Prescribing for Presbyopia

Keys to Success for Dispensing and Follow-Up Visits

By Jason R. Miller, OD, MBA

We've all heard that presbyopes can be a demanding group in general and especially with multifocal contact lens fits. They don't like what has happened with their vision, they know what they want, and they expect results.

Most soft multifocal contact lens designs are based on the simultaneous vision principles. Patients need to understand this to some degree up front and to understand the general fitting process. This education process needs to come from the practitioner and should incorporate time for answering any questions.

The Dispensing Visit

A multifocal lens fit may take extra time and energy. Success depends on making this initial visit efficient for patient flow while maximizing vision for patients before they walk out the door. You can enhance your success for this challenging process by developing your own specific protocol as in the following example.

• Scheduling Ask patients before they arrive whether they are considering contact lens wear. For new wearers, consider allowing a few extra minutes for the lens fitting.

• Exam The exam flow is critical. It may make sense to apply the lenses in the exam room and allow them to settle 15 minutes while patients do something else (look at frames, sunglasses, etc.). Make any obvious adjustments before they leave to maximize this starting pair of lenses. It may help your flow to dilate patients at the follow-up appointment. Make sure to think through the process ahead of time to improve success.

Interpreting Complaints Visit

After the initial dispensing visit, our primary job is to interpret the patient's complaints. This follow-up visit can come in one of four basic scenarios:

1. The patient presents perfectly happy—loves his newly improved near vision while the distance vision remains good. My staff understands that binocular visual acuity readings are the only ones that they need to document before I come into the room. If the patient is perfectly happy and his vision is good, be careful not to introduce any extra minus. There is no reason to show the patient something that you are not planning to give him.

2. The patient presents with only distance complaints—loves his newly improved near vision, but feels like his distance vision is not as sharp as he would like. After checking his monocular visual acuity, use flippers to see whether any changes will improve the distance vision. Make minor changes if possible. It may be as small as reducing the add power in the dominant eye.

3. The patient presents with only near complaints—loves the distance, but still needs readers for everyday tasks. Definitely start with trying to push the plus in both eyes—it could be that your initial refraction was off. If the patient does not accept any plus in the distance, try pushing plus or increasing the add in the nondominant eye.

4.The patient presents with distance and near complaints. You may want to re-check your refraction, change to a different multifocal lens design and/or reeducate the patient that his vision is not going to be perfect. The patient may be expecting too much, and you may need him to focus on just one aspect. Ask him what is most important and focus on that initially.

Planning for Success

Multifocal lens wearers can be a challenging group, but a focused and well-designed approach can maximize success with this growing patient population. CLS

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Dr. Miller is in a partnership private practice in Powell, Ohio, and is an adjunct faculty member for The Ohio State University College of Optometry. He has received honoraria for writing, speaking, acting in an advisory capacity, or research from Alcon, Argent Media, Aton Pharma, CooperVision, and Hoya. You can reach him at drmiller@eyecarepowell.com.