It has been estimated that presbyopia affected 1.8 billion people, or 25% of the world’s population, in 2015, and this number is expected to be at least 2.1 billion in 2030.¹ In 2019, 41.8% of the U.S. population was aged 45 or older.² As a result, increasingly more patients require presbyopic vision correction. A recent bibliometric study reported that multifocal contact lenses (MFCLs) have shown exponential growth, and this growth shows no signs of slowing.³

This article provides an overview of current attitudes and beliefs relating to presbyopia and MFCLs, requirements for presbyopic contact lens (CL) correction, and MFCL design options. It also investigates prescribing trends for MFCLs, recommendations for prescribing, and patient satisfaction with MFCLs.

PRACTITIONER BARRIERS

Despite presbyopic patients representing an ever-increasing opportunity for prescribing CLs for vision correction, many eyecare professionals (ECPs) continue to be reluctant to offer MFCLs to their patients. In an international survey investigating CL prescribing for presbyopia between 2005 and 2009, Morgan and coworkers hypothesized that the principal barriers to fitting MFCLs were a lack of fitting skills, technical knowledge, product awareness, and clinical confidence among ECPs, along with the general preconception that visual compromises introduced by available presbyopic designs were too great.⁴

However, in a survey conducted in India, ECPs who were actively fitting MFCLs reported that their primary motivators in prescribing these lenses were professional satisfaction and enhanced business opportunities. Furthermore, these ECPs reported that their success in MFCL fitting was enabled by increased confidence due to trial lens availability and correct patient selection.⁵

WEARER PERCEPTIONS

Interest in CL wear has been reported among presbyopes. In a survey investigating the opinions and vision correction preferences among 496 presbyopic and pre-presbyopic individuals, 57% of the presbyopic spectacle wearers reported having attempted wearing CLs (although this could have been prior to becoming presbyopic), and 67% reported that they would prefer to wear CLs.⁶

Indeed, the authors concluded that presbyopes, regardless of all refractive error, prefer CL correction when they are able to achieve good vision and comfort with them. Additionally, the authors cautioned that ECPs should not have preconceived notions regarding whether presbyopia, refractive error, or gender are factors that would preclude a patient from being interested in CL wear.

There are only limited reports of the effect of presbyopia and presbyopic vision correction on quality of life (QoL); however, these are factors that are known to have a negative impact on individuals’ day-to-day activities and self-esteem, compared with younger and emmetropic individuals.⁷ Kandel and coworkers qualitatively explored issues related to refractive error (including presbyopia) that affect people’s QoL.⁸ The most prominent theme was the participants’ concerns about their cosmetic appearance with glasses, although difficulties carrying out day-to-day activities and inconveniences of glasses, along with economic implications relating to vision correction, were also identified as being important.

MFCL OPTICS

The majority of soft MFCL designs incorporate two or more power “zones” that continually cover the pupillary area, resulting in multiple images being superimposed on the retina. The patient’s brain suppresses or ignores the blurred images and chooses the one that is clearest for the visual task being undertaken.⁹ The term “simultaneous vision” is frequently used to describe MFCL designs; however, as these CLs do not rely on movement on the eye, as is the case with GP alternating or translating designs, the preferred terminology of “simultaneous image” designs is recommended.⁹ By increasing the depth of focus, the reduction of amplitude of accommodation that occurs with presbyopia can be counteracted; however, visual performance can be compromised, particularly in conditions of low lighting.¹⁰

MFCLs can be broadly classified as being spherical, concentric (or annular), or aspheric, and having more than two refractive powers, or a combination of these design features. Concentric MFCL designs usually incorporate a primary viewing zone in the center of the lens which may be of greater plus power (center-near) or less plus power (center-distance), surrounded by concentric rings of near, intermediate, or distance powers.¹¹ These lens designs differ from soft bifocal CL designs, which only incorporate two distinct powers in different zones, one power for distance vision and one for near vision.^11,12

Aspheric designs allow MFCLs to incorporate a progressive, radially symmetric gradation of power across the optical zone with either greater plus power in the center of the CL (center-near) and controlled amounts of negative spherical aberration, or greater plus in the periphery (center-distance) and controlled amounts of positive spherical aberration.^19,12

Figure 1 illustrates examples of concentric and aspheric MFCL designs. In addition, some manufacturers have developed further nuances to these designs. One MFCL utilizes a center-distance concentric design that incorporates alternating aspheric zones of power,¹³ another incorporates a center-distance zone that transitions into an aspheric intermediate power surrounded by a spherical near power annulus in the peripheral optic zone, and the center-near design has a spherical distance power ring in its periphery.¹⁴ These lenses can be prescribed contralaterally in order to optimize individual patient requirements.¹⁵

MFCL PRESCRIBING DATA

In 2011, Morgan and coworkers published the results of international surveys conducted to determine worldwide patterns of fitting contact lenses for the correction of presbyopia over a preceding five-year period.⁴ The authors reported at that time that there appeared to be significant under-prescribing of CLs for the correction of presbyopia, but that for those fitted with CLs, three times more MFCLs were prescribed compared with CLs for monovision correction.

The International Contact Lens Prescribing Trends Consortium has continued to conduct the surveys each year since 2003. In addition, a recent report evaluating seven key markets (169,440 fits across all ages in Australia, Canada, Japan, the Netherlands, Norway, the United Kingdom, and the United States) showed an increase in fits to presbyopes from about 20% of all fits to about 35% in 2019.^16,17

Figure 2 illustrates these findings, along with MFCLs and monovision CLs that were fitted as a proportion of all soft lens fits. Although presbyopic wearers account for 35% of all fits, only about 20% of lenses are either MFCLs or monovision; a significant number of presbyopes are still fitted with single vision CLs used in conjunction with spectacles for reading. In 2003, only 30% of presbyopes received a multifocal or monovision correction; however, this increased to 58% in 2019, primarily due to the increase in MFCL prescribing and the increased availability of daily disposable MFCLs.

Furthermore, the prescribing of MFCLs was found to be relatively high in young presbyopes (45 to 54 years) and mid-presbyopes (55 to 64 years), but less common in older presbyopes (65+ years). While MFCL fitting has increased significantly over the last 17 years, prescribing of these lenses is still relatively low, highlighting that they are under-indexed in the vision correction category compared to their potential. There is undoubtedly a huge opportunity for ECPs to prescribe more MFCLs.

According to the International Contact Lens Prescribing Trends Consortium, MFCL prescribing has increased from approximately 25% of lenses fitted to presbyopes in 2005 to around 50% in 2020 (Figure 3), with a further 10% of this group being prescribed CLs for monovision. This suggests that close to 40% of presbyopes were being fitted with single vision, distance-only correction, presumably to be used in conjunction with spectacles for reading. The Consortium also reported that overall, the proportion of presbyopes within the cohort of CL fittings has increased over the past 15 years.¹⁸

PATIENT/LENS SELECTION

Lens selection for individual presbyopic patients should be guided by consideration of all the patients’ visual needs and the degree to which distance, near, or intermediate tasks dominate their daily activities. For successful MFCL fitting, the correct lens selection and ECP expertise should be considered. It is important for the lens to be fitted to the patient, and not the patient to the lens.

As success is also influenced by age and, hence, near addition power, these factors should be considered when fitting patients with MFCLs. ECPs need to consider the working distance and illumination encountered by presbyopes while they are conducting habitual tasks at home or in their workplace.¹⁹

Patient selection considerations (e.g., degree of refractive error, astigmatism, age, prior contact lens wear, motivation, etc.) and their habitual tasks, visual demands, and viewing distances (e.g., computer work, writing, driving, sports, etc.) should also be carefully considered when determining the optimal MFCL design and modality of wear.^19,20

If an MFCL is offered in both center-distance and center-near designs, ocular dominance should be assessed, following the manufacturers’ fitting guidelines.^14,15 In some cases, toric MFCLs may be prescribed to correct both presbyopia and astigmatism, providing optimal distance, intermediate, and near visual performance without compromising binocular vision.²¹

SATISFACTION WITH MFCLS

ECPs would benefit greatly from being able to better predict which of their presbyopic patients can be successful with MFCLs. Zeri and coworkers have summarized the primary factors that are considered to be important for the success of presbyopic CL wearers.²² These include the type and degree of refractive correction, the overall ocular health and tear film quality, and a number of personal characteristics of the patient. The authors subsequently conducted a multicenter survey designed to clarify some of the factors predicting the success or failure of CL use among presbyopes. Both successful and unsuccessful wearers completed the survey and the most important reason for continuing to wear CLs was convenience (61%), while the most important reason for discontinuing wearing CLs was poor vision (80%). The absence of astigmatism, higher subjective satisfaction, better subjective perceived vision at distance, and a lower subjective loss of visual contrast were all found to be able to predict the success of CL use for presbyopia.²²

Rueff and coworkers conducted a survey of current or lapsed presbyopic CL wearers that was designed to determine the reasons for discontinuation and the opinions relating to comfort and visual quality with CLs.²³ The authors reported that among presbyopes, vision and discomfort were equally reported as primary reasons for CL dropout, followed by inconvenience.

These findings differ from previous studies investigating discontinuation from CL wear, in which dryness and discomfort have been reported to be the primary reasons.^24,25 However, the higher proportion of participants reporting poor visual quality as their reason for discontinuation is consistent with the findings of Sulley and coworkers, whose study sample included a higher proportion of presbyopes.²⁶ Rueff and coworkers also noted that CL wearers who start their use after the onset of presbyopia are no more or less likely to drop out of lens wear than habitual wearers.²³

As there are several different MFCL designs available, it would be expected that design may play a role in the overall success of presbyopic patients who are prescribed these CLs. One multicenter study was designed with this specific objective in mind.²⁷ In the study, 150 successful single vision soft CL wearers were randomly assigned to wear either a spherical near-center lens, a distance-center lens, or an aspherical near-center lens. After one month of wear, a higher proportion of the individuals randomized to the spherical near-center lens had discontinued when compared with the other two designs. The principal reason for discontinuation was poor vision: 32% reported poor distance vision and 28% reported both poor distance vision and poor near vision.

The criteria for satisfaction and success with MFCLs is not well defined and will also vary significantly for the individual wearer. While some presbyopes may expect to be able to successfully wear their MFCLs every day of the week for all waking hours and all visual tasks, others may be extremely satisfied with a more part-time wearing schedule that allows them to realize the benefits of MFCLs for work, sporting activities, or social occasions. It is therefore extremely important for the ECP to discuss each patient’s expectations and requirements for MFCL wear at the outset.

PRACTICE GROWTH OPPORTUNITIES

Given the rapidly increasing number of presbyopes worldwide, MFCL fitting is an often-overlooked practice-building opportunity. ECPs are encouraged to bring up MFCLs with all presbyopes, regardless of the type of visit for which they are in the office. Having routine conversations and educating presbyopic patients about MFCLs and their benefits goes a long way toward building a multifocal practice.^28,29

Discussions encouraging MFCL wear should be a practice-wide commitment, not just between the ECP and patient. In addition to improving patients’ vision and quality of life, MFCLs provide a way to build a practice and increase profitability from professional fitting fees and multiple eyewear purchases.

Conversely, contact lens dropout in early presbyopia can have a significant long-term impact on a practice in terms of lost revenue over time. Factors such as multiple correction-type purchases, additional fitting fees, and frequency of follow-up make contact lens patients more profitable on average than spectacle-only wearers.³⁰

CONCLUSIONS

The number of presbyopes worldwide is rapidly increasing, and while a high proportion will continue to be prescribed spectacles, increasing numbers of patients are expressing interest in MFCL correction, and ECPs’ attitudes toward recommending and prescribing these CLs is changing. MFCLs are a great option for new and established presbyopes, offering good vision performance with the added benefit of improved cosmesis and convenience compared to spectacles. CL manufacturers are continually innovating in this area, with the increased availability of soft MFCLs that have novel designs in a range of replacement frequencies from daily disposable to monthly replacement and different materials, including silicone hydrogels.

Successfully fitting MFCLs provides ECPs with enhanced professional satisfaction and business opportunities. Helping to prevent presbyopes from lapsing and introducing new wearers into the CL category can improve patient loyalty and profitability.

Fortunately, there is now a wide range of MFCL designs and materials. Yet, while selecting the most appropriate option for each individual patient is so important, it is no longer a case of “should I prescribe a MFCL?” but rather “which MFCL should I prescribe?” For the greatest opportunity for success, ECPs need to counsel patients on how MFCLs work, expectations, and potential benefits associated with their wear. Individual patient visual demands must be carefully considered and the appropriate fitting guides and recommendations for adaptation should be closely followed. CLS

A similar article appeared in the October 2021 issue of Optician.

This article was funded by CooperVision Inc.

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