Contact Lenses
Boomers and Bifocals They're Not Your Father's Rx

These five steps can help you and your patients overcome your misconceptions about multifocal lenses.

by Carmen F. Castellano, O.D., St. Louis

We optometrists have often looked longingly at presbyopes as potential contact lens patients. And, there are more than enough of them to look at. The Census Bureau says more than 114.3 million people, or 42 percent of the U.S. population, are 40 and older. For many of them, bifocal contact lenses are the best option to meet their varying visual demands.

Simultaneous Vision Bifocal Designs—Center Distance With simultaneous vision designs, distance and near corrections stimulate the eyes simultaneously. The eye learns to focus on the sharpest of the images, depending on whether the patient needs distance or near correction at the time.

Many of us, however, encounter a huge hurdle when it comes to putting more of our patients in multifocal contact lenses. A Review of Optometry survey last year found that seven out of 10 O.D.s fit fewer than two dozen pairs of soft multifocal lenses in a year. Another survey a year earlier found that nine out of 10 O.D.s fit fewer than three dozen patients in rigid multifocal lenses a year.

Yet, bifocal contact lenses can be the ideal practice builder. Most managed-care plans don't cover this service, so you have greater control of the care of these patients vs. those in traditional eyeglass plans. And, you don't have to discount your fees. These specialized fits require more chair time, so you're justified in charging—and actually collecting—a fair fee for your services. Fortunately, this group of patients has the most disposable in- come, so they appreciate the value of your services and care the most. Finally, satisfied bifocal contact lens wearers are enthusiastic referral sources. One happy patient equals many more through your door.

Unsure about how you can clear this hurdle? Try these five steps.

Simultaneous Vision Bifocal Designs—Center Near Simultaneous vision lenses either have a circular near correction in the center surrounded by distance correction or vice versa.

1. Present All Options
Look, there's no perfect system for correcting presbyopia. Half-eye readers, bifocal spectacles and progressive addition lenses are all appropriate options for many patients. For others, however, they may present limitations and compromises.

It has been said before, but I'll say it again: At least tell your presbyopic patients that contact lenses are another option. Many of them don't realize they can wear contact lenses until you tell them.

You don't want to exclude any patients from bifocal contact lens wear, but sometimes you should try. Be extra cautious with patients who expect too much, or who don't have a good track record with contact lens wear.

2 . Know the Products
Many new bifocal contact lenses have been introduced in recent years that have dramatically improved our ability to satisfy most presbyopes who want to wear contacts. These choices come in soft and RGP designs, in both conventional and disposable modalities. Recent advances in bifocal contacts have been with soft lenses, but bifocal RGPs also remain an ideal option for patients and doctors who are willing to invest some time and effort.

Alternating Vision Bifocal The patient looks straight ahead for distance and lowers his eyes to look through the reading zone.

While you don't need to work with every lens on the market, I suggest you become comfortable with at least three or four of them. For example, you might want to become experienced fitting an aspheric lens, a rigid translating design, a concentric lens and perhaps one other lens. (For more on these designs, see "Definitions by Designs," left.) This should give you enough of a repertoire to please most presbyopes who ask about contact lenses.

3. Find Out What They Need
There's rarely enough time to talk about every option with every patient. By using a lifestyle questionnaire—either a written questionnaire or a computerized patient interview system—you can quickly learn more about each patient's needs and preferences.

A simple question to start with: Have you ever worn or thought about wearing contact lenses? This also alerts presbyopes that contact lenses are an option for them.

Also, ask about hobbies, sports and work demands. These can be starting points for your discussion about bifocal contact lenses. For example, you might ask the tennis player if his glasses affect his game. His answers will help direct you to the most appropriate lens option for that patient.

4. Match the Lens to the Patient
These needs and preferences will help you determine the best lens design and wear schedule for the patient:

• Age. More mature presbyopes often prefer alternating vision lenses. Emerging presbyopes, however, may do well in aspheric lenses, although they may find the add powers of up to +1.50D too limiting as they grow older. Fortunately, some aspheric designs such as the LifeStyle GP are available in both standard and higher adds. Unlike many aspheric simultaneous vision lenses, centration with these products is not essential. In fact, some attachment to the upper lid is preferred.

• Visual demands. An accountant or an attorney, whose work requires critical acuity, might be an ideal candidate for a rigid translating lens. Someone who doesn't have the same critical needs may prefer a simultaneous vision lens.

There is no cookbook approach for fitting bifocal contact lenses. I've fit attorneys who preferred simultaneous vision lenses and homemakers who preferred the clarity of a translating lens.

• Multiple lens options. The best solution at times is to prescribe more than one type of lens. Maybe you've prescribed one type of lens for a patient who's happy with his reading correction but not so with his distance acuity. One possible solution: Leave the bifocal lens on one eye and put a single vision lens on the other eye for better distance correction. Or, consider an aspheric lens. This will provide better distance correction plus some intermediate correction.

A different case: The patient's concentric bifocals provide clear distance and near vision. However, she works on a computer most of the day and can't see the screen clearly. Again, an aspheric lens in one eye will give her some intermediate correction.

There are contact lenses that can help these patients with particular needs. For example, Lifestyle's Monovision2 (MV2), an enhanced form of monovision, corrects one eye for distance, the other for near and incorporates an intermediate zone over each lens.

Another product, the Ultravue from Acuity One, incorporates a spherical central zone and aspheric periphery. The larger central zone (Ultravue P) enhances distance vision on one eye, while a smaller central zone (UltraVue C) enhances near vision on the other eye.

5. Spread the Word
Once you've perfected your fitting techniques, you'll want to tell patients and prospective patients about bifocal contact lenses. Here are some approaches to try:

• If you're a presbyope, wear them yourself. Also, encourage your staff who are presbyopic to do the same. You'll have more credibility with patients when you broach this option, and you can show them that the lenses really work.

• Make yourself available as an expert. Speak to civic organizations about presbyopic correction and write articles for local publications. Let the news media know of your expertise and that you're available as a source.

• Hold open houses after hours. This is an ideal way to educate patients about the many new bifocal designs available. Offer to do a trial fitting on those patients who attend. Even if patients don't become contact lens wearers, they'll still learn about the other services you provide.

There is no perfect system for correcting presbyopia. The key to successfully fitting presbyopes with contact lenses is to tell them about all the options and give them plenty of information. This will make your middle-age patients happy. It can have the same effect on you once you watch your private-pay practice grow.

Dr. Castellano is a partner in The Koetting Associates, a private optometric practice that specializes in contact lenses. He is an adjunct assistant professor at University of Missouri-St. Louis School of Optometry and the Department of Ophthalmology and Visual Science at the Washington University School of Medicine.

Definitions by Designs

Bifocal contact lens designs usually fall into these two main categories:

• Simultaneous vision. With this option, distance and near corrections stimulate the eyes simultaneously. The eye learns to focus on the sharpest of the images, depending on whether the patient needs distance or near correction at the time. Simultaneous vision lenses include both aspheric and concentric designs. Some newer aspherics are available in planned replacement and disposable modalities.

A concentric design alternates distance and near. The lens either has a circular distance correction in the center, surrounded by near correction, or vice versa. Vistakon's new Acuvue bifocal has alternating rings of distance and near. Many laboratories offer concentric RGP lenses as simultaneous or translating designs.

• Alternating vision. This works much like conventional bifocal spectacles, with clearly demarcated distance and near zones. The patient looks straight ahead for distance correction. As he lowers his eyes to read, the lens "translates" on the eye, allowing him to look through the reading zone. You may need to help these patients learn proper posture that will help them read through these lenses, although they usually learn this quickly on their own.

Why isn't there a workable alternating vision soft lens bifocal? Several factors have inhibited manufacturers from producing one. Soft lens materials and fitting characteristics neither allow for adequate translation nor acceptable use of both distance and near zones. However, some recent developments with simultaneous vision soft lens designs, such as the Acuvue Bifocal, Acuity One and MV2 have created a resurgence of interest in bifocal contacts.