Today’s presbyopes, which include Generation X (Gen Xers; born between 1965 and 1980 and currently 40-to-55 years old) and Baby Boomers (born between 1946 and 1964 and currently 56-to-75 years old) enjoy more affluent and active lifestyles than ever before. Gen Xers are in their prime earning years, and Baby Boomers are just beginning to retire and to enjoy life outside of work. Both groups are regular users of digital devices,¹ which add to their visual demands. Both have significant disposable income.² More than two-thirds value looking younger,³ and they are willing to spend money on products and procedures, ranging from hair coloring and teeth whitening to cosmetic surgery, to maintain a youthful appearance.⁴

Yet, despite the introduction of new multifocal contact lens (MF CL) designs by virtually every major manufacturer in recent years—and the fact that multifocal lens wear helps maintain a youthful appearance by reducing the use of readers—the percentage of MF lenses fit in practices globally remains low.⁵ The use of CLs tends to drop sharply at the same time that vision correction needs increase in the presbyopic population. Interestingly, as many as four in 10 CL wearers are 40+ years old; yet, according to a poll conducted by Gallup in 2015, only 9% of adults requiring MF correction in that age group received a recommendation for CLs as a means of vision correction.⁶ This is a massive untapped opportunity for CL practitioners who have not currently engaged in MF fitting.

NAVIGATING A SUCCESSFUL JOURNEY

A journey analogy is useful in considering how to capitalize on this opportunity—you have many different starting points (patients), destinations (visual goals), and routes and modes of conveyance (Figure 1). And while the presbyopia correction journey is generally, but not always, easy, it is usually worth it—67% of multifocal wearers in Multi-sponsor Surveys Inc’s 2015 Gallup study of the U.S. multifocal contact lens market reported being very satisfied with their soft MF CLs⁶ and likely to tell their family and friends.

So how do you get started? The first step in a successful journey is to make sure that everything is tuned up and ready to go. Then it’s time to open your favorite navigation app and get going!

THE TUNE UP

Before diving in, take some time to make sure that everything is in working order and that you have everything needed to start the journey. Think of this stage as the “Tune Up.” Starting with the wrong patient, or with an incomplete set of tools, is a sure way to meet with difficulties. Table 1 includes some key considerations for this stage when selecting patients, and Table 2 summarizes guidance on tools to assist you.

TABLE 1 KEY PRE-FIT CONSIDERATIONS FOR PATIENT PREPARATION

• Start YOUNG As soon as presbyopia is evident, especially when first getting started
• Start HEALTHY Identify and address lid or ocular surface disease
• Start FRESH Maximum-plus distance Rx, functional add, identify sensory dominance
Start SPHERICAL Avoid cylinders greater than –0.75DC

TABLE 2 KEY PRE-FIT CONSIDERATIONS FOR TOOL AVAILABILITY

• Start BALANCED Select a preferred design and one backup design, each with distinct characteristics
• Start EQUIPPED Include glasses in your tool kit to supplement your best CL selection (near, distance, MFs, PALs, sunglasses)

Patient Considerations Start with the “easy” ones! A younger presbyope who is already successfully wearing CLs has already demonstrated “road readiness” to some degree. These wearers can be prone to dry eye and to lid disease and should undergo a comprehensive evaluation of the ocular surface and lid status.

For any issues identified, institute procedures to address them prior to fitting MF CLs. Pucker et al found that the odds of dropping out were significantly increased with each worsening grade of upper or lower eyelid meibomian gland (MG) plugging, upper eyelid meibum quality, and upper eyelid MG tortuosity.⁷ Simple interventions such as thermal pulsation⁸ or microblepharon exfoliation⁹ can have significant impact on contact lens-wearing comfort, retinal image quality, and, therefore, success.

Performing a new refraction is also essential, even with a seemingly well-corrected patient. There is a documented progression toward more plus in distance refractions with age,¹⁰ and most MF CLs perform best with a maximum-plus distance refraction—adding +0.50D should easily blur the best-corrected visual acuity line (which monocularly should be a solid 20/20). It is also not advisable to rely on a current or previous CL prescription in lieu of a good spectacle refraction. Avoid patients who have astigmatism exceeding –0.75DC. While there are new toric multifocals available, it is highly advisable to first get comfortable with spherical multifocals before attempting to add astigmatism to the mix.

Determine the lowest “functional,” age-appropriate add required to perform day-to-day activities. A general rule of thumb for maximum add is +1.00D to +1.25D (low) for patients in their 40s, +1.50D to +1.75D (medium) for those in their 50s, and +2.00D to +2.50D (high) for patients in their 60s—considerably lower than many progressive addition lens (PAL) prescriptions. With a maximum-plus distance refraction, this should provide a comfortable range around their preferred working distance for typical activities. Do not use visual acuity as a standard for determining near addition power (add).^11-13 Rather, use a functional technique with relevant near target materials, font sizes, and lighting. Mobile phones, handheld devices or other simulations of near work are recommended for refining the reading add.

Use All of Your Tools If you cook, you probably have different knives, pans, dishes, and spices to help prepare the perfect meal. People wear different shoes for walking, running, playing tennis, and special occasions. Every sport requires different equipment. It seems that presbyopia correction is one of the few areas of life in which we expect one tool to do every job!

We have many tools, and on the presbyopia journey, we will have the most success if we employ them all: MF CLs, PALs, and segmented reading glasses. The key is to combine them to meet critical needs for appearance, convenience, and functionality.

THE DESTINATION

Once your tune-up is complete, it’s time to pull out the “app” and go through the steps to accomplish the actual journey. First, set the “destination”—more importantly, the CL-specific destination. Identify the situations for which CLs are the best solution (and/or for which glasses are unacceptable), and jointly agree on a measure of performance in the patients’ real world that they can use to judge success. This will be your “contract” with the patient in determining any future tweaks or solutions. It’s helpful to also identify areas of flexibility, such as periods of fixed activity for which glasses would be acceptable. Remember, these questions should highlight situations for which CLs are the best option, and they will help identify a concrete definition of success for you and your patients. Helpful topics/questions for this step include:

• Complete the following sentence: If I could do “X” without wearing glasses, I would consider these CLs successful.
• When is it really annoying to wear glasses (PALs, bifocals, readers)?
• When would you consider wearing some form of glasses to be acceptable?

THE ROUTE

Typically, there are multiple ways to get to a destination, and sometimes it’s just a matter of personal preference. On the presbyopia journey, it’s important to understand the preferences and the pain points for your patients in planning which of your tools will help them get to their destination. Never make assumptions for them, you need to ask.

It’s also key to realize and to communicate to patients that you have many tools in your toolbox to help them navigate through various situations and to enable them to keep wearing lenses as their presbyopia evolves. Make sure that you understand the specific situations/reasons for wanting to avoid use of glasses. The three typical areas are appearance, convenience, and functionality; each may lead to different solutions.

Appearance Sometimes people avoid reading glasses or progressives out of fear of looking old in front of their friends or colleagues, but they have no absolute objection to wearing them when out of the public eye. Others may actually enjoy wearing glasses in some situations for appearance reasons. Helpful questions include:

• Is there something specific about how you look in glasses that bothers you?
• Are there times that you would prefer to not wear glasses or that you wouldn’t mind wearing glasses?

Convenience If someone is often on the move between meetings, different projects in the home, or many activities with varying distance and near tasks, having to locate their readers may be very frustrating. Solutions could include having multiple pairs staged around the house or workplace or using PALs, but this is a great opportunity to suggest MF CLs, which travel with them everywhere. Helpful questions can include:

• What does a typical day look like for you in terms of near work versus distance tasks? How does this differ on the weekend or on vacation?
• Are there times when you do sustained periods of near or distance work in the same place each day at which you could keep a pair of supplemental glasses handy if required?
• How well can you control your environment (lighting, distance, contrast, image size, etc.) for your desired activities?

Functionality Some multifocal glasses can impair depth perception and edge-contrast sensitivity at distances critical for detecting obstacles in the environment and have been associated with trips and falls in the elderly.^14,15 In fact, the effect was demonstrated for bifocal and trifocal glasses in addition to PALs, so it appears to be an effect of looking through plus-powered additions in general. If a patient has concerns about PALs or multifocal glasses while driving or navigating stairs, etc., CLs could help in those situations, and multifocal glasses could still be used for more sedentary situations. Helpful questions include:

• Are there things that you feel you just can’t do well in glasses?
• Are there specific situations for which using PALs or multifocal glasses concerns you?

Multifocal Contact Lens Design Options In recent years, consensus has become quite clear with regard to the monovision-versus-multifocal question, and the science is largely in favor of MF CLs.¹⁶ Monovision reduces binocularity, binocular summation, and, therefore, high-contrast visual acuity and offers a limited window of success for patients—essentially wasting the period when adapting to MF CLs is arguably easiest.^17,18 Further, several studies show that when exposed to both monovision and MF CLs, both early and more mature presbyopes prefer MFs,^11,18-20 the wear of which helps practitioners keep them satisfactorily corrected through the evolution of their presbyopia.

With rare exceptions, today’s soft MF CLs offer a choice of center-near aspheric designs or a zonal aspheric system consisting of a center-near design paired with a center-distance design—an evolved version of modified monovision. Among the many center-near designs, one also offers pupil size optimization to account for changes with age and refractive error as well as a hybrid aspheric-center/spherical-periphery design for improved centration. These are potentially important considerations, as pupil size is known to decrease with age and refractive error; myopes and patients of younger ages have larger pupils than do hyperopes and patients of older ages.^21-23 The desired optics may be compromised if any mismatch occurs.²⁴ Placing the most critical near optics in the center ensures that those powers will be available across a range of luminance for a patient with a given age and refractive error (Figure 2).

It is additionally important to ensure that the intermediate and distance optics are available and optimized within the given range of pupil sizes. It follows, then, that centration of these complicated optics over a generally smaller pupil is also highly relevant, as decentered MF CLs induce significant amounts of third-order aberrations.²⁵

These factors should all be considered when deciding which fitting sets to incorporate into the practice and when selecting a lens of first choice. It is certainly not necessary to carry all of the possible designs, but having two that offer unique fitting approaches is probably wise, with an overall preferred design to act as first choice. In addition, with the complexities inherent in MF CL fitting, having consistency in designs across materials and modalities from the same manufacturer can provide some advantages.

Lens Material, Modality, and Other Features Having access to both hydrogel and silicone hydrogel materials as well as to both daily disposable and reusable lenses in the practice enables you to satisfy a wider range of patient needs. Hydrogels are known for their demonstrated ability to maintain a low inflammatory response, and they provide acceptable levels of corneal oxygenation, with a low infection risk profile when worn for daily wear.^26,27 Silicone hydrogels provide improved corneal physiology from decreased hypoxia across a wide range of powers and thicknesses and may offer some long-term wearers a comfort benefit, though this is very difficult to predict.^7,28 Daily disposability offers superior flexibility and convenience, and reusable lenses offer a cost-effective option for many wearers.

THE REROUTE

As 2020 more than adequately demonstrated, life doesn’t always go as planned, and sometimes we will need to make course adjustments. Keep in mind that with MF CLs, very small tweaks can result in large differences. A few hints can help you determine when to make a small adjustment, when to make a radical course change, or when to postpone the trip altogether! Always follow the manufacturer’s fitting guide, and avoid making changes until after patients have “lived” in their world with the lenses for several days. General guidance is as follows:

• To improve distance performance, lower the add in the most affected eye.
• Always use real-world near situations and materials to evaluate range and near functionality—not visual acuity charts or cards.
• To improve near performance, increase plus in +0.25D steps in the distance power (if tolerated); test by adding plus lenses with both eyes open and viewing the target.
• Limit lens changes to one or two at most; if not successful, change designs or try again another year! Motivations can change when people experience the ongoing challenges of presbyopia.
• Alter the environment (e.g., improve lighting or change text size or working distance) to enhance near performance.
• Use distance or reading glasses to “fill in” for occasional use in irregular or unique situations such as theater, movies, and night driving.

POST-JOURNEY WRAP UP

Fitting MF CLs provides a great opportunity to gain personal and professional satisfaction. Once you experience the “wow” moment when presbyopic patients realize that they can actually do the activities that matter to them without glasses, you’ll want to do it again and again.

It’s similar to fitting glasses or contact lenses to young myopes who didn’t realize what they were missing in the world—the reactions of successful patients are immensely satisfying! Dedicating yourself to a positive and flexible approach to fitting presbyopic patients with MF CLs provides a great opportunity to not only gain this satisfaction but to differentiate yourself and your practice.

The benefits of MF CL fitting to your practice can be summed up in “Three Rs”:

• Retention Chances are that you have a wealth of potential patients already in your practice. By tapping into your current CL wearers who are beginning to experience early signs of presbyopia, you have an excellent chance to help them continue to appreciate the benefits of CLs throughout presbyopia and to keep them in your practice. Chair time with current lens wearers will be reduced compared to non-contact lens-wearing patients, and the current lens wearers can be highly motivated to stay in CLs.
  If you occasionally need to add some form of spectacle vision correction to supplement MF CLs in cases of unusual or more extreme need, don’t present it as a failure but as just another tool in your toolbox to help them on their journey. Just having the conversation about options and exploring options can create tremendous loyalty to your practice.
• Referrals Never underestimate the power and pervasiveness of the “40-something grapevine.” Presbyopic patients have many presbyopic friends, and being the only one not borrowing readers or using the phone flashlight to see the menu at a restaurant is sure to attract attention and generate questions. And, presbyopes have families as well, so you may gain younger patients as an added benefit.
• Revenue Confidently fitting MF CLs is still a rare skill—and a specialty—so charge appropriately for your services. It is well established that when looking at all income to the practice, a CL patient is significantly more profitable over the long term than a spectacle-only patient is.²⁹ Successful MF CL patients will virtually always be dual wearers of CLs and glasses, often high-margin glasses such as progressives. So, consider a fee structure that covers a “suite” of solutions that also includes pricing and policies for sunglasses and spectacles or that offers some form of credit toward spectacle options if the CL option ends up not working out. Promotions can encourage patients to check out more products in your practice, and that perfect pair of non-prescription sunglasses may help tip the scales in favor of the CLs!³⁰

Finally, have fun! Use all of your tools, and always follow the manufacturer’s fit guide. Be proactive about offering the option to both current CL patients and to new presbyopes, and persist even when you hear a series of “No’s.” A seed planted this year could bear fruit in the future. CLS

A similar feature article appeared in the May 7, 2021 issue of Optician.

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