As our population continues to age, optometrists can anticipate caring for a rising number of patients struggling with presbyopia.
For many, the onset of presbyopia marks the first time they have trouble with near vision. This decline in vision can have profound impacts, including diminished quality of life, anxiety, eyestrain, and reduced productivity—resulting in significant economic losses for society as a whole.1,2
When presbyopes turn to providers for assistance, we must thoughtfully manage their expectations and create a personalized treatment plan that maximizes functionality, prioritizes comfort, and promotes their overall sense of well-being.
Addressing the needs of presbyopes with multifocal contact lenses
Spectacles and contact lenses are among the most commonly prescribed corrective solutions for presbyopia.3 While spectacles remain a reliable choice, many presbyopes prefer contact lenses for added convenience, flexibility, and aesthetic appeal.
Recent advancements in contact lens technology have positioned multifocal contact lenses as an optimal choice for presbyopic individuals seeking a seamless blend of comfort while not compromising vision correction.
A comfortable wear experience is desirable for all contact lens wearers, but it holds added significance for aging eyes that are vulnerable to ocular surface diseases (OSDs).4
Today's multifocal contact lenses are specifically designed to improve the fit, retain moisture, enhance breathability, and reduce irritation. These enhancements are achieved with cutting-edge silicone hydrogel lens materials combined with improved lens designs and manufacturing techniques.5,6
Multifocal contact lenses, presbyopia, and the aging eye
Despite significant performance improvements in today's multifocal contact lenses, some patients may have trouble adapting to these lenses. These challenges are commonly associated with contact lens discomfort and suboptimal visual function.7,8
In some cases, these issues may result from deficiencies in binocularity, either as a standalone issue or secondary to contact lens wear itself.9 The aging population is also prone to develop astigmatism, light sensitivity, and other ocular and systemic co-morbidities that can affect contact lens performance.
Beyond poor vision, contact lens dryness is a primary contributor to patient dropout.8 To address this issue, practitioners should consider a lens with enhanced moisture retention properties to alleviate discomfort.
Additionally, presbyopia is frequently accompanied by age-related OSDs, such as dry eye disease, which can further complicate contact lens fit, diminish comfort, and disrupt vision.10,11 Addressing any deficiencies on the ocular surface prior to your contact lens fitting will set up the patient for success.
Notwithstanding these challenges, today's current multifocal contact lenses represent remarkable progress in narrowing the performance gap compared to glasses. Patients can now enjoy not only improved vision but also a greater sense of comfort and ease as they make the switch from conventional glasses to contact lenses.
Lifestyle and clinical factors that affect a multifocal lens fit
A common misconception is that only a specific subset of presbyopes are suitable candidates for multifocal contact lenses. Compared to other demographics, fitting contact lenses in presbyopes can pose additional challenges due to their complex visual needs and age-related changes to the ocular surface.
To determine the most compatible multifocal lenses, I start the discussion by exploring a patient's work habits and lifestyle. These factors significantly influence the desired performance in near and distance vision. They are also crucial considerations that complement clinical factors, such as pupil size and refractive error.
Elements in a patient’s medical history to consider for multifocal lenses
Prolonged computer use reduces blinking frequency and disrupts tear film distribution,12 so choosing a lens that helps to maintain adequate hydration is crucial. Patients who spend extended hours in front of digital screens are best suited for a daily lens that offers excellent intermediate vision and enhanced hydration.
Additionally, the candidate's previous experience with contact lenses and their desired frequency of lens wear can influence the choice of modality, such as daily versus monthly or bi-weekly replacement.
Other factors to consider when selecting the best multifocal option include:
- Duration of everyday use.
- Current medications that may impact accommodation, pupil size, or tear film integrity.
- Pre-existing ocular diseases.
Communicating the visual impact of multifocal contact lenses with patients
During brief patient interactions, it can be highly beneficial to discuss hypothetical scenarios in which multifocals can enhance daily routines. When limited to general lifestyle discussions alone, patients may not appreciate the potential benefits of multifocal lenses.
Further, relaying other successful multifocal wearers' experiences can help candidates better understand the tangible, day-to-day benefits and potential limitations that multifocal lenses would have in their daily lives. To address this, I typically initiate the conversation with two scenarios in which the patient is wearing multifocal lenses.
Outlining conditions where multifocal lenses can address patients’ visual needs
In scenario one, I ask the patient to imagine they are driving down the road with a 20-year-old passenger. I ask if they think that while wearing multifocals, they would be able to see further down the road than their passenger.
Usually, the answer is no. However, I reassure the patient that they will at least feel comfortable driving on familiar roads, with maybe some glare at dusk and nighttime. I also emphasize that, while wearing multifocal contact lenses in this scenario, their GPS and dashboard should remain clear.
In scenario two, I ask the patient to imagine they are wearing multifocals while engaging in near activities. I explain that threading needles, reading medicine bottles, or reading instructions on tax forms, for example, will be highly visually demanding activities with multifocal lenses.
For up close, realistic goals include comfortably reading a dinner menu in normal lighting, checking their phone and watch, and working on the computer for a few hours at a time.
By providing comprehensive education, I aim to empower patients with the knowledge to co-determine if multifocal contact lenses best suit their presbyopic needs. This patient-centered approach places the candidate in greater control and enhances overall satisfaction.
Current multifocal contact lens designs
Recent introductions, such as the ACUVUE OASYS MAX 1-Day Multifocal and Alcon DAILIES TOTAL1 Multifocal contact lenses, combine the exceptional comfort of daily disposable silicone hydrogel material with better optics that help deliver consistent focusing power.
To accomplish this, ACUVUE OASYS MAX 1-Day Multifocal Lenses include three specific designs—TearStable Technology, Pupil Optimized Design, and OptiBlue Light Filter.13 These technologies work together to improve moisture retention, enhance fit, and filter blue-violet light.
Alcon's DAILIES TOTAL1 Multifocal Contact Lenses are another exceptional daily disposable option, with innovative Water Gradient Technology that elevates the water content at the lens surface to nearly 100%.14 The lens is also designed for high breathability, seamless vision at all distances, astigmatism correction, and stabilization of the lipid layer of the tear film.
As one of the latest entries in the daily multifocal contact lens category, INFUSE Multifocal contact lenses stand out by combining several innovative technologies into a single lens. The lens incorporates the proven 3-Zone Progressive Design, an optical approach that accounts for seven biometric factors, including pupil size and adjusting for higher-order aberrations.15
INFUSE Multifocal Contact Lenses are crafted from kalifilcon A, a silicone-hydrogel material that received FDA 501(k) clearance in 2020.16 Kalifilcon A was uniquely designed for advanced moisture retention—the lens contains a 55% water content, with 96% of its moisture maintained after 16 hours of wear time.17
The lens also maintains a low modulus of 0.5MPa, which offers more flexibility, improved comfort, and reduced inflammation from evaporative stress. A 134Dk/t yields improved oxygen transmission while preventing corneal hypoxia and hypoxic stress.18,19
Inspired by the findings of the Tear Film & Ocular Surface Society Dry Eye Workshop (TFOS DEWS) II, INFUSE Multifocal Contact Lenses contain a unique combination of osmoprotectants, electrolytes, and moisturizers that help maintain ocular homeostasis and hydration.17,20
Improved multifocal contact lens fitting experience
INFUSE lenses have also gained positive reception among providers, who commend the simple 2-ADD power setup for making fitting incredibly easy. In addition, because these lenses integrate the same 3-Zone Progressive Design as ULTRA Monthly contact lenses, practitioners do not need to adapt to fit a new optics system.
In one noteworthy case, a hyperopic individual with moderate presbyopia wanted the convenience of daily disposable modality for part-time lens wear after 3 weeks of wearing ULTRA for Presbyopia Monthly lenses. Following a trial of INFUSE multifocal contact lenses, the patient reported comfort in their vision while enjoying the same flexibility in the optics system that they already knew and loved.
In another case, a high myope (about -6D) with moderate presbyopia presented with a primary complaint of experiencing poor distance and near vision while wearing DAILIES TOTAL1 Multifocal lenses. DAILIES TOTAL1's minus peripheral edge design can offer great optics at a distance, which makes it a preferred option among my myopic patients. However, a common error lies in prescribing patients with excessively high ADD powers, which leads to disruptions in both distance and near vision.
After hearing this complaint, I transitioned the patient from a high ADD to a medium ADD and introduced a +0.50D sphere for distance vision. We next looked outside the exam room to the street signs for a realistic vantage point. Finally, I incrementally adjusted the plus power until the tradeoff was noticeable.
Takeaways for matching patients with multifocal contact lens designs
In addition to the considerations mentioned above, eyecare practitioners can utilize these additional strategies:
- Foster close relationships with colleagues and lens manufacturers' support teams to navigate challenging cases.
- They can offer valuable guidance beyond the fitting guide in complex situations.
- Keep the fitting guide readily available to increase the likelihood of a successful multifocal fitting process.
- Cultivate fitting expertise by initially mastering one or two brands of multifocal contact lenses.
- This approach empowers eyecare practitioners to understand the strengths and limitations of each brand, ensuring the best fit for every patient.
A holistic strategy to multifocal contact lenses
Fitting multifocals can be both challenging and enjoyable for practitioners. Rather than focusing on identifying candidates suitable for multifocals, providers should prioritize finding the ideal lens for each patient.
Ultimately, approaching multifocal contact lens fitting with the right mindset and strategy can bring immense satisfaction to both practitioners and patients.
