Multifocal cl by ankit varshney

Opportunities and current
options with presbyopia
Optom. Ankit S. Varshney
M.Optom, Ph.D. in Optometry (pursuing) Fellow of IACLE (Aus.), Fellow of ASCO(Mum.)
Prof. at (Shree Bharatimaiya College of Optometry & Physiotherapy, Surat)
Educator Member of International Association of Contact lenses Educators (Australia)(IACLE)
Associate Member of Association of Schools and Colleges of Optometry(ASCO)
Life Member of Indian Optometric Association (IOA)
Member of Optometry Council of India(OCI)
Mail id: ankitsvarshney@yahoo.com
Whatsapp no. +918155955820

Accommodation
 Lens varies in shape to provide
near focus (accommodation)
– Ciliary body contracts
– Zonules relax
– Lens becomes ‘steeper’
– Near vision becomes clearer
14 July 2020 Optom. Ankit Varshney 2

Cause of Presbyopia
 Arises due to loss of flexibility in the lens
– Prevents sufficient change in shape
– Reduced shape change reduces power change

Presbyopia
 A problem with near vision only
 Occurs in the 4th-5th decade of life (earlier in some
ethnic groups)
 Usually increases from +1.00D and stabilizes +2.50D
(depend on reading distance)
 Independent of:
– Myopia
– Hyperopia
– Astigmatism14 July 2020 Optom. Ankit Varshney 4

 Upon completion of this presentation, you will be
aware of
1. Options for Presbyopic patients
2. How to set expectations
3. Soft simultaneous vision multifocal designs and
parameter selection
4. Trouble shooting procedures for multifocal lenses

How many Presbyopes?
 Presbyopes make up about 25% of the world
population, about 1.9 billion people.
– In India about 35 million over the age of 50.
 94% > age 50 need correction

Not all of them want contact lenses but a significant number could
benefit from wearing lenses.
1.Bifocal/Progressive spectacles
2.There are numerous options in CLs;
I. Contact lenses with reading glasses: Single vision,
II. Monovision
III. Multifocal lenses.
3. Surgical options to correct near vision are being developed.

Presbyopic Patient Prescribing
Determine needs, wants, desires of patient
Life Style:
- activities they wish to do
while wearing lenses
- percent of time spent performing those
activities

Identify patient’s expectations
 Ask patient about critical vision needs
– What is the amount of time spent doing distance,
intermediate and near work
 At which distance do you need to see the best?
 How often do you want to wear contact lenses?
– Every day
– Occasionally

Identify expectations
What activities will you be doing
while wearing contact lenses?
•Driving
•Reading
•Computer work
•Reading menu
•Weddings : Eating Mithas

Identify environment
 Environment: Lighting: bright, dim
Humidity: dry air might create dry eye
Cleanliness: particulate airborne matter (dust)
irritates eye with CL’s

Prescribing summary
 Motivation
– Why does the person want to wear CL’s?
– Is it realistic?
 What Medications are used?
– Drying effects
 Is the eye healthy enough for lens wear?
 Are they aware of the costs?
 Realistic expectations?14 July 2020 Optom. Ankit Varshney 12

Patient selection
 Needs reading correction, +1.00 add or more
 Healthy eyes
◦ Clear anterior segment
 Cornea
 Lids
 Lashes
 Meibomian glands
◦ No significant dry eye
◦ No or less papillae
 Understands visual requirements

40+ Ideal patients
 Want to look young
 Have money to spend
 Social circles
 Kitty parties
 Want to continue wearing lenses
 ? No Uncle or Aunty

Setting expectations
 Talk about advantages of CL’s
– Good functional vision
 Different than glasses but no frames in the way
 No fogging of lenses when changing temperature
 No need to wear reading glasses
 Let the patient know they must adjust to a different
way of seeing
– Tell them not everyone can adjust
 Supplementary spectacles
– will CLs + supplementary spectacles be OK to meet all the
wearer’s visual needs?

Patient Management
 The psychology of working with the
presbyopic patient is as important as the
physical fitting of the contact lenses.
 “Promise less,
 Deliver more”14 July 2020 Optom. Ankit Varshney 16

Counseling
 Most important requirements
 Inform about the modalities
 Select one or two with reasons
 Bring down the expectations
 Collect fees!

 We have affinity towards fellow professionals
 Gujjus during Navratri
 Mawaris during wedding seasons
 Conduct a trial activity at ladies club meetings
 If you don’t wish to rack your brains, target every
body!
The secrets

The secrets
 Ladies are great patients
 If they get one or two compliments the lenses are sold!
 Ask them to whatsapp you the compliments that they
get
 Their daughter & sons become your CL patients
 Even if they don’t buy, they will visit in future whenever
there is a function in the family
 Referrals will increase

How to increase trials
 Kitty party ladies
 Sports playing men
 Wedding seasons (special occasions) are
best
 Get an additional invite
 Few compliments and lenses are sold

Option 1 = CL’s + Glasses
Distance CLs and “half eyes”

Option 2 = CL’s + Glasses
Near CLs + distance over correction

Contact Lens Presbyopia Correction
Three main types of contact lens
presbyopic correction:
1. Monovision correction
2. Alternating / Translating vision lenses
3. Simultaneous vision lenses

Monovision
Monovision is the technique in which one eye is
corrected for distance vision and the other eye for
near vision

MONOVISION
 Monocular add for near vision
– one eye biased to distance vision
– one eyed biased to near vision
 Used since the 1920s
 Similar principle to a monocle
 Minimal prismatic and magnification effects
– this is not so with spectacle monovision
 Can use any type of CL

 How to start prescribing
 Show vision first then give a detailed explanation
MONOVISION

Monovision: Ocular dominancy
Dominant eye for distance using “hole in
hand “ ocular dominance test.
Plus acceptance test is better.

Monovision
Advantages
• Better peripheral vision & Stable central vision
• Not affected by pupil size & light condition
• Simple to fit
•Less adaptation & Less expensive than bifocal CLs

Monovision
Disadvantages
• Adaptation
• Reduced stereopsis
• Reduced contrast sensitivity
• Blur suppression required
• Patient satisfaction?

Multifocal Contact Lens
Lens design
Translating or Alternating
Non-translating or Simultaneous

 Contact lens options:
– Monovision
– Bifocal / Multifocal
 Alternating vision
– Translating design (segmented)
 Simultaneous vision
– Concentric bifocal
– Aspheric
– Diffractive
Presbypoia Correction Methods

1) Alternating / Translating vision
– Like spectacle bifocals
– Distance + reading segments
– Typically RGP lenses, soft are also there
– Translating bifocal contact lenses
– Works by translation/alternation
Bifocal CL’s
The patient must look through two separate
portions to see either near or distant objects
Near and far cannot be seen clearly
at the same time14 July 2020 Optom. Ankit Varshney 32

• Executive type segment
• Superior portion: Distance
• Inferior portion: Near
• Visible demarcation line
• Gaze dependent
• Head & Lid positions are critical
Translating Vision
 For Distance vision patient looks in primary gaze
 For Near vision
– Patient looks in down gaze
– The lens is held up by the lower lid

Translating Design
Translating Soft bifocal design

Translating Design
Translating RGP bifocal designs
Fused
Straight top
Crescent
Solid one piece
Reversed
Crescent
Straight top Crescent

1) Alternating / Translating vision
• Adaptation
• Comfort
• Cost
• Dependence on eye-lens
relationship/ gaze
• Thick designs
• Sharp near/far vision
• When it works well, it is very successful
• Works better in RGP & less successful /
common in SCL
• Good Visual quality
• Contrast sensitivity is maintained
• Stereopsis is present
ConsPros
Bifocal / Multifocal

2) Simultaneous vision
 Distance and near images focused on retina (fovea) simultaneously (At
any one time, there are one clear & one blurry image on the retina & the
brain will learn to selectively pick up the proper image)
“Ghosting” (doubling) of image sometimes a problem, especially with
bifocal designs
Most popular option now
Three groups of lenses:
1. Concentric segment lenses
2. Aspheric multifocal lenses
3. Diffraction
Bifocal / Multifocal

Simultaneous vision
 Concentric (Segmented)
 Diffractive
 AsphericTwo Concentric
Optic Zones Diffractive design

1. Concentric segment lenses
– Two distinct regions of power (bifocal)
– Sharp demarcation between zones
– Pupil covered by distance and near portions
– Can be center-near or center-distance
Bifocal
-2.00
-2.00-3.50 -3.50
Centre-near
-3.50-2.00 -2.00
Centre-distance

Concentric Bifocal Design
Two-zone Concentric Bifocal
(Centre-Near Design)
Distance power
Near power

Concentric Bifocal
(Simultaneous Vision)
 Viewing distance object
E

Concentric Bifocal
 Viewing near object
E

2. Simultaneous vision
 Concentric segment lenses
Concentric Bifocal
• Only a bifocal
• Compromised intermediate
vision
• Ghosting (doubling) is
sometimes a problem
• Sharp near and far
• Image clarity relatively
independent of pupil size (e.g.
multi-concentric design in Acuvue
bifocal)
ConsPros

2. Aspheric Multifocal design
– Gradual, progressive power
change from dist to near
– Pupil covered by distance and
near portions
– brain ‘selects’ clear image at
required distance
Aspheric Multifocal

 Aspheric Multifocal design
– Power gradually changes from center to edge
(multifocal/progressive effect)
– Can be center distance or center near
Aspheric Multifocal
-2.00-3.50 -3.50
Centre-near
-3.50-2.00 -2.00
Centre-distance

Aspheric multifocal
(Centre-Near Design)
Aspheric Multifocal Design
Distance power
Near power
Intermediate power

 Viewing distance object
Aspheric Multifocal

 Viewing near object
Aspheric Multifocal

 Aspheric Design
Aspheric Multifocal Design
• Pupil size dependent• No jumping of image as in translating
design
• No Ghosting as in Concentric
• Clarity of vision at all distances
• Simplified fitting
ConsPros

ASPHERIC
Aspheric Back Surface
• Fit well over aspheric cornea
• Aspheric posterior curve
• Increasing PLUS power peripherally as it is flatter.
 Achieved by inducing positive spherical aberrations
• Provide central distance correction
• Intermediate power
• Pupil size and location of the add
E.g.:Patients who need better distance vision
in bright light
Simultaneous vision

ASPHERIC
Aspheric Front Surface
•Aspheric anterior curve
• Back surface is spherical
• Increasing PLUS power centrally
•Front surface aspheric promote –ve spherical aberration
• Provide central near correction
• Intermediate power
• Pupil size and location of the add
E.g.: Teachers, office workers
Simultaneous vision
-2.00-3.50 -3.50 -3.50-2.00 -2.00
Centre-distanceCentre-near

Aspheric Design
 Aspheric Design
• Pupil size dependent•No jumping of image as in
translating design
•No Ghosting as in Concentric
•Clarity of vision at all distances
•Simplified fitting
ConsPros

3. DIFFRACTIVE LENS
• Multiple circumferential Fresnel type
Diffractive bifocal has a phase plate containing
prisms on the back surface of the lens
These prisms split the light into two focal points,
one for the distance and other for near
• Distance & near images at the same time
• Pupil size is not important
• Distance brightness = near brightness
• Halos
• May not be good for excessive night driving
• Contrast sensitivity is reduced
E.g.: Who work in different light conditions
Simultaneous vision

Fitting of SL MultiFocal
Step A: Base Curve Selection
 Try 8.8mm base curve first.
Step B: Distance Power Selection
 Determine patient’s spherical equivalent power after vertex distance
conversion
Step C: Add Selection
 Emerging presbyope (up to +1.50D) use Low ADD
 Mature presbyope (+1.75D to +2.50D) use High ADD14 July 2020 Optom. Ankit Varshney 54

Step D: Initial Lens Evaluation
 Check lens fitting >10 min, a good fitted SLMF should center
well & provide adequate movement on blink.
 Perform an over-refraction in normal room illumination. Deliver
the lens if dist & near binocular VA are ok.
 Use daily use reading task for testing e.g. newspaper, outside
examination room

Example 1:
Refraction
R: -4.50 D, Add +1.25 D
L: -3.00 D, Add +1.25 D
Fitting & Patient Response:
• Happy with vision at all distance
• Acceptable fitting in both eyes
Delivery:
R: 8.8/ -4.25 D, Low Add
L: 8.8/ -3.00 D, Low Add
schedules 1-week aftercare visit
Trial: 8.8 Base Curve
R: -4.25 D, Low Add
L: -3.00 D, Low Add

 If patient is not satisfied, enhance the vision by refining the Rx
using hand-held trial lens with both eyes open.
 Check ocular dominance
 Rule of Thumb
 To improve DISTANCE visual acuity: add –0.25D to the DOMINANT EYE; or
change to low add in the DOMINANT eye when possible.
 To improve NEAR visual acuity: add +0.25 to the NON-DOMINANT EYE; or
change to high add in the NON-DOMINANT EYE or BOTH EYES when possible.

How can I determine patient’s ocular dominance?
Step 1: Instruct the patient to view a distance object binocularly with
the distance correction.
Step 2: Using hand-held trial lens, hold the patient’s add power first in
front of the right eye and then in front of the left eye.
 The eye that feels greater degree of blur is the dominant eye.

Example 2 (Improving Distance):
Refraction
R: -5.25 D, Add +1.50 D (Dominant)
L: -4.75 D, Add +1.50 D (Non-dominant)
• Distance vision not fully satisfied
1st Adjustment:
R: -5.25 D, Low Add
L: -4.50 D, Low Add
R: -5.00 D, Low Add
L: -4.50 D, Low Add
To improve Distance visual acuity:
• add –0.25D to the dominant eye
• or change to Low Add in the dominant
eye when possible
2nd Adjustment:
R: -5.25 D, Low Add
L: -4.75 D, Low Add

Example 3 (Improving Distance):
Refraction
• Distance vision not fully satisfied
1st Adjustment:
R: -4.25 D, High Add
L: -4.25 D, High Add
To improve Distance visual acuity:
• add –0.25D to the dominant eye
• or change to Low Add in the dominant
eye when possible
3rd Adjustment:
R: -4.00 D, Low Add
2nd Adjustment:
L: -4.50 D, High Add14 July 2020 Optom. Ankit Varshney 60

Example 4 (Improving Near):
Refraction
• Near vision not fully satisfied
1st Adjustment:
R: -1.75 D, Low Add
L: -2.25 D, Low Add
R: -1.75 D, Low Add
L: -2. 50 D, Low Add
To improve Near visual acuity:
• add +0.25D to the non- dominant eye
• or change to High Add in the non-dominant
eye when possible
3rd Adjustment:
R: -1.75 D, Low Add
2nd Adjustment:
R: -1.50 D, Low Add
L: -2.25 D, Low Add14 July 2020 Optom. Ankit Varshney 61

Availability in India
 Johnson & Johnson
– Acuvue bifocal – Multizone design
– Center design

 Bausch & Lomb
– SL multifocal – Aspheric center near
– Available in two additions – Low add and High
add
– B&L recommends:
 Full distance correction
 Upto +1.50 add Rx low add
 +1.75add and +2.00 add Rx Low add for distance
and High add for near
 +2.25 and +2.50 add Rx high add

 Ciba Vision
– Focus progressive – Aspheric center near
– Has only 1 add power (upto +3.00add)
– Cibavision recommends:
 Add the distance refraction to one half of the the
add power
 Ex.+2.00dsph hyperope with add of +2.00 - Rx
+3.00 Focus progressive

 CooperVision
– Frequency 55 Multifocal – Balanced progressive
technology
– Cooper vision recommends:
 Center-dist for dominant eye
 Center-near for non-dominant eye

What I should tell before trial?
Manage patient’s expectation
Patient Benefits
Patient Adjustment
Patient Benefits

What I should tell before
trial?
Step 1: State the patient benefits
“With this lens design, distance and
near light enter the eye at the same
time. The beauty of this design is that
it gives you the freedom to see far
away and up close in any direction”

trial?
Step 2: Anticipate normal adaptation
and method to reduce it.
“A little give and take exists, perhaps most
significant in situations such as night-time
driving or detailed near activities such as
removing a splinter. Eyeglasses may be a
better choice for these types of activities”

trial?
Step 3: Reinforce the pateint benefits
again
“After the initial adaptation, I believe
you can enjoy once again the
freedom to naturally see far away and
up close in any direction in most
activities.”

Tips of Delivery
 Use concave (magnifying) mirror on lens insertion instruction for new
patients.
 Remind patients reading lamp can always help reading.
 Wearing sunglasses in bright light environment can improve distance
vision.
 Remind patients for follow-up since fine tuning of Rx after adaptation may
solve significant problem.
 Properly prescribed glasses are also needed for back-up or specific vision
tasks.

Business Potential of SL Multi-Focal
Potential Patients & your extra business
 Spare progressive or reading glasses
 Fashionable sunglasses
 CL related products
 Increase patient loyalty
 Extra patient referral

Summary
 Presbyopia affects those in their 40s and 50s
 Correction is independent of other sight defects
 Contact lens correction methods:
– Monovision
– Alternating vision
– Simultaneous vision
Concentric lenses
Aspheric lenses

Closing thoughts…
 Get over your fears
 Practice
 Build Expertise
 Be the expert!
 Take advantage of this oppertunity

Thank
you14 July 2020 Optom. Ankit Varshney 74

Multifocal cl by ankit varshney

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