Over the course of the past six years, I have dedicated most of my time to promoting the use and fitting of multifocal contact lenses. A number of misperceptions continue to arise. There are 8 in particular that I’d like to address. The first four are:
1) Fitting multifocals is not profitable.
2) Emergent presbyopes do not see well at distance with multifocals.
3) Myopes are easier to fit with multifocals than hyperopes.
4) Monovision is easier and more successful for emergent’s than multifocals.
MYTH #1: Fitting multifocals is not profitable.
FACT: This myth can best be debunked by looking at the large number of practices that use multifocals regularly and with a high degree of fitting success and practice profit.
Following a dinner presentation where I presented on the “Practice Management Advantages of Multifocals” one of the registrants made a very telling statement. He said to the audience, the single most common error made by the practitioners causing them to shy away from multifocals is under pricing the service fees associated with fitting and follow up. He went on to say that he sets his fees with the understanding that he will have 3 visits. Each routine contact lens visit in his office is valued at $55.00 therefore he charges a fitting fee of $165.00 for routine spherical Proclear multifocals. He went on to discuss the maturing of his single vision contact lens patient population and the increase in the interest with those patients when he presented the multifocal option to them. He maintains his patients generally love their lenses and so does his accountant!
Another consideration as to profitability has to do with the annuity that comes from the multifocal wearer. If one considers that the presbyope will need an Rx update in their contact lenses approximately every 2 years and with the understanding that they should also be updating their glasses it is easy to see how the value of prescribing both contacts and glasses contributes to the bottom line.
According to the above mentioned doctor, one of the key considerations that separate the winners from the losers in terms of profit is “fees”. He presents the option to all presbyopic candidates for contact lenses, discuses the fees up front and proceeds based on the patient’s interest and enthusiasm. He further commented that the indirect financial benefit is the amazing referral rate of the happy presbyope - they just keep coming.
MYTH #2: Emergent presybopes do not see well at distance with multifocals.
FACT: Today we have an option with optical design that can bust the myth regarding the preservation of single vision quality acuity while correcting both eyes for near work as well. The option is Proclear EP from CooperVision, which is built particularly for the emergent presbyope – the 38 to 42 year old that has begun to develop symptoms of the “short arm disease”. The optics are really simple, which is the secret to the overwhelming success with the lens.
First, identify the truly emergent patient. Many of the practitioners I speak with tell me they use the near point as their guide. A near point of 16 inches or worse is a pretty good indicator that the patient is beginning to struggle, especially in poor lighting (like a restaurant). They may not bring this to the doctor’s attention in the form of a complaint but it is there.
The beauty of the Proclear EP is that it continues to provide spherical optics in each eye for distance. The ADD power is in a concentric zone surrounding the central distance zone and provides for a solid +1.00 ADD. Binocular single vision distance and a binocular ADD give the perfect balance. Because the ADD is fixed the only decision is distance prescription. Example: OD -3.00 ADD +1.00, OS -3.00 ADD +1.00. Lenses selected -3.00 OU. Simplicity, reduced chair time and increased referrals, I believe the distance vision myth is busted.
Try it on your next ten patients - that’s what our colleagues tell me it takes to become a believer. Your patients will love the convenience of this transitional lens instead of readers.
MYTH # 3: Myopes are easier to fit with multifocals than hyperopes.
FACT: Motivation and visual demands seem to play the leading roles when it comes to success with multifocal contact lenses.
In my experience and in the hands of many of the aggressive multifocal fitters, success has more to do with patient selection and timing of the fit with hyperopes. We all understand that patients with latent hyperopia who first begin to experience symptoms at near can pose a challenge. They understand that some of their friends and family have needed glasses for distance all their lives, yet do not understand why they would be struggling with near vision at this point in their lives. Their distance vision still seems just fine.
I believe the first challenge is to determine the actual degree of hyperopia. In some cases, a cycloplegic refraction may be revealing. If the patient also describes some late day fatigue and perhaps night driving discomfort with vision, the use of single vision distance lenses may be best. Managing the hyperopia will allow them to forestall the use of a multifocal until they are truly presbyopic.
Often the hyperope will not tolerate the total correction of the latent hyperopia. By using the Proclear EP you can fit the manifest hyperopia and still provide the additional relief they need of their near demands. By managing their near challenge, while at the same time getting them accustomed to the distance correction that they will ultimately need for the total correction for their hyperopia, you can transition them with minimum complication.
In the future I would be interested in looking at the use of this method of management as it relates to young people with accommodative issues. I can say from personal experience that hyperopes are very receptive to management with both single vision and multifocals. My Rx is approximately +1.75 -0.25 x 90 ADD + 2.00 OU. I wore single vision lenses beginning at age 35 and multifocals by age 40. Do they work for me? Absolutely.
The issue is not hyperopia. It is the method of management. Find them early, educate and manage them. They will be back.
MYTH # 4: Monovision is easier and more successful for emerging presbyopes than multifocals.
FACT: Monovision reduces the distance vision in the non dominant eye and should be supported by glasses which neutralize the near power (+) for driving or other tasks requiring best binocular distance vision for both comfort and safety.
In moments of candor it is still accepted that monovision is the preferred method for managing presbyopes, especially for emerging presbyopes. Many patients will accept the VA reduction at distance of 2 or 3 lines to perhaps 20/40. I suppose when you consider that legal driving vision in many states is in fact 20/40, perhaps we haven’t crossed the line...
I do believe we can do better and assist those patients that will not, and should not, accept or tolerate the imbalance in their vision. The question is: how do we do this? We all know it is challenging to fit the emergent presbyope with conventional multifocals because of the severe shift in optics from single vision. We need a better option. We need a lens that will replicate single vision for both eyes while still correcting the near vision demand, also in both eyes. If we could achieve this, would it not be more comfortable and safer for the patient? Many of my friends and colleagues believe it would be.
There are designs available that will service these patients. However, there is only one design that will correct the distance vision with a spherical optical zone in both eyes. Try the Proclear EP – this lens is designed specifically for these patients. It is a transitional design allowing the patient to capture the advantage of a multifocal with none of the adjustment issues. It has a large central spherical zone for distance surrounded by a concentric aspheric band providing a near ADD up to a +1.25. Fit on both eyes just like their previous single vision spheres and you will maintain the excellent distance acuity and stereopsis to which they are accustomed.
Here is a tip I learned from an experienced doctor in California: do not tell the emerging presbyope that they need “bifocals”. Simply let them know that this lens is designed to provide excellent vision at all ranges and distances. Patients in denial do not need to be told they are getting old!
Here’s a suggestion – ask your front desk staff to red tag all contact lens wearers over 38. When you see a red tag – check near point and you will be amazed at how many of your patients will enjoy their new lenses.