. Or could it be that some of us may fear, especially in this challenging economic era, that patients will view these specialty contact lens designs as cost-prohibitive?

While some practices view the above thoughts as challenges, my partners, staff, and I have successfully turned these challenges into opportunities. We all believe that the rewards of investing time and effort into promoting multifocal lenses in our practice are well worth it. Here's why we believe that this form of vision correction will continue to enhance our contact lens practice growth over the next decade.

Soft Multifocals Actually Work

For many years, my partners and I have heavily relied on a variety of GP multifocal designs to manage our presbyopic patients, and we still do. The ability to customize these designs to accommodate a broad variety of fitting and optical requirements is a widely recognized advantage, and GP multifocals continue to serve many of our patients very well in many unique ways. Yet, we have all had patients who are unable to tolerate GP lens wear due to various factors such as persistent lens awareness, tear film/ocular surface factors or, in some cases, optical issues such as lenticular/residual astigmatism. The need in these cases for reliable soft multifocal products has been great — and thankfully, reliable soft multifocal products in high quality designs and materials have delivered excellent satisfaction for my patients in many of these cases. Improvements such as silicone hydrogel multifocals and even toric multifocal lenses are making the clinical process of meeting and/or exceeding patient expectations easier, more efficient, and profitable. Consider the following case and decide whether more of the patients in your practice could benefit from today's lens technologies.

The Presbyopic Pathologist

One of my best friends, Sam, is a highly myopic 65-year-old pathologist who, for many years as his presbyopia advanced (currently at a +2.25D add level OU), tolerated an increasing degree of vision compromise associated with his monovision, low-watercontent, non-ionic soft hydrogel lens wear in lieu of wearing his prohibitively thick spectacle lenses. At Sam's initial evaluation, he exhibited a clinically unacceptable degree of peripheral corneal neovascularization as a result of his long history of overwear of –10.00DS soft hydrogel lenses. His lens wear later in the afternoon and evening was particularly problematic, not only because of his mild dry eye and monovision-related complaints, but also because of haloes and a "steamy" quality to his vision (20/30 best corrected distance/near visual acuity) as a result of his contact lens-induced corneal hypoxia/edema.

I opted to prescribe a silicone hydrogel to address the above physiologic/optical factors. Because Sam also expressed a great deal of frustration with his history of frequently torn contact lenses, I was confident that a logical "first choice" design for him would be B&L's PureVision Multi-Focal in a "high add" (+1.75D to +2.50D) design. In my experience, its optics with a center-near "low add" (up to +1.50D) or "high add" are simple to prescribe, available in a broad parameter range (+6.00DS to –10.00DS), and usually provide rapidly appreciable, easily discernable vision benefits to patients.

One month after initial dispensing and after a few minor power modifications to accommodate his intermediate vision requirements at the computer, Sam's vision had improved to 20/20– OU at distance and to 20/20 at near. He was ecstatic with his better overall vision (especially during long days at his computer) and vastly improved ocular comfort — even throughout the course of 16 hour-plus days at the hospital. Recently at his six-month follow-up visit, Sam told me how relieved he was that he could still comfortably wear contact lenses when he had previously been desperate enough to consider refractive surgery despite his very significant fear of any type of permanent corneal modification — and especially with the risk that refractive surgery might further aggravate his already dry eyes. As a bonus, Sam has yet to damage or tear any of his lenses even though he handles these monthly replacement lenses on a daily wear basis. I have received numerous referrals from Sam for new soft multifocal fits due to his great vision and comfort with this modality.

You Can Do This

In general, the optics of soft multifocals — while sophisticated — are not overly complicated and are designed to make your job easier. Don't get intimidated by the fitting process. Lens manufacturers will gladly assist you with a fitting consultation. Just remember to identify patients who will derive practical benefit from multifocal lens wear, establish realistic expectations with potential wearers, and establish fees for multifocal lens fitting that accurately reflect your time and professional expertise. Most patients in search of high quality, specialty contact lens correction rarely complain about fair fees so long as they obtain good overall value. And for some of you who are contact lens management "control freaks," you can't do this all by yourself. A team approach with active and informed staff involvement is vital. The day-to-day process of helping patients succeed is not difficult if you provide your staff with the requisite training. You can "ramp up" the enthusiasm by trying the lenses yourself or fitting staff members who work with contact lens wearers. Then you can powerfully advocate and internally market multifocal lens options through personal examples and experiences.

The ingredients for growing your presbyopic contact lens practice are all in place. Patients who desire the clearer, consistent vision that modern multifocal lenses can deliver are out there and they are hungry for your guidance. All it takes is your willingness to believe in the technology and to devote a modest investment of time to improving your patients' understanding of the potential benefits of the new alternatives that are available. CLS

To obtain references for this article, please visit http://www.clspectrum.com/references.asp and click on document #163.