My patient perfectly typified the mildly ruffled retired college professor. At 72 years old, he had an impressive silver mane and an easy smile. A twinkle in his eye revealed his natural curiosity.

In his retirement, he’d become quite taken with stargazing. However, he expressed exasperation with the nuisance that his glasses had become while trying to view the stars through his binoculars.

He’d taken to removing his glasses during this activity, but then he felt the need to reapply them so that he could study the detailed celestial hand map that he’d brought to the office with him. He wondered “Is there anything that you can do to help?”

Understand the Task

Contact lenses were an obvious option to facilitate the use of binoculars, but the need for a crisp view of the night sky precluded simultaneous vision optics. This ruled out virtually all soft, hybrid, and scleral multifocal lens offerings. Three contact lens options remained: single-vision distance correction OD and OS, monovision, or translating GP bifocals.

Exam Findings The patient’s spectacle refraction was OD –1.75 –0.75 x 175, +2.50D add, 20/30+ and OS –1.25 –1.50 x 005, +2.50D add, 20/20-3. Keratometry readings were OD 43.50 @ 179, 44.25 @ 089 and OS 43.00 @ 005, 44.50 @ 095.

Slit lamp assessment revealed healthy corneas OD and OS as well as early nuclear cataracts OD and OS, but more advanced in the right eye. The posterior segment was unremarkable OD and OS.

Correcting the Astigmatism

If soft lenses were employed, a toric design would be needed for each eye to correct this patient’s astigmatic error. Any rotation of the lens would cause a degradation in vision, particularly in the more astigmatic left eye.

The corneal astigmatism matched the vertexed spectacle astigmatism, so a simple spherical GP lens would be quite effective in correcting the astigmatism. Because optical clarity was paramount in this case, I decided that GP lenses were the best option. But, should I recommend distance-only correction, monovision, or multifocals?

Sorting Out the Options

Binocular Single-Vision Distance Correction Correcting both eyes for distance vision would provide an excellent option for optimal viewing of the night sky, but the patient would require glasses to view the hand-held celestial map. This would not solve the original complaint of hassling with glasses.

Monovision Correcting one eye for distance and the other for near would provide vision at both distances without the need for spectacles. However, would it provide adequate visual performance for such demanding visual tasks?

Note that the acuity is somewhat reduced in the right eye due to the presence of cataracts. Whichever distance to which this eye was corrected to view would likely be problematic, making the monovision option less than optimal.

Translating Corneal GP Multifocals An ideally performing translating corneal GP multifocal would provide clear vision in each eye at both of our target distances, far and near. To do so, the lower lid must hold the lens in place as the patient looks down.

The patient’s lower lid was tangent to his lower limbus, so a translating corneal GP multifocal was recommended. The patient agreed, and we commenced with fitting. He has performed quite well with this form of correction.

Matchmakers Extraordinaire

Our relationships with our patients allow us to have an intimate understanding of their visual needs, and our expertise provides us with an understanding of what tools are available to meet those needs. Employing a methodical thought process allows practitioners to put the two together. Resist the temptation to offer a list of corrective options to your patients. Be the matchmaker, and make a strong recommendation. CLS