10/22/2018 1 Tips for Prescribing Soft Contact Lenses in Presbyopes

10/22/2018 1 Tips for Prescribing Soft Contact Lenses in Presbyopes

10/22/2018 1 Tips for Prescribing Soft Contact Lenses in Presbyopes

  • 10/22/2018 1 Tips for Prescribing Soft Contact Lenses in Presbyopes Alex Nixon, OD, MS, FAAO & Erin Rueff, OD, PhD, FAAO Disclosures Dr. Nixon: Travel funding from CooperVision Dr. Rueff: None Current Prescribing Trends The Good News: Utilization of presbyopic contact lens options is on the rise 2011
  • 37% of presbyopic contact lens wearers utilize an presbyopic modality (i.e. monovision or multifocal) * 2017
  • About 50% of presbyopic-aged contact lens wearers are wearing a multifocal, & about 9% are fit with monovision** *Morgan et al, Clin Exp Optom, 2011 **Morgan et al, Contact Lens Spectrum, 2018 Current Prescribing Trends The Bad News: The average age at contact lens fitting is at or approaching 40 years* Mean Age of Contact Lens Fits: Australia: 37.2 ± 16.6 Canada: 37.2 ± 16.9 Germany: 40.6 ± 15.3 United Kingdom: 40.2 ± 16.6 United States: 37.0 ± 16.5 *Morgan et al, Contact Lens Spectrum, 2018

10/22/2018 1 Tips for Prescribing Soft Contact Lenses in Presbyopes
  • 10/22/2018 2 Current Prescribing Trends Why so low?*
  • Lack of fitting skills
  • Lack of product awareness
  • Absence of a “perfect” option
  • Preconceptions of practitioners *Morgan et al, Clin Exp Optom, 2011 Current Prescribing Trends: Why So Low? Preconceptions? Misconceptions!
  • Symptoms of dryness and signs of dry eye are not associated with age in contact lens wearers (Young et al, Optom Vis Sci, 2012; Young et al, Cont Lens Ant Eye 2011)
  • The disruption caused to the tear film and ocular surface by a contact lens is similar in presbyopes compared to non-presbyopes (duToit et al, Optom Vis Sci, 2001) Misconception: Presbyopes have worse dry eye than non-presbyopes. “Wearing contact lenses seems to influence dry eye symptoms more than age or gender.

Therefore, presbyopes should not be excluded from consideration of contact lens fitting.” - duToit 2001 Misconception: Presbyopes have worse dry eye than non-presbyopes.

10/22/2018 1 Tips for Prescribing Soft Contact Lenses in Presbyopes
  • 10/22/2018 3 Presbyopes wearing presbyopic corrections (i.e. monovision or multifocals) wear their lenses longer than those in spherical or toric single vision designs. (Morgan et al, Eye & Contact Lens, 2013) Misconception: Presbyopes aren’t motivated to wear contact lenses. Compared to non-presbyopes, presbyopes have similar experiences with, opinions of, and preferences for contact lens wear. (Rueff et al, Cont Lens Ant Eye 2017) Misconception: Presbyopes aren’t motivated to wear contact lenses. 10 20 30 40 50 60 70 80 Spectacle wearers who have tried contact lenses Spectacle wearers who would prefer contact lenses Contact lens wearers with a history of discontinuation Percent Non-Presbyopes Presbyopes X2 = 1.6, p = 0.2 X2 = 0.008, p = 0.9 X2 = 1.6, p = 0.2 Misconception: Presbyopes aren’t motivated to wear contact lenses. Misconception: Presbyopes have more discomfort & drop-out
  • It has been reported that contact lens discomfort and discontinuation is associated with increasing age
  • Discomfort and/or dryness are the primary reasons for discontinuation in all contact lens wearers.

(Richdale et al, Cornea, 2007; Dumbleton et al, Eye Cont Lens, 2013)

  • 10/22/2018 4
  • Most discontinuation studies include samples of the entire adult age range.
  • Reasons for discontinuation and discomfort may be different in our presbyopic contact lens wearers. Misconception: Presbyopes have more discomfort & drop-out Factor Presence in Population Associated with CL Discontinuation? Age (years) 57 ± 9 (40 to 92) No (p = 0.7) Female (%) 68% No (p = 0.2) Lens Material Soft 70% Gas Permeable (GP) 30% No (p = 0.1) Lens Design Monovision 21% Multifocal 35% Mono & MF 4% Single Vision 40% Monovision: No (p = 0.3) Multifocal: No (p = 0 .8) 15% (n = 496) reported permanent contact lens discontinuation Misconception: Presbyopes have more discomfort & drop-out Discontinued presbyopic wearers have worse overall opinion of their vision at all distances: Near p = 0.002 Intermediate p = 0.01 Distance p = 0.03 Misconception: Presbyopes have more discomfort & drop-out 5 10 15 20 25 30 35 40 45 Poor Vision Discomfort Convenience Cost Percent (%) p = 0.7 Reasons for Presbyopic Contact Lens Discontinuation Misconception: Presbyopes have more discomfort & drop-out
  • 10/22/2018 5 Discomfort and VISION are equal motivators for presbyopic contact lens discontinuation You can not address presbyopic visual dissatisfaction without utilizing presbyopic contact lens designs. Misconception: Presbyopes have more discomfort & drop-out What are the options to avoid reading glasses? Monovision Near Distance Monovision Benefits
  • Toric availability
  • Good vision quality at distance and near
  • Do not need separate fitting Deficits
  • Reduced range of near vision
  • Reduced stereopsis
  • Reduced intermediate in full presbyopia
  • Glare & problems with night driving

  • 10/22/2018 6 What MV Add is Best? Multifocal Contact Lenses Multifocal Contact Lenses Benefits
  • Better range of vision
  • More normal stereopsis Deficits
  • Difficulty in dim lighting
  • Glare, halos, shadowing with higher add powers

  • 10/22/2018 7 Which is Better?
  • Multifocals offer better: (2006)
  • Subjective clarity of vision
  • Subjective satisfaction with correction
  • Depth perception
  • Monovision measures better in office for high contrast distance VA and near VA (40cm) (2009)
  • Multifocal CL can potentially provide a better balance of real-world visual function because of minimal binocular disruption (2006 & 2009) In Context:
  • ~10 years ago studies demonstrated preference for the range of clear vision offered by multifocal lenses
  • Has anything changed in the last 10 years? Then and now... Then and now...
  • 10/22/2018 8 Then and now... Why wouldn’t multifocal contact lenses experienced the same type of revolution? Before You Fit: Consider Refractive Error Astigmatism
  • How much is too much?
  • When astigmatism near 1.00, higher sphere to cyl ratio predicts more success (i.e. -4.00 -1.00 x 180 more successful than -0.50 -1.00 x 180) Emmetropes/Low Hyperopes
  • First time experiencing blur
  • More communication and education Before You Fit: Replacement Schedule Daily Replacement Modalities offer the most advantages:
  • Convenience
  • Consistent comfort
  • Reduced deposits and wetting issues
  • Great for dry eye, ocular allergies
  • Reduced risk of complications
  • Parameters and design quality continue to expand
10/22/2018 9 Before you Fit: Consider Lens Parameters Center Near vs. Center Distance Which is better: More or Less Add Powers? Before You Fit: Find the Fitting Guide Don’t Be Too Proud to Use the Fitting Guide:
  • Based on extensive product research and development
  • Aids in understanding of how the lens works
  • Reduces chair time and follow-ups Before You Fit: Communication What are the visual goals for your patient? When and how often does your patient want to wear contact lenses? What is your patient’s history with contact lens wear? Before You Fit: Adaptation Education Explain lens design in easy-to-understand terms Talk about adaptation symptoms before they happen Convey confidence in this lens modality Changes can be made at follow-up, but adaptation needs to happen first
10/22/2018 10 Where to Start? Need:
  • Ocular Dominance
  • Spherical equivalent refractive error
  • Add power Put lenses in and allow “settling time” Bad use of settling time... Hmmmm...those letters don’t look clear? Based on my calculations, these lenses aren’t working...
  • 10/22/2018 11 “I’m not mad, just disappointed” Good Use of Settling
  • Viewing real world targets
  • Highlights the objects they can see (up close)
  • Picking out glasses/sunglasses What do you think of your new CLs? Strong Negative:
  • “I’ll never be able to drive with vision like this”
  • “I can’t read my watch/phone/tablet at all” New Experiences:
  • “I can read the letters, but they aren’t perfectly clear”
  • “Things I’m looking at are shadowy or double” Positive:
  • “I’m reaching for my readers out of habit but realize I can read things without them” Framing the Vision
  • 10/22/2018 12 Framing the Vision Measure/Assess the Contact Lenses VA Distance – OU & each eye separately
  • Single lines
  • Start around 20/40 and force guesses Over-Refraction -- Distance Only Optimize refractive error correction, whether plus or minus is accepted (flippers or phoropter acceptable)
  • If vision is the same or better, the patient ACCEPTED plus
  • 10/22/2018 13 VA Near – OU Only Used word based measurement
  • Demo with and w/o stand lamp to highlight the benefits of good lighting
  • What is the smallest print you are typically using? Smallest you can read? Smallest you can read easily?
  • Avoid snellen acuity if possible. Why? Demo real world objects such as computer, tablet, and phone for feedback. If you want to add minus, demo change at distance and near with real life objects Make a change Day 1 if...
  • Patient accepts plus at distance (dreams come true)
  • Dominant eye worse than non-dominant at distance
  • Patient has strong negative feelings about either distance or near vision (Demo change)
  • Based on your knowledge of patients needs, you feel current vision not adequate
  • Worse than 20/25 OU at distance
  • Worse than 20/40 near OU or cannot read phone
  • 10/22/2018 14 Parting Messages for the Patient
  • Some situations are challenging with MF CLs, such as:
  • Dim lighting
  • Very small print or objects
  • Low powered (+1.25ish) readers will help in difficult settings
  • Take note of normal daily activities when your vision seems difficult. Pay attention to the object size and distance.
  • If you cannot function adequately with new CLs, call to move your appointment up.
  • If you lose or tear a lens, please call our office to pick up a new one before your follow-up Testing at the follow-up is just like initial testing
  • Ask open ended question about vision. If problems reported, get more specific about print/object size and distance
  • Distance VA
  • Distance over-refraction
  • Near VA How to Improve Vision Distance
  • Optimize refractive error
  • Reduce Add power Near
  • Increase Add power
  • Add plus to non-dominant eye When to abort and change MF brand?
  • Contact lens material specific comfort issue
  • Rule out allergies, dry eye, solution toxicity,
  • Patient returns with strong negative feelings about vision that cannot be resolved with over-refraction or ADD changes
  • Ensure patient has appropriate expectations and is good candidate for MF

  • 10/22/2018 15 Conclusions
  • If you aren’t addressing your presbyopic contact lens wearers’ visual needs, someone else will.
  • Utilize the ever-improving multifocal technology available to you
  • Be open-minded about the fitting process and realistic about visual outcomes

You can also read
Going to next pages ... Cancel