AROUND 30% OF MY PRACTICE IS PRESBYOPIC. FOR SOME OF you it is more, and for others a little less. But the reality of presbyopia is not going away. We see it daily and experience the frustrations of our patients. While no treatment returns us to the vision of our youth, we continue to advance in our treatment options and our understanding of how to better use those treatments.

One treatment option that often gets pushed to the side is multifocal contact lenses. Several opinions have given multifocals a bad rap, but they have some major advantages. I’d like to discuss 4 steps to help make multifocal lenses matter in your practice. Whether you fit the lenses or your technician does, look at these solutions for added success.

1 Eye Dominance

Many of you skip over this section. After all, we have a 50:50 chance of getting this factor correct, right? Wrong. I have observed in my practice that few patients have a singular strong dominant eye. Rather, I have observed three possibilities:

• A strong affinity to use both eyes together;
• A weak affinity to need to use both eyes together; and
• A strong affinity to use one eye for distance and the other for near.

Most of us gravitate toward the third option for our patients and assume that we can provide a better near eye and a better distance eye. However, this assumption leaves out a substantial number of patients. If a patient has a strong affinity for his or her eyes to work together, when we provide a strong near lens in one eye and strong distance in the other, the patient will not like it.

To determine eye dominance, look to the swinging +1.50 lens test in the distance to show you how the patient will adapt. If patients have a repulsion to the lens in front of either eye, they are type 1. If they can’t tell the difference, they are type 2. If they notice a big difference between the eyes, then they are type 3.

For type 1 patients, make sure to have even adds between the eyes. For type 2 patients, mix and match however you like for best success. For type 3 patients, do a traditional fitting, maximizing distance in the distance eye and near in the near eye.

2 Consider Your Options

I see patients every year who have failed with past multifocal contact lens options, and we always try them in something new. This may be a new soft lens that has just come on the market, a new gas-permeable (GP) multifocal, or more recently, scleral multifocals. If you can make the finances and time constraints of multifocal fitting work for patients, they generally will be very eager to try new things and will hail you as an innovator, saying you are always looking for new and better options for them.

3 Decentered Optics

Sometimes our patients are not symmetrical! Wait, what? Yes, sometimes one arm is longer than the other, one leg is shorter than the other, and sometimes the geographic center of the eye does not align with the visual axis. This is the reason that many of our surgical colleagues slightly decenter the intraocular lens. With contact lenses, most of them have the optical center of the lens aligned exactly with the geographic center of the cornea. As such, when our patients look through their multifocals, they are not getting the exact vision that the lens is intended to provide.

We have a solution! Labs are now starting to take this point into consideration. When ordering custom (soft and scleral) lenses from labs, you may be able to request a relocation of the optical center of the lens so that it will align with the visual axis of the patient. This may help to reduce glare and halos, and it will often make the patient’s vision much better.

4 Scleral Multifocals

GP multifocals traditionally have fit into aspheric designs or translating lenses. Both of these lenses are very dependent on where the lens centers and how it moves. All movement and lens/lid interaction must be taken into account in order to be successful for the patient. With a scleral lens, we place the lens on the eye and find the optic center, and it does not move. Then, we are able to adjust the optics so that they best fit the patient. Having a still optic location gives scleral lenses some (not all) advantages over soft lenses and other moving GP lenses.

There are many methods to make multifocals matter. Try implementing some of these methods to see whether you can gain a higher level of success in your practice! ■

Dr. Kading owns 3 practices in the Seattle area (Specialty Eye), focusing on dry eye disease, specialty lenses, and front of the eye problems. He performs research as part of the postgraduate residency that he hosts in Seattle, and he lectures internationally.