Most of the new contact lens fits I’ve done recently have been multifocal lenses.  I tend to ask about contact lens wear at the beginning of history and symptoms, after talking about hobbies and current visual correction.  I do this for everyone, including presbyopes.  Even if someone seems unsure about lenses, I’ll describe how they work and then say, “I can order you in a trial, if you want.  I’ll let you think about it and you can tell me at the end of the eye exam.”

Bringing the subject up at the start and giving the px time to mull it over seems to work.  A good number of the presbyopes I test end up trying multifocal lenses.  At the beginning of my pre-reg, I would ask about previous CL wear during history and symptoms and then not mention it again until making my recommendations and usually, the “I could order a trial for you” was met with a polite “No, thank you.”  That 20 minutes between explaining and asking really seems to work.

Anyway, I wanted to write about my experiences fitting multifocals.

First of all, you may remember the lady I fitted with monovision who thought her reading glasses made her look old.  She’s still doing really well with monovision but, if I could go back in time, I would try and fit her with multifocals instead.  Why? Well, multifocals are better for intermediate distances than monovision and so, ideal for someone working in an office environment.  Wearing only one lens has the benefit of being cheaper but there is a limit to the “add” power that most people can tolerate.  My patient may be fine at +2.00DS but struggle at +2.25 or +2.50DS.

As an interesting aside, I recently saw a lady who was a long-time monovision CL wearer (wearing a J&J lens) who had a cataract in her (uncorrected) distance eye but not the one with the lens.  Her VA was now 6/9 in her “distance” eye but still 6/5 in her “reading” eye.

Anyway, I have come to see monovision as a temporary solution.  The Plan B if multifocals are too pricey for the patient or if the patient can’t come to terms with the loss of contrast that comes from the multifocal design (I have had this happen a couple of times).

So, you’ve got a presbyopic patient who is interested in trialling multifocals.  If they have worn lenses before, find out which ones and how they got on with them.  If someone likes Oasys and currently wears it then try Oasys for Presbyopia.  Many of the lenses on the market have a multifocal equivalent so you can stay in the same lens family.

If my willing presbyope has never tried lenses, I talk about daily and monthly lenses.  Now, I don’t like fitting the Focus Daily Progressives (have a look at the fitting guide if you want to try them but I’ve not had much success – they seem to move around a lot) so I would go for the Clariti 1-day MF if they wanted a daily.  There aren’t many MF daily lenses on the market and they are pretty expensive so I tend to fit monthlies more than dailies.

For a monthly lens, you have lots of options for a spherical Rx but if someone has -0.75DC or more, you may have to look at toric multifocals.  The two toric multifocals I tend to fit are the Proclear MF Toric and the mark ennovy Saphir MF Toric.  The Proclear is a giant (14.5mm) lens with a very blue tint – I’ve had pxs reject it based on the tint, believe it or not, as you can see a blue circle around their iris when they are wearing it.  Strangely enough, the Saphir has the opposite problem – the handling tint is very very light so some pxs have difficulty finding the lens in the case.  The Proclear is a hydrogel material and it comes in centre near and centre distance.  The Saphir is a silicone hydrogel and has the advantage of coming in a wide range of base curves, adds and axes.  I really like this lens.

mark ennovy also do a new MF toric (Gentle 80) but I haven’t tried it yet.  Given my success fitting the Saphir, if it’s a similar design, it should be a good lens.  Here are the specs/fitting guide for the Saphir:

http://www.markennovy.com/en/products/product-catalogue/saphir-rx-monthly/item/23-saphir-rx-mf

And the fitting guide for the Proclear:

https://coopervision.com/sites/default/files/PCMF%20Toric%20Fit%20guide_XLITERAPRO029-2May2008.pdf

Okay, so, if someone was interested in a MF toric, like any MF lens fit, I would test to see which was their dominant eye.  The recommended way of doing this is to pop their distance Rx in the trial frame, put on the chart and then add their reading addition to one eye then the other.  The eye that is the most blurred/uncomfortable with the add in place is the distance eye.  Ta da.  At this point, I will pop the reading add in the non-dominant eye and ask the patient to look at the distance chart then the reading chart a couple of times to experience what it’s going to be like when I fit them with the lenses.  I tell them that it’s normal to find this a little disorientating and that’s why we need them to try the lenses in the real world for a week (or two) – in order to get the brain used to it.

After your px has worn their lenses and adjusted to them, you can over-refract as usual at both distance and near.  It’s that simple.

Here’s 10 random tips:

1) The dominant eye should always be distance, except when it’s not.  Centre near lens designs such as Air Optix MF and PureVision MF are one exception, the other is for hyperopes.  Consult the fitting guide before you order.

2) Pxs should be asked to wear lenses for a week or two before modifying the Rx.

3) Warn your patients that the lenses might need to be tweaked a couple of times to get them right.

4) If someone falls between two MF adds (say they are +2.25DS and the lenses come in +2.50 and +2.00), always order the lower add first.

5) Don’t fit centre near design lenses on patients with very small pupils.  They’ll be getting reading Rx only.

6) For those presbyopes who want extended wear: you can sleep in Oasys for Presbyopia for up to a week, Biofinity MF for a month and Purevision MF for a month.  Exercise the same caution with all EW lens wearers: see them after they’ve worn the lenses overnight for the first time, don’t wear EW lenses swimming, avoid getting water in the eyes, take the lenses out if the eyes are red or sore.

7) You can fit multifocals that maximise intermediate and near and then have a pair of over glasses with a little minus in it to sharpen up distance.  It’s like the opposite of reading specs! Great for those who just can’t handle the distance being a little blurry when driving/playing golf/etc.  I got my mother in law a pair of -0.50DS sunglasses for the golf course to wear on top of her MFs because we couldn’t find a balance between distance and near so I optimised near and intermediate in her lenses as she spends most of her time on computers, tablets, reading and watching TV.

8) Remember there will be a loss of contrast and some pxs will interpret it as blur.  Even though they can read 6/4.5, it won’t be as sharp as with their specs because of the MF design.

9) Tell your patients which lenses are suitable for them, give them a choice at each stage.  So, daily, two-weekly or monthly? EW? Tailor to their lifestyle.  If someone swims a lot, they can have monthly lenses and buy some dailies for use in the swimming pool (to be discarded after their swim) or just go for dailies.  If someone wants to wear the lenses for 14+ hours a day, then go for a SiHy.  If someone has hay fever or lid wiper epitheliopathy then a hydrogel (lower modulus than SiHy) might be better.  If someone is outside a lot without sunglasses (maybe running or playing sport), UV protection might be a good idea – J&J lenses have class one UV protection, for example, and Coopervision lenses such as MyDay have class two protection.

10) BE ENTHUSIASTIC.  If you wear lenses, tell your patients.  Tell them how much you love your lenses.  How great it is to walk in the rain or open the oven door without your specs steaming up or walking into a shop and buying a pair of sunglasses off the shelf.  For EW, it’s amazing to wake up at 3am and groggily look at your alarm clock and actually see the time.  If you don’t wear lenses, tell about all this stuff anyway.

While this is, by no means, an exhaustive guide to fitting multifocals, I hope you feel a little more enthused about them.  It’s not magic but to your patients, it sure seems like it.

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