Contact Lenses
Three New Ways of Looking at Presbyopic Prospects

Presenting Bifocal Contact Lens Options
Scripting the RGP Bifocal Presentation

by Edward S. Bennett, O.D., M.S. Ed. and Carol A. Schwartz, O.D., M.B.A.

Suppose you were to trying to build a successful contact lens practice and someone offered you the chance to tap into a market of millions of underserved, potential contact lens wearers, the majority of whom would pay out of pocket.

Someone has. They're patients between 30 and 70 and they can help grow your contact lens practice significantly. The U.S. Census Bureau tallies more than 136 million people in that age group. By 2005, it estimates another 5 million will join them.

Despite their potential impact on our practices, we tend to vastly under serve this group as contact lens candidates. We must recognize their value and take advantage.

One reason is because these patients can afford the more expensive custom bifocal designs. Census Bureau figures show the median household income for all ages in 1997 was $37,000. For those 35-45, the figure was $46,000 and it rose to almost $52,000 for those 45-54; for 55-64-year-olds, it was $41,000.

Your Contact Lens Armamentarium Here's what you'll need on hand in order to fit the 35-and-up group: • Aspheric RGP multifocal diagnostic fitting set • Translating RGP bifocal diagnostic fitting set • Disposable soft bifocal lens inventory • Soft bifocal diagnostic fitting set (in different designs than disposable bifocals)

They're also more likely to pay out of pocket than your typical patient is. Review of Optometry re-search shows that about 37 percent of contact lens patients in optometrists' practices have some form of third-party coverage vs. about 46 percent for all optometric patients.

Many of these people are interested in contact lenses but at the same time fear them. You must take the initiative to present and discuss various contact lens options with them. And, once you successfully fit them, these mature patients become loyal and enthusiastic wearers who refer other patients to your practice.

A Presbyope by Definition
All presbyopes are not the same, and a 40-year age span is too large for generalization. Rather than judging by age, it's more practical to look at the stage of presbyopia. Thus, you can separate this group into three specific patient groups:

• Pre-presbyopes, 30-40 years of age.
• Emerging presbyopes, 40-50-year-olds.
• Moderate presbyopes, 50 and older.

As with any other patient, you must decide whether to fit RGP or soft lenses. Soft lenses are a viable option if the patient is motivated and will not compromise his or her vision. For patients with critical vision demands, we recommend RGPs. RGP bifocals have much higher success rates and provide better vision than soft bifocals, and fitting single-vision RGPs now will make the transition into bifocals that much easier. (See "Scripting the RGP Bifocal Presentation" .)

Most patients will adhere to your recommendations, and you'll be surprised how many will be successful with RGPs. The approach you use to present RGPs to patients is critical, because many have gone 30 or more years without anything touching their eyes. This is challenging because you must address physical and psychological barriers before achieving a successful fit.

It's imperative to present contact lenses in a neutral or non-threatening manner. When discussing RGPs, don't use fear-arousing words such as "uncomfortable," "hurt" or "pain." Instead, talk about "initial lens awareness," "the sensation of wearing a lens on your eye" or "the lids sense the movement of the lens on the eye." Emphasize that the lenses will be more comfortable in a few days.

Never underestimate the power of the first few minutes of lens wear. All new contact lens patients, most notably older patients, are apprehensive about what a contact lens will feel like. If the first application is a positive experience, you've in-creased your likelihood for success. Use a topical anesthetic during the fitting visit to make the patient more comfortable. It will wear off during the diagnostic fitting, allowing the patient to slowly adapt to the sensation of the lens.

The 30-and-older group is often busy. They may be more prone to drop out of contact lens wear, especially if they become frustrated during adaptation. Be sure to evaluate patients in this group no later than one week after you dispense the lenses. This not only helps to ensure they'll comply with your instructions; it serves as a double-check that the patient is comfortable with care and handling. Train your staff to use extra patience and tact when teaching application and removal. Review these procedures again at the first follow-up visit to ensure patient confidence.

Finally, warn high myopes in their late 30s and early 40s about the change in near accommodative de-mand when switching from spectacles to contact lenses. For example, the -6.00D myope refitted into contact lenses will have about 0.37D more accommodative demand, possibly resulting in near symptoms.

The Emerging Presbyope
This group falls into two categories:

• New contact lens wearer. You can handle this patient the same way you would the pre-presbyope. However, if the patient has near symptoms, explain the various options. Mention bifocal lenses last, but emphasize them as a viable option (see "Presenting Bifocal Contact Lens Options"). It's surprising how many patients have either not heard of bifocal contact lenses or heard from other practitioners that "they don't work."

Soft bifocal designs are an excellent option for patients without critical vision requirements who are motivated to wear soft lenses. There are many benefits of having a disposable bifocal in the practice. Among them: You can keep an inventory; use them as trial lenses; they're less expensive than other bifocals; and they minimize deposit-related complications.

Present RGP bifocal options, too. Typically, patients with large pupil diameters, critical vision requirements and a normal fissure size (notably a lower lid near to or above the lower limbus) are good candidates for translating designs. Patients who have low lower lids and are active in sports are better aspheric candidates. Aspheric lenses fit somewhat tightly and are less likely to dislodge during contact.

• Current contact lens wearer. Current single-vision, soft lens wearers often take to either monovision or a soft bifocal lens. If the patient selects the latter, advise him or her that there may be a mild compromise in vision and it might take several weeks to successfully adapt to the lenses. This minimizes the complaints about poor vision and possibly discontinuing lens wear we often hear at the first follow-up visit. If they're receptive, you might try refitting these patients into RGP bifocals. Again, we recommend you use a topical anesthetic.

If the patient already wears RGPs, refitting him or her into an aspheric multifocal design is often successful. At this age patients typically only need a +0.75D to +1.50D add, which is possible with most aspheric designs. Like soft lens bifocals, these lenses are easy to fit.

Most current designs are fitted 1.00-2.00D steeper than "K" in an effort to achieve centration. If you do not achieve good centration, attempt a steeper base curve. If the lens continues to decenter or move more than 1mm with the blink, try another design.

Make patients aware that they may witness slightly reduced night vision at distance because distance and near powers are in front of the eye at the same time.

Translating bifocals are ideal for patients with critical vision demands and who are not active in any contact sports. For contact sports, we recommend spherical RGPs or daily disposable lenses. They can be used in combination with a translating bifocal for all other activities.

The Moderate Presbyope
Much of the same advice you would give the pre-presbyope and emerging presbyope applies to the new wearer in this group. Soft lens applications are more limited due to the higher add requirements. Monovision induces a greater amount of blur at distance due to the power disparity. In addition, soft lens bifocals are almost all simultaneous vision designs that typically provide low add powers. Likewise, aspheric multifocal RGP designs often don't give patients enough near correction. Even designs with high adds rarely provide more than +1.50D of effective add power.

If the patient is not a good candidate for translating bifocals, we recommend a modified monovision approach with aspheric multifocals. Correct one eye optimally at distance, slightly over-plus the other for crisp near vision. This especially benefits patients who have a high intermediate vision demand (i.e., a computer user). Although some trifocal translating designs are available, we rarely prescribe them.

Translating bifocals are indicated for many individuals in this age range because they can translate or shift the near zone in front of the pupil on downward gaze. There are different lens designs available, in-cluding executive, crescent and D-shaped. It's important to have both a translating bifocal and an aspheric multifocal diagnostic set.

Translating bifocals are prism-ballasted, and are intended to fit on or close to the lower lid with little movement after the blink so they provide reasonable initial comfort. Assess the position of the segment line with straight-ahead gaze. It's typically located at or near the lower pupil margin. If, upon blinking, the segment is lifted well into the pupil, increase the amount of prism by 0.50PD.

Next, assess the translation. If the near zone doesn't translate into the pupil, attempt a flatter base curve lens by increasing the edge lift and possible lid interaction, or use another lens design. During the fitting process, use either trial lenses or +/-0.25D, and 0.50D flipper bars.

Patients between 30 and 70 can build your practice if you let them. The introduction of the Acuvue Bifocal is driving many patients into our offices who are asking about contact lenses. Many may not be candidates for a soft bifocal, but could be great candidates for RGP bifocal lenses. Their enthusiasm and the referrals they send to your practice make it worth your while to fit these patients. And, there are enough of them out there who need our services.

Dr. Schwartz is a health-care marketing consultant in Vista, Calif. Dr. Bennett is Executive Director of the RGP Lens Institute.

Presenting Bifocal Contact Lens Options

Several contact lens options are available to the 35-and-over crowd. The simplest: reading glasses over conventional, distance-vision only contact lenses. This provides good vision at both distance and near out of both eyes. However, many of our patients are not motivated to wear spectacles. We've had more than one patient who has become tired of putting them on and taking them off frequently.

Of course, another option is monovision. This only requires fitting conventional contact lenses. This option, however, doesn't allow the patient to see well at all distances, out of each contact lens.

The third option is bifocal contact lenses. These perform similarly to bifocal spectacles, as there are at least two powers in each lens. They're a bit more expensive, but the patient can see both distance and near out of each lens.

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Scripting the RGP Bifocal Presentation

Here's a simple way to explain RGP bifocals to your patients:

"There are essentially two common types of RGP bifocal lens designs. The first is called the 'aspheric' design. Aspheric lenses are the 'no line,' or progressive bifocal spectacles. The distance power is in the center of the lens, and the power gradually changes to the near zone as you move toward the edge of the lens.

"The other type of design is called 'alternating' or 'translating.' In this design, the two powers are distinctly separate and have a line separating the two powers. Just as in the spectacle version, the eye looks through the distance power when looking straight ahead, and through the near power when looking down. In most cases, the lens sits on the lower lid. This helps stabilize the lens so the eye can look down through the bifocal portion of the contact lens.

"Bifocal contacts are a little more complicated than bifocal spectacles. We're talking about two dynamic, little pieces of plastic moving up and down on the eye. Therefore, achieving a good fit is very important. I might have to make a lens change or two to fine-tune the fit. But if you are patient and motivated, I'm sure we can work together to find a fit that is comfortable, and provides you with good vision at distance and up close."

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