5 reasons to upgrade patients from monovision to multifocals

Although multifocal contact lenses have existed since 1938,¹ it wasn’t until the 1990s that multifocal designs advanced enough for widespread use by eyecare practitioners.

Given that multifocal contact lenses have almost 80 years of existence, why does monovision persist as a treatment of choice for many presbyopes even if they are good candidates for multifocals?

Why monovision persists
One explanation is there is no clear-cut evidence-based conclusion on which modality is superior.

A study of presbyopic contact lens corrections by Arthur Back in 1992 concluded that monovision provided superior visual performance.² In 2006, Rajagopalan concluded visual performance with multifocal correction was superior to monovision.³ However, Gupta’s 2009 study found monovision superior on objective visual acuity tests, but that superiority was not supported by subjective patient ratings.⁴

Another explanation may be practitioner perception that fitting monovision requires less chair time than fitting multifocals.⁵

Many optometrists use the “if it aint broke, don’t fix it” excuse for not fitting multifocals. It is time for ODs to get comfortable with multifocal contact lenses and the opportunity they provide our practices as well as the ability they give us to meet modern patient demands.

Here are five reasons why.

Related: Top multifocal contact lens tips 

1. It really is an upgrade

With the demands that our technology places upon near and intermediate vision, modern life is hard on presbyopes.

A third of Generation Xers and a quarter of baby boomers spend nine hours a day on digital devices.⁶ Plus, blink rates can decrease as much as 66 percent when using a digital device, according to a literature review conducted by Marjorie Rah, OD, PhD, making comfort as much a factor as fatigue.^7-9

Technology has also helped make our current multifocal lens options the best we have ever had. Advances in lens design deliver better vision at distance and near. Material designs have brought comfort and visual stability to the forefront, allowing us to successfully fit more patients. Early bifocal designs did not have the fit success that we now enjoy with modern designs and materials, often with the first trial lens.

Technology upgrades can be as much of a marketing tool as a patient care option. In its most basic form, upgrading patients to new technology shows you and your practice stay on top of advances-not just the status quo.

Some 97 percent of patients want know about or try new technology.⁸ Not upgrading your patients is no longer “if it ain't broke, don't fix it.” We are actively ignoring patient desires and falling behind. If your patients find they have friends who visit a doctor “who has these ‘new’ contact lenses for seeing near and far,” your patients perceive that you do not offer such lenses and are behind the times.

Think beyond baby boomers; Gen Xers actually outnumber boomers,¹⁰ and their demands and expectations are completely different. As a Gen Xer and an emerging presbyope, I can tell you I expect technology to solve all my problems. There had better be an app for this!

More sobering is that in 2015 millennials surpassed all others as the largest generation in the U.S. workforce.¹¹ As ODs, we need to adapt how we react to presbyopia and continuously evolve to meet the greater demands from patients. If we minimize patient complaints and fail to integrate new technology, we could find ourselves well behind the times as the first millennial presbyopes walk into our offices in the next few years.

2. Binocularity

While binocularity can be unexciting, it matters from a safety standpoint.

For example, the Federal Aviation Administration does not allow airline pilots to wear monovision contact lenses for flying.¹² The FAA’s position is scientifically sound: distance stereopsis decreased significantly with increasing contact lens powers (P < 0.01 with +2.50 D lens power).13

Related: 3 correction options for presbyopes

Consider that after your monovision patient shells out extra to see that cool new superhero movie in 3D on date night, he will be very disappointed. Multifocal treatment of presbyopia not only gives back binocularity, it can restore range of vision from distance to intermediate to near as well.

3. Improved night vision

Yes, increased night visual acuity. We talk about multifocal scotopic visual acuity negatively so often we forget that while multifocals may not be the same as spherical distance vision contact lenses, vision can be much better than with monovision.

One of the biggest feedback points you will hear as you convert more monovision wearers to multifocal lenses is improved night visual acuity. This is especially true, in my experience, for hyperopes with higher add powers.

Contrast sensitivity may explain what is happening for these patients. Monovision photopic and mesopic distance contrast sensitivity decreased significantly with progressive increase in power.¹³

4. We don't have three eyes

Monovision worked well for many patients who had discrete distance and near demands, but it stumbles now that intermediate vision is so important.

Intermediate demands are now critical across all age groups. For example, Pew Research Center data shows almost 60 percent of the elderly use the Internet.¹⁴ Grandma doesn’t sit around knitting and waiting for a letter from the grandkids-she stalks them on social media.

The ability to provide clear distance, intermediate, and near vision with smooth transitions among working distances is a very real challenge.

Bausch + Lomb used virtual models to develop its 3-Zone Progressive Design for its Ultra for Presbyopia and BioTrue for Presbyopia lenses. Rather than power steadily changing from near to distance, the design incorporates areas of consistent power at distance, intermediate, and near with seamless transitions between zones. The result is a high consistency of power than can provide better vision at multiple distances.

Related: Embracing new contact lens technology 

5. Satisfy patients

Increased patient satisfaction retains more than fitting fees and materials fees-it retains patients.

Some 76 percent of patients preferred multifocals to monovision.¹⁵ Presbyopes want and need more from their eyecare providers and their contact lenses, but we are busier and inundated with product options and new fit guides.

However, the process is also easier than before. When surveyed about fitting 3-Zone Progressive Design multifocals, 92 percent of eyecare providers said they are easy to fit, and 96 percent of patients were successfully fit by the second visit.¹⁶

Optometrists must break the habit of adding plus over the nondominant eye and instead start the patient in a multifocal when she is an emerging presbyope, not when she needs high adds. Why start an early presbyope down a road we cannot sustain? Use those low add lenses. Set yourself and your patients up for future success.

Another perspective

To get another opinion on fitting processes, I spoke with Amanda K. Lee, OD, who has a full-scope family practice in Myrtle Beach, SC. She says that in the late 1990s and early 2000s, practitioners didn’t have many choices for soft multifocal contact lenses.

“At the time, my lens of choice was Acuvue Bifocal (Johnson & Johnson Vision),” she says. “Wanting to use new technology for my patients, I reached a lot for that product. Although I had less success fitting that product that today’s disposable multifocals, I had at that time equal success to fitting monovision. Fast forward to today and the newest technology in multifocals, and we get 80 to 90 percent success even with the first trial lens selection. I can fit a modern-day multifocal as fast as I can fit a spherical or toric product.”

Dr. Lee says two things prevent eyecare practitioners from fitting multifocals.

“One is the unwillingness to break ingrained habits of fitting monovision and the misperception that monovision is easier or faster as well as cheaper for the patient,” she says. “The other is the unwillingness to take the time to understand and try new technology.”

Dr. Lee brings up the multifocal option to patients by asking if there is a time that vision in their contact lenses has failed them-she calls this “needs-based” prescribing.

“Patients will often answer one of two ways: ‘I can’t see well at night when I try to drive,’ or ‘I can’t see my computer screen unless I move my head around.’ That allows me to open the conversation and offer them new technology so they can achieve those activities or unmet needs. Many patients still do not even know that soft disposable multifocal contact lenses exist,” she says.

Related: Low-cost contact lens site looks to improve compliants, drive exams

Great lens options
Putting a patient in multifocal contact lenses historically required material compromises. Our latest materials were often available only in spherical lenses, but today we have our most wettable, breathable, and comfortable materials available in multifocal designs.

In the past, our lens options often limited fitting options. Most practitioners wanted to avoid mixing wear schedules or materials, which led to difficult-to-fit situations. If a patient wanted daily disposable lenses but needed a toric design, the patient and practitioner needed to choose between the desired modality or the required vision. Multiple manufacturers offering complete families of sphere, toric, and multifocal lens designs gives us the ability to provide for most-if not all-patient needs. 

Alcon’s Air Optix Aqua and Dailies Aqua Comfort Plus have had complete families of monthly and daily sphere, toric and multifocal for some time. Johnson & Johnson Vision’s Acuvue Oasys and 1-Day Moist are also available in sphere, toric and multifocal designs. CooperVision spans all three designs with monthly Biofinity, includes extended parameter ranges in Biofinity XR, and offers full daily disposable correction options in Clariti. Bausch + Lomb recently expanded its Ultra and BioTrue platforms to include toric designs, making full family options for daily and monthly as well.

Our multifocal contact lens options are better than ever before. With patient satisfaction we would have dreamed of in the past and a fit process that is simpler and more streamlined, we are able to bring better technology to make happier patients even when we are under pressure to see more patients and find them solutions faster.

References:

1. Toshida H, Takahashi K, Sado K, Kanai A, Murakami A. Bifocal contact lenses: History, types, characteristics, and actual state and problems. Clin Ophthalmol. 2008 Dec;2(4):869-77.

2. Back A, Grant T, Hine N. Comparative visual performance of three presbyopic contact lens corrections. Optom Vis Sci. 1992 Jun;69(6):474-480.

3. Rajagopalan AS, Bennet ES, Lakshminarayan V. Visual performance of subjects wearing presbyopic contact lenses. Optom Vis Sci. 2006 Aug;83(8):611-615.

4. Gupta N, Naroo SA, Wolffsohn JS. Visual comparison of multifocal contact lens to monovision. Optom Vis Sci. 2009 Feb;86(2):E98-E105.

5. Bennett ES. Contact lens correction of presbyopia. Clin Exp Optom. 2008 Jan;91:265-278.

6. The Vision Council. Digital eye strain. Available at: https://www.thevisioncouncil.org/content/digital-eye-strain. Accessed 6/15/17.

7. Bentivoglio AR, Bressman SB, Cassetta E, et al. Analysis of blink rate patterns in normal subjects. Mov Disord. 1997 Nov;12(6):1028-1034.

8. Argiles M, Cardona G, Perez-Cabre E, et al. Blink Rate and Incomplete Blinks in Six Different Controlled Hard-Copy and Electronic Reading Conditions. Invest Ophthalmol Vis Sci. 2015 Oct;56(11):6679-6685.

Skotte JH, Nojgaard JK, Jorgensen LV, et al. Eye blink frequency during different computer tasks quantified by electrooculography. Eur J App Physiol. 2007 Jan;99(2):113-119.

9. Rah MJ, Reindel WT, Mosehauer G. (2015) Interest and acceptance of a new contact lens technology in today’s practice. Poster presented at the American Optometric Association Annual Meeting.

10. Pew Research Center.  Millennials surpass Gen Xers as the largest generation in U.S. labor force. Available at: http://www.pewresearch.org/fact-tank/2015/05/11/millennials-surpass-gen-xers-as-the-largest-generation-in-u-s-labor-force/. Accessed 6/15/17.

11. Pew Research Center tabulations of monthly 1995-2015 Current Population Surveys, Integrated Public Use Microdata Series (IPUMS, 5/2015).

12.United States Department of Transportation, Federal Aviation Administration, “Guide for Aviation Medical Examiners.” https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/app_process/app_history/item17b/.

13. Durrie DS. The Effect of Different Monovision Contact Lens Powers on the Visual Function of Emmetropic Presbyopic Patients (An American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc. 2006 Dec;104:366-401.

14. Pew Research Center Report American's Internet Access 2000-2015.  http://www.pewinternet.org/2015/06/26/americans-internet-access-2000-2015/

15. Richdale, K Mitchell GL, Zadnik K. Comparison of multifocal and monovision soft contact lens correction in patients with low-astigmatic presbyopia. Optom Vis Sci. 2006 May;83(5):226-73.

16. Orsborn G, et al. Evaluation of new multifocal soft lens design in real world conditions. Poster presented at the American Optometric Association Annual Meeting, June 2013.