Fitting Contact Lens Multifocals for Astigmatic Presbyopes
Wm Edmondson MAT, O.D. Northeastern State University, Oklahoma College of Optometry
Abstract
This workshop provides clinicians with guidelines for successfully fitting the new generation of contact lens
multifocals for astigmatic presbyopes. Discussions of recently introduced multifocal designs are included.
Objectives
1.
2.
3.
4
5.
To utilize universal principles in fitting most hydrogel & GP CL multifocals.
To provide clinicians who only occasionally utilize bifocal contact lenses with hands-on experiences.
To identify & select patients with the most appropriate presbyopic corrections
To become acquainted with the basic “out-of-phoropter” techniques to evaluate the performance of
the multifocal contact lens & to utilize patient feedback to modify the dist. & add power of the lens
To incorporate the most current contact lens options to maximize patient success
Experience with Multifocal Contact Lenses for Astigmatic Presbyopes
A.
Specialty Soft Multifocals
1.
2.
Toric Hydrogel Multifocals
a.
Cibasoft Toric Progressive – CIBA Vision
b.
Proclear Toric Multifocal – CooperVision
c.
Other current designs
New developments and special uses
B.
SynergEyes Multifocal
C.
New Generation of GP Multifocals
a.
b.
Simultaneous-type multifocals
Alternating type multifocals
Soft Specialty Multifocals
1.
CibaSoft Progressive Toric Multifocal
a.
b.
c.
d.
e.
f.
CIBAVision
Single progressive add up to +3.00 / aspheric, center near design on back
Dist Rx: Sph: +9.00D to -9.00D / Thin Zone design
Cylinder: every 5 degrees & 0.25D from -0.75 to -2.75D Cyl
MTO : Made to Order/Custom  Tefilcon 37.5% / dk 8.9
B.C.:8.6 / 8.9 (42.00DK) / Dia. 14.5mm / DW: i.e. One lens
Ordering:
1.
Empirical: Call Ciba Technical Consultation: 1-800- 241-7468
2.
Use on-line calculator: http:www//virtualconsultant.cibavision.com
3.
Calculate yourself:
a.
Vertexed Spherical Equivalent Distance Rx + 1/2 the add Rx
b.
Include full cyl & round Axis to nearest 5˚
3.
Ex: Rx =-3.00 -1.00 x 180 /+2.00 add -> -3.00 + ½(+2.00 add) = -2.00
-> Calculated Order -2.00-1.00 x 180
Proclear Multifocal Toric
1.
2.
3.
SynergEyes M:
1
2.
3.
4
5.
CooperVision
Design: Center distance progressive multifocal for dominant (dist. enhanced eye)
Center near progressive multifocal for non-dominant (near enhanced eye)
a.
Distance Rx: PL to +/-20.00D Add: +1.00 to +4.00
b.
Cylinders powers/axis: -0.75 to -5.75 every 5 degrees
Lathed front & Molded Back toric, double-slab off with markings at 3 & 9 o’clock
c.
Group 2- 59% / Dk 34.0 / CT.07/ 8.4 / 8.8mm BC/ 14.4 dia. / handling tint
d.
Some clinicians prefer to start with steeper base curve
e.
Monthly replacement: 6-pack -> start with one Dx lens -> then order 6 pack
www.coopervision.com/us/fitting_tutorial_web
Ordering: Consultation: 1-800-341-2020 or calculate yourself
Hybrid Multifocal
Design: Hybrid – GP optics with soft skirt
a. Center progressive add
b. Astigmatism correction by GP tear film optics without orientational instability
Initial Parameters: Dist. +2.00 to -6.00 in 0.25D steps
Add Power: +1.25, +1.75, +2.25 Add dia. 1.9mm or 2.2mm
Other: Skirt Curve Radius: 1.0 (steep) 1.3 (medium); Lens Diameter: 14.5mm
Add Segment Base Curves: 7.10 to 8.00 in 0.10mm steps
Current GP Bifocal & Multifocal Designs
1. Simultaneous Vision GP Multifocals
a. Pts that have near point tasks at or above eye-level that would be difficult with
alternating contact lens bifocals i.e. plumbers, etc.
b. Fit by over-refracting a diagnostic lens or empirically ordering first lens
c. Renovation Multifocal:  Art Optical: Consultation: 1-800-253-9364
d. Improved design: Back surface spherical -> Dx fitting or call consultation
2. Alternating/Translating GP Multifocal Pt
a.
b.
c.
d.
MUST have a firm lower lid positioned at or slightly above lower limbus.
Near Rx positioned below line of sight when looking at distance -> used when looking down
TruForm Optical: Consultation 1-800-792-1095: LlevationsThin GP Multifocal: a Trifocal
X-Cel/Walman Consultation 1-800-241-9312: Solutions Bifocal : Crescent seg.
Universal Truths to maximize success in presbyopic fitting
This flow-chart “suggested” for maximum early success
1.
2.
Don’t rely on current glasses (or SV CL) Rx -> re-refraction
Selection of patients -> evaluate based on spectacle Rx and astigmatism
a.
3.
b.
Refractive cylinder:
1.
0.75D or less --------> Soft Multifocal or GP Multifocal
2.
0.75D-2.50D ------ --> GP/Soft Toric Multifocal
Other options ------- SynergEyes M
Significant Distance spherical spectacle Rx –> greater than +/- 1.00D
1.
Yes ---------> RGP or Hydrogel Multifocal
2.
No ----------> Alternatives to binocular multifocals:
- Multifocal in one eye only
- Traditional Monovision or near lens only
- Distance contact lenses plus reading spectacles
- Other
3.
Pre-fitting Consultation
a.
b.
c.
d.
4.
5.
6.
7.
Lens Selection: Use fitting guide for 1st diagnostic lens to try
Identify patient’s Dominant eye
a.
b.
Hole-in-card, camera, handed, camera, etc
Plus lenses: +1.50/+2.00 trial lens; phoropter blurring out 20/40
a.
b.
Use Flippers, Free lenses, or Trial frame,<-->
Evaluate Binocularly -----> Both eyes open —> “How do things look”
1.
Dist. ---> Initially use whole chart with 20/30 as bottom row
2.
Near ---> use magazines or newspapers: 20/40 to 20/30 print
Use Fitting Guide for Initial Lenses, Use time to let lenses settle & add motor activity
-> Have Pt walk out of exam lane.
Normal “room” illumination (Avoid mirrored rooms if possible)
Out of the Phoropter - Difference between success & failure
c.
8.
Modification based on Patient Feedback -> Problem Solving Spherical lenses
a.
b.
c.
9.
10.
Add trial lenses binocularly until you obtain the best balance between:
Distance vision vs. near: Add (+/-) O.U. -> depending if clarity needed at near/dist
“Cannot binocularly make distance sharp without losing near vision”
1.
Monocularly add minus to dominant eye,
a.
do not occlude non-dominant eye while testing
b.
typically -0.25D to -0.50D
c.
Both eyes still have a dist. and near Rx;
“Enhancing” distance in one eye”
2.
Use the next lower add in the dominant eye;
Enhances distance clarity:
“Near vision not good, but distance isn’t bad”
1.
Monocularly add plus to non-dominant eye
a.
Both eyes still have a dist. and near Rx
b.
“Enhanced” vision at near in non-dominant eye
2.
Monocularly use the next higher add in the non-dominant eye
d.
Success vs.failure: Typically monocular addition of 0.25D-0.50D power
a.
b.
c
Binocular acuity: for you and patient
Monocular acuity: for medico-legal documentation in chart
Reconfirm appropriate lens centration & movement with slit-lamp
a.
You will be working with them to “fine tune” their Rx to meet problems
and there may yet be lens changes
There may be an adaptation period (including slight shadowing of letters)
Night driving, be cautious (halos around lights)
Insert final lenses to be dispensed
Patient education:
b.
c.
11.
Evaluation: Visual needs, & Ocular health & Physical characteristics
Pre-fitting Consultation: Patient expectations
Review findings make recommendation
Emphasize correcting presbyopia (not just fitting this new bifocal)
Let the patient know
Return to office: in 3 about days:
Long enough to evaluate vision, short enough to prevent frustration.
Use patient feedback to modify CL prescription
a.
Their job to come back and tell you what they need
b.
Patient displeased with “Crispness” of vision with soft -> RGP Multifocals
c.
d.
e.
Health issues with hydrogel lenses --------> Silicone Hydrogel or RGP Multifocal
Pt displeased with comfort of RGP’s -------> Soft Multifocal or SynergEyes M
Part time wearer ----------------------> Soft Multifocal (Dailies ?)