Give Your Boomers a Boost: Update on Presbyopic Contact Lenses

Modern Management of Presbyopic Contact Lens PatientsThomas G. Quinn, OD, MS, FAAOI. PresbyopiaA. Population stats1. Over 1 in 4 patientsB. Predictable!1. First step to avoiding drop-out : inform the patient of what’s to comeII. Multifocals vs Monovision: You’re the DeciderA. The Standard Paradigm1. push a little plus in non-dominant eye to buy time2. push a little more plus the next year3. The result: Monovision4. Multifocals as a late arrival problem-solverB. What the Studies Show1. Multifocals preferred over monovision approx 70% of time2. Most challenging: near vision in low light* Situ, P et al, Successful Monovision Contact Lens Wearers Refitted with BifocalContact Lenses, Eye Contact Lens, July 2003.* Richdale,K., Mitchell, GL and Zadnik,K Comparison of Multifocal and MonovisionSoft Contact Lens Corrections in Patients with Low-Astigmatic Presbyopia,Optom.Vis.Sci, 83(5):266-273, May 2006.* Johnson T et al, Multifocals vs Monovision: A Comparative Study, CLAO, February2000* Rajagopalan et al Optom Vis Sci. 2006 Aug;83(8):611-5.C. The New Paradigm1. Start them in multifocals early2. Why haven’t we done this in the past?III. Presbyopia: New Rules of the Vision GameA. Single Vision Correction1. May get by with one primary form of correctionB. Presbyopic Vision Correction1. May need multiple toolsa. multipurpose progressivesb. occupational lensesc. contact lensesd. added light source2. Goal: “To design contact lenses that will meet most of your needs mostof the time”C. The Expectations Game1. “The Sandwich Approach”a. positive statementb. the “meat” of the messagec. positive statementIV. Translating GP Multifocal Designsa. Desirable patient characteristicsi. Lower lid position1. tangent to limbus ideal2. above limbus acceptable

3. below limbus undesirableii. Detailed near demandsb. Fitting pearlsi. Placing seg height1. at least 50 percent pupil coverage in down gaze2. not sure? Bias highii. Enhancing lens translation1. flatten base curve 0.50D2. increase prism 0.50Diii. Dealing with excessive lens rotation1. flatten base curve 0.50D (if WTR only?)2. steepen base curve 0.50D if ATR3. increase prism 0.50D4. truncationa. the upswept lower lid5. offset prism by 15 degreesiv. Solving the high riding lens1. flatten base curve 0.50D2. increase prism 0.50Dv. Assessing seg position and dynamics1. slitlamp2. ophthalmoscope3. subjective responsec. Dealing with the computeri. Computer glassesii. Trifocal designsiii. “seek the light”V. Toric Translating GP Multifocal Contact Lensesa. Moderately toric cornea: consider aspheric designsb. Highly toric cornea: consider translating designi. Stability of fitii. Vertical translation necessaryc. internal astigmatismi. correcting residual astigmatismd. Toric fit factorsi. SPE vs. CPE designVI. Aspheric Gas Permeable Multifocal DevelopmentsA. Prior limitations1. Translating designsa. lid positionb. intermediate distance2. Aspheric designsa. near visionB. Advancements in Manufacturing Optics1. Aspheric curvesa. back surfacei. prolate curve= center distanceii. oblate curve= center neariii. corneal topographic considerationsb. front surface

i. prolate curve= center nearii. oblate curve= center distanceiii. corneal topographic considerations2. Annular zonesa. center nearb. center distancec. controlling zone size3. Combining design featuresC. Desired Patient Characteristics1. Disposition2. Ocular characteristicsVII. Hybrid Multifocal DesignsA. SynergEyes MF1. Distinct central, spherical add; various powersB. Duette MF1. Oxygen permeable materials2. Aspheric center near add optics; no add power selection neededa. large depth of fieldb. guard against over-minusingi. +1.50 fog testVIII. Soft Multifocal DevelopmentsA. Prior Limitationsa. Compromise in distance visionb. Finding balance between distance and nearB. Fitting Guide <strong>Update</strong>sa. PureVision/ Soflens MFb. Air Optix MFC. The Biofinity MFa. Based on design principles employed with Freq 55/ Proclear MFb. Optics “tweeked”c. Silicone hydrogel materiald. Modified fitting guidei. Low adds, go “D” OUIX. CommunicationsA. <strong>Your</strong> attitude: empathetic, supportive, patientB. Take time to set patient attitude: The Sandwich ApproachX. Lens SelectionA. Detailed refraction1. No more minus than is absolutely necessary2. No more add than is absolutely necessaryB. Eye Dominance1. Sighting Dominance2. Sensory DominanceC. Follow the Fitting Guide1. Distance Rx: most plus power equivalent sphere2. Add: Follow the charts!

XI. Assessing PerformanceA. Scouting Report: release the patient from the exam room1. Open-ended questioningB. Real-world Environment1. Lights up!2. Binocular conditions3. Real world tasksXII. Enhancing PerformanceA. Knowing when to initiate change1. Symptom driven2. Just enough to get the job done3. The benefits of loose lensesB. Distance complaints: Follow the Fitting Guide!1. Usual need to improve vision in dominant eye (monocular VA’s)2. If low add, probably modify distance Rx (usually add minus)3. If high add, probably decrease add power4. If distance complaints persist and less than 20/40 distance VA in nondominanteye, use above strategies with non-dominant eyeC. Near complaints: Follow the Fitting Guide!1. Usually need to improve vision in non-dominant eye (monocular VA’s)2. Push plus in distance on non-dominant eye3. Increase add on non-dominant eye4. If near complaints persist and less than 20/40 near VA in dominant eye,use above strategies with dominant eyeXIII. The Astigmatic PatientA. Corneal astigmatism matches vertexed spectacle cylinder1. GP Multifocal2. Hybrid MultifocalB. Internal astigmatism1. Toric Multifocal2. Toric Monovision3. Toric Distance OU with readersXIV. Parting WordsA. To Patients1. “Light is your friend”2. “These lenses are designed to work together”3. “It’s a process”B. To You1. There is a need for MF contact lenses2. Be enthusiastic3. Communicate the benefits4. It’s about functionality