PRESBYOPIA CAN BE one of the most challenging visual conditions to resolve with contact lens wear. It is critical to have many fitting tools and focus on the follow-up appointments to ensure a successful fit. Though there are medical conditions that can complicate contact lens wear, visually speaking, presbyopia is the toughest to match a patient’s expectations.

“Matching expectations” is the key phrase there, as many patients don’t understand why there is not a simple pill or laser out there to fix presbyopia. Additionally, variability in outcome with the contact lens technology is by far the biggest reason for not matching those high visual expectations.

Eyecare providers are used to determining a patient’s refractive error and correcting that error perfectly. Unfortunately, with presbyopia, a wide variety of demands are made on each and everyone’s visual system throughout the day. Some patients are happy with 20/20 at distance and 20/50 at near, while others are frustrated with 20/20 vision at distance and 20/20 at near. For those reasons, it is important to have a full tool bag of contact lens designs, materials, fitting techniques, and tricks of the trade. Here are a couple helpful tips:

1. Pivot early if needed. Be ready to change designs if things are not going in the right direction early on. Sometimes a presbyopic patient is being fit with multifocal contact lenses and they are not happy with their vision. The eyecare provider makes a change based on the fitting guide and their experience, but the patient returns complaining even more about their vision. Pivot to something different, like another design, material, or technique. Three different things will often occur after that:
   1. The patient returns with things improving and seems to be on the right track to a solution.
   2. The patient returns saying the change made their vision even worse than before. They will often realize their original vision was better than they thought.
   3. The patient returns and is still not happy, but offers their own ideas, like trying something they heard a co-worker or friend was doing. For example, they might say they think they want single-vision distance contacts with over-readers. This is a common “patient pivot” that rarely works.
   None of these ideas are wrong—but understand that it is difficult to predict how the fitting process will go. Some presbyopic fits go smoothly, while others can take the eyecare provider in circles. It is OK if things get worse; do not be afraid of that. Make the effort to try something new early on; even if it fails, it is still important information to achieve a successful contact lens fit.
2. Keep your eye on patients’ unique visual needs and customize based on those needs. I continue to refer to that idea during the fitting process. For example, when a patient returns and states they are having a hard time seeing someone’s license plate with their multifocal lenses, ask them how many times they are doing that throughout the day. If the patient is a police officer, that is probably a more important task than it is for someone who works on the computer most of the day. Focus on providing good vision for 90% of the visual tasks that the patient performs daily and use the newest technology and proper fitting tips to help accomplish that.Presbyopia and contact lenses can be a challenge, but they can also be very rewarding. Understand your protocol and stay firm on that process. It’s fine if you try something and the patient feels like things get worse. Log that response into their chart as important information that will help in the long run. Continue to add to your tool bag of techniques that will enable successful contact lens fits with presbyopia. CLS