Presbyopia presents many visual challenges for patients and practitioners alike. In terms of soft multifocal contact lenses and the optical challenges presented to practitioners, a contact lens needs to provide distance, intermediate, and near vision at the same time.

For patients in this scenario, the visual difficulty is a real estate issue; there is only so much room to present the distance, intermediate, and near optics within the lens at the same time, as the optics must be presented simultaneously. In addition, a patient’s visual system is expected to sift through the image provided and to resolve the necessary images at all three distances. Not yet stated is the complexity that this presents to contact lens manufacturers in producing soft multifocal contact lenses that are ideally suited for the compensation of distance, intermediate, and near optics simultaneously but do not provide the accommodation to which presbyopic patients are historically accustomed.

Improved Designs

Contact lens manufacturers are not only continuously attempting to improve the optical designs within their soft multifocal lenses, they are also researching and analyzing the fitting guides and philosophies that are intended to help practitioners and patients be as successful as possible as quickly as possible.

In looking at the fitting guides and prescribing philosophies, some common best practices emerge. Initially, practitioners should begin with an updated spectacle Rx and add power to ensure that they correctly vertex both primary meridians to the plane of the cornea. Recently, several soft toric multifocal contact lenses have entered the market in addition to the custom soft toric multifocals that were already available.

The most common soft multifocal design is a center-near aspheric design. As a general rule, begin with low adds in both eyes for add power needs of +1.50D and below. For patients who require add powers of +1.75D and above, the initial lens recommendation generally changes to possibly incorporate an intermediate or high add to one or both eyes.

As an alternate to the center-near aspheric design, there are center-distance aspheric designs. For patients needing these lenses, the general recommendation for initial lens selection is again based on add power. For those who need add powers of +1.50D and below, a center-distance design in both eyes is recommended. For patients requiring add powers of +2.00D and above, a combination of center-distance over the dominant eye and center-near over the nondominant eye is suggested. To determine the dominant eye, the “swinging plus”/fog test is generally recommended. (Lampa, 2019).

Dispense Adjustments

Trialing lenses for one-to-two weeks in the real world is encouraged prior to making any significant changes on the day of the dispense. If an over-refraction is necessary after the initial trial lenses are applied to the eye and allowed to settle, practitioners should perform the over-refraction with spherical loose lenses outside of the phoropter. Additionally, they should push as much plus as possible in the distance. Even 0.25D shifts can provide significant changes to the overall visual performance with soft multifocal contact lenses.

In Summary

Though there are complexities and optical challenges in the management of patients who have presbyopia and who desire to wear soft contact lenses, the above recommendations are intended to increase efficiency and success for today’s soft multifocal contact lens patients. CLS