Fitting Presbyopes

Overcoming the Presbyopia Problem

Matching patient expectations for vision and comfort will help you succeed with presbyopic contact lenses

By Marty Carroll, OD, FAAO, & Josh LaHiff, OD

Drs. Carroll and LaHiff are in private group practice in Cheyenne, Wyo. Contact them at (307) 638-6610.

According to a 2008 Gallup poll, 56 percent of teenagers and 45 percent of young adults (aged 18 to 34) who need vision correction wear contact lenses. In the emerging-to-early presbyopic age bracket (35- to 49-year olds), the rate of contact lens wear drops to one-third. Only 7 percent of people older than age 50 who need vision correction are wearing contact lenses. Obviously our current contact lens options aren't meeting their needs.

"The onset of presbyopia is more of a problem visually than it ever has been in the past," notes Robert A. Davis, OD, a private practitioner from Pembroke Pines, Fla. "Presbyopes today are challenged by a multitude of near-point tasks that go well beyond reading," he says. "Most people in this age group are using computers and small handheld electronics at home and at work. Even in the car, new devices such as GPS and satellite radio have added to our near vision requirements."

By their 40s, many contact lens patients are struggling not only with presbyopia, but also with lens-related dryness and discomfort. In a number of studies, discomfort is the biggest reason cited by patients for discontinuing contact lens wear (Pritchard et al, 1999; Schlanger, 1993). In a recent study (Richdale et al, 2007) that looked at 453 current and former contact lens wearers, about one-quarter (24.1 percent) had permanently discontinued lens wear and more than another quarter (26.3 percent) were dissatisfied with lens wear. Of these dropouts and dissatisfied wearers, nearly three-quarters (73 percent) cited ocular symptoms, primarily dryness and discomfort, as the reason for their dissatisfaction or discontinuation. Only 20 percent cited poor vision as a reason.

A Problem Worth Solving

Clearly there is a "comfort crisis" for contact lens wearers. In our practice, we use every modality we can to keep patients in contact lenses. But there is no denying that it becomes increasingly challenging as presbyopia advances.

An aging U.S. population provides a powerful incentive to solve this problem. As Figure 1 shows, the spherical contact lens category is pre-dominantly made up of myopic patients whereas today's multifocal contact lens category is comprised primarily of high-add myopic and hyperopic patients. The missed opportunity lies in keeping current myopic contact lens wearers in contact lenses as they emerge into presbyopia.

Figure 1. Practitioners need to better meet the challenge of keeping myopic wearers in contact lenses as they become presbyopic.

We know there is strong interest in presbyopic contact lens options. According to the 2008 Gallup study, more than six in 10 adults ages 35 to 49 who wear contact lenses and eight in 10 of those older than age 50 say they are interested in bifocal or multifocal contact lenses. Moreover, about one-third of adults who currently wear only spectacles say they are interested in trying (or returning to) contact lens wear. If we can help our emerging presbyopic patients hold on to that motivation and give them appropriate lens options, the potential is huge.

Evaluating the Growing Menu of Choices

In terms of simply correcting vision, we have a number of options for contact lens wearers as they become presbyopic:

1. Continue wearing their current contact lenses for distance and add reading glasses for near work. (Occasionally, patients who have heavy near demands prefer contact lenses for near with over spectacles for distance.) This is an easy and inexpensive option, but patients may find it a hassle to constantly put on and take off readers.

2. Replace contact lenses with bifocal spectacles or progressive addition lenses (PALs). This is another "easy" option, but it puts lens wearers right where they don't want to be — in glasses. In addition to all the other disadvantages of wearing glasses, PALs can cause some distortions when looking to the side.

3. Single-vision contact lenses fit for monovision. As professionals taught to maximize binocular vision, monovision goes against the grain of our training, and some patients aren't able to adjust to it. Nevertheless, we have many successful monovision and enhanced monovision contact lens wearers in our practice, and it continues to be a good option especially when we can use lenses that address dryness and comfort issues.

4. Bifocal or multifocal contact lenses fit in one or both eyes. Creating sharp optics at both near and distance without visual artifacts has been a big challenge for lens manufacturers. Aspheric designs are lighting- and pupil size-dependent; ring-based designs compensate better for lighting and pupil size, but may cause ghosting or halos. Newer designs may do a better job than either of these.

In a recent study (Gupta et al, 2009) comparing monovision to multifocal contact lenses of the same material (balafilcon A), researchers found that distance and near visual acuity were significantly better with monovision. Intermediate vision, reading speed, contrast sensitivity, and the subjective assessment of near ability were all similar. The multifocal lenses provided better stereoacuity and near range of clear vision compared to the monovision lenses, with little difference in contrast sensitivity. The authors concluded that monovision performed better than a center- near aspheric simultaneous vision multifocal contact lens of the same material but that the multifocal lenses might achieve a better balance of realworld visual function.

Another study (data on file, Vistakon) compared PALs to a new multifocal contact lens. Subjects were randomly assigned to one modality or the other initially. After several days, they crossed over to the other modality for the remainder of the first week. For the next 10-to-12 days, patients could choose freely between the contact lenses and the PALs.

At the end of the study, a large majority (78 percent) said that the combination of a multifocal contact lens and progressive spectacles met their vision correction needs better than either modality alone. The spectacles provided superior vision and were preferred for stationary and solitary activities such as reading, while patients preferred the multifocal contact lenses for seeing actively, providing a more natural experience, and giving them control over their appearance. Patients preferred the multifocal lenses for the majority of tasks during the day, but often switched between modalities within a single day.

This corresponds to our experience that presbyopic contact lens wearers are highly motivated to stay in contact lenses and are willing to tolerate some visual tradeoffs for the lifestyle benefits of wearing contact lenses.

And as this study also indicated, patients seem to switch back and forth easily between PALs and multifocal contact lenses. "I have many patients who wear progressive spectacles most of the time, but there are times when they prefer not to wear glasses, whether for social reasons or for comfort during exercise," says Dr. Davis. "For example, I have one patient who does a lot of public speaking. Multifocal lenses allow her to see the podium, the teleprompter, and the audience and to photograph well. On normal work days, she switches back to the PALs," he says.

Comfort Leads to Success

There is an art to maximizing near and distance vision, but in our experience the biggest challenge in fitting presbyopes with contact lenses has never been the vision — it is comfort. In a windy, dry climate such as where we practice in Cheyenne, Wyo., patients really struggle with ocular comfort. As they become presbyopic and we ask them to try multifocal lenses — which, until recently, have not been available in the most comfortable materials — the likelihood of dropout increases. In the past, monovision has sometimes been the only option to keep patients in contact lenses when they were struggling with comfort. However, monovision may not be the best modality to start with.

"Even though I do a lot of monovision fits, monovision is rarely my starting point," says Dr. Davis. "I find that the earlier patients start wearing multifocal lenses, the easier their adjustment is as presbyopia advances." He prefers to start with a multifocal lens and/or PALs.

A new multifocal lens that recently entered the market may help resolve the comfort conundrum. In our experience, we have found that the Acuvue Oasys for Presbyopia (Vistakon) lens addresses many of the situational dryness challenges that presbyopes face, whether they choose to wear the lens part-time or as their primary vision correction. Made from the same senofilcon A material as Acuvue Oasys and Acuvue Oasys for Astigmatism, we have found that this lens makes it very easy to transition emerging presbyopes into a comfortable multifocal contact lens.

It settles very quickly, so chair time tends to be minimal. We have found that we usually know whether it's going to work before the patient leaves the office, and we've rarely had to make more than one adjustment to the prescription.

We have one 43-year-old female patient, a busy accountant who needs minimal correction for distance (−1.00D OD / −1.25D OS). She constantly works at near and hated putting her glasses on and taking them off all day. None of the other monovision or bifocal contact lens options that we tried worked for her due to discomfort, dryness, or reduced distance vision, and she couldn't adapt to progressive spectacles. We fit her with Acuvue Oasys for Presbyopia, and she has been thrilled with the results claiming that the lenses have improved her productivity at work and her quality of life.

Because of its comfort, this lens has become our starting point for most early presbyopes. For those who have more advanced presbyopia, B&L's PureVision Multi-Focal and CooperVision's Proclear XR offer higher add powers. CIBA Vision's Focus Dailies Progressives design is the only option right now for presbyopes who need or want the convenience of daily disposability.

Dr. Davis adds, "For patients who have a lot of astigmatism, I like the SynergEyes Multifocal (SynergEyes) lens or the Proclear Multifocal Toric lens."

Succeeding With Presbyopes

Patient education is key to successfully fitting presbyopes with contact lenses. Even before patients start to have near vision problems, we give them a primer on the eye and how it changes with age. Then we talk about the options we have to help them cope with those changes.

As with any contact lens fit, you must start by fitting the patients' expectations. You need to find out what each patient's visual needs are and then tailor a contact lens recommendation to those needs, taking into account the patient�s most frequent visual tasks, personality, and other health issues.

When your recommendation is for a multifocal contact lens, "You have to be able to explain simultaneous vision to the patient," says Dr. Davis. He uses the analogy of the brain tuning out a radio in the background to focus on a conversation, or the ability to look through a screen door at the action beyond, rather than just seeing the screen grid. "Not everyone can adjust to simultaneous vision, but those who can gain the advantages of binocularity," he says.

You and your staff need to understand how each of the presbyopia-correcting lenses work and be enthusiastic about recommending them. Too many practitioners leave out staff training, to their own detriment because patients typically spend more time with staff members than with the practitioner and may identify more closely with them.

As long as patients are basically satisfied at the first fitting with a multifocal lens, we advise sending them home in the lenses for a few days before making any adjustments. Sometimes patients need to see how the lenses work in their daily activities, or perhaps there is some neuroadaptation that occurs, but we find that changes made after a few days of normal activities are more likely to be satisfactory.

Definitely be willing to solve problems. Some patients will be most satisfied with a single-vision lens for distance in the dominant eye and a multifocal lens in the non-dominant eye — or some other variation. "It does take more fitting skill and expertise to fit presbyopes, and practitioners should make sure they are compensated fairly for that," says Dr. Davis.

If you're just starting to fit multifocal or bifocal lenses, it's important to choose the right patients. Ideal candidates:

• Fit within the lens parameters
• Have low or no cylinder
• Are early-to-moderate presbyopes (approximately 43-to-50 years old)
• Have a positive, easygoing personality
• Dislike their current eyewear and/or like to try new things
• Have no ocular pathology, including cortical cataracts
• Have no history of prior ocular surgery such as LASIK or PRK. Due to changes in corneal shape, these procedures may make it difficult to fit presbyopic soft contact lenses
• Have reasonable expectations

With more experience, you can certainly branch out to less-than-ideal patients. We recommend maximizing your use of trial lenses with presbyopic patients. When we culled our database for presbyopes to try a new multifocal, we were pleasantly surprised at how universally grateful they were to try out a new lens, whether they ended up changing to it or not.

There's no doubt that we need more contact lens options for presbyopes. Practitioners should welcome each new entry into the market as an opportunity to broaden the range of presbyopic patients who can wear contact lenses more comfortably and with crisper vision as they age. CLS

Dr. Davis is in private practice with The Eye Center, a five-doctor practice in Pembroke Pines, Fla. He is an adjunct clinical professor at Nova Southeastern University College of Optometry and the Pennsylvania College of Optometry. Contact him at (954) 432-7711 or visit the practice at www.eyecenter.com.

For references, please visit http://www.clspectrum.com/references.asp and click on document #168.