Presbyopes, multifocal lenses, and managing expectations

The challenges of fitting multifocal lenses was the theme of a CooperVision discussion workshop during 100% Optical 2024 (24–26 February).

The session, titled In a muddle with multifocals?, was hosted by professional affairs consultant at CooperVision, Tom Elliot.

Elliot began by identifying common fitting challenges with presbyopic patients, one of which is often confidence.

He noted that a successful fit and continued management of soft contact lens wearers can often assuage these fears.

The patient journey should be simplified if it is to be effective and so that issues can be resolved confidently and easily, he said, adding that presbyopes are more likely to drop out of contact lens wear than other groups, due to discomfort and poor vision.

Elliot also noted that the visual demands of presbyopic patients are different to what they might have been 20 years ago.

He said: “20 years ago, we may have said to our patients, ‘do you use a computer?’ Nowadays, we say, ‘how many screens to use?’

“The lives of presbyopes are completely different from how they were 10 or 20 years ago,” Elliot added.

Three types of multifocal contact lens patient

Attendees then split into groups in order to discuss three fictional patient case studies: the first-time wearer, the dissatisfied patient, and the patient who is new to the practice.

In the first scenario, a 51-year-old male, who worked in a secondary school and was a first-time contact lens wearer, attended for a post-fit follow-up appointment.

Practitioners were encouraged to address a series of questions: is this patient a good candidate for contact lens wear? How might he feel at the appointment? Why might he be struggling? And, how might his visual expectations be discussed?

Elliot noted that, as an established hyperope who needs distance vision to read as part of his job, the patient is likely to be highly motivated, making him a good candidate for contact lenses.

“He has motivation, because of the environment he is in. I think he's a great candidate,” he said.

He might be feeling frustrated or disappointed during his appointment, depending on how his expectations are being managed, Elliot added.

“Presbyopes wish they could live like they used to,” he acknowledged.

Elliot added that the patient might be struggling because the prescriptions in their current lenses are too high.

The importance of managing expectations and making it clear that the patient’s vision would not be as good as it is in glasses, but that the practice will guide them through, was emphasised.

In the second case study, a 42-year-old woman who had attended practice a number of times but still had not received a prescription five weeks after her initial appointment was discussed.

Questions to consider included the costs she might have already incurred, and how her journey could have been made more efficient.

As the patient had already attended a contact lens teach, attendees identified that posting out her lenses and scheduling a phone call to provide tips and check on how she was doing could have meant she did not have to attend practice so many times.

Ensuring that trial banks were full in case she did need to try another solution was also identified as important by attendees.

Elliot revealed that 30% of practice staff said contact lens patients make more than three additional non-urgent chair visits, but that 67% of contact lens wearers would buy online or go elsewhere if they were required to attend a practice several times.

Attendees were also encouraged to consider how many lens options the patient should be given, how to obtain the best vision possible for her, and what her ideal journey would look like going forwards.

Practitioners noted that she would likely be glad that she no longer needed glasses, but that she might be confused by multiple contact lens options so might seek advice online rather than from the practice.

Providing just two options in order to show that the practitioner knows best was advised.

The value of having a follow-up appointment booked in improving compliance and avoiding the patient seeking advice online was also noted, as were the use of the fitting guide and CooperVision online calculator in ensuring the best possible vision from the beginning.

Attendees concluded that the goal for a journey like this would be fewer visits: an eye examination, followed by a contact lens fit and a teach on the same day, would be the ideal scenario.

 
The third scenario presented was that of a 48-year-old woman, attending her first eye examination at the attendees’ practice. The woman explains that she is struggling to read, but that glasses make her feel old.

Questions raised included why she has moved practices, the advantages and disadvantages of monovision and of multifocal contact lenses for this patient.

That she might have moved practices on a recommendation, that she might have wanted a second opinion, or that she had not been provided with a solution previously, were all considered.

Practitioners were also encouraged to share what their recommendation would be.

The idea of multifocals, which could be expensive but might work for the patient socially, was discussed.

Attendees noted that monovision contact lenses were likely to be cheaper, providing less depth perception and making the difference between the eyes more noticeable over time.

One suggested recommendation was for rigid gas permeable multifocal toric monthlies to be fitted, which Elliot agreed was a sensible option.