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GP lens eye Rounds

PRESBYOPIA: Decision-Making for Presbyopia

Roxanne Achong-Coan OD, FAAO, FIAMOC, FSLS

Best candidates and prescriptions:

  • Patients who are highly motivated to use their glasses with limited use. These patients will also have normal lid tonicity, ocular health, and no clinical signs or symptoms of dry eyes.
  • The best prescription for multifocal/ bifocal contact lenses is for patients with at least 1.00D of hyperopia or more than 1.25D of myopia.1
  • Patients who are emmetropic and are emerging presbyopes or low myopes are accustomed to having good vision without any correction. These patients may be more challenging but should not be excluded from being fit with multifocal lenses. These patients tend to successfully use a distance lens if needed in their dominant eye and a multifocal/bifocal in the non-dominant eye.

A soft contact lens should be considered for the following reasons:

  • The prescription has a small or moderate amount of astigmatism, myopia, or hyperopia.
  • Various designs (e.g., simultaneous vision, concentric rings) are available to meet different visual needs. These lenses provide good overall functional vision across distances (near, intermediate, and distance). Many soft multifocal contact lenses are aspheric with a center-near correction. However, some brands of contact lenses have a center-distance lens, which is fit on the dominant eye. Several manufacturers make soft toric multifocal contact lenses if a patient has an astigmatic refractive error.
  • Dry eyes. Today, there are more options for daily soft contact lenses, eliminating the need for multi-purpose solutions that contain preservatives that will exacerbate dry eye symptoms. This type of contact lens also either retains or releases moisture (depending on the brand).
  • Has a history of wearing soft contact lenses.
  • Was not successful with monovision.

A gas-permeable contact lens should be considered if the patient:

  • Has had a long, successful history of gas-permeable lens wear. Otherwise, these patients may experience a longer adaptation period due to the rigid nature of GP lenses.
  • Desires to have excellent optical clarity at a distance and near, especially if astigmatic.
  • Is not involved in activities and /or hobbies that require rapid eye movement.
  • Has more significant corneal irregularities, such as keratoconus or irregular astigmatism.
  • Desires a more cost-effective lens. Although they require specialized cleaning and handling techniques, their longevity can save costs over time.

Corneal topography can also be used to determine which lens could be used. When prescribing gas-permeable lenses, an aspheric design can be used on a cornea with a central apex, and a segmented/translating design can used on an inferior-positioned apex.4

Gas-permeable contact lenses are available in:

  1. Aspheric multifocal designs
  2. Translating designs
  3. Back-surface aspheric optics
  • Aspheric Multifocal Designs
    • Early-to-moderate presbyopes are best suited with this design and patients who need better distance and intermediate vision.
    • Near and distance optics are present within the pupil simultaneously (simultaneous vision), so it is best suited for patients with intermediate distance demands such as computer usage at eye level.
    • This design is also more successful in patients with small-to-medium pupils (less than 5mm) because of the effects of glare and ghosting in the plus periphery.
    • Early presbyopes who were previous gas permeable lens wearers will adapt easily from a thin spherical design into a relatively thin aspheric design
    • They are also recommended for patients who are not good segmented, translating candidates (i.e., flaccid lower lid and/or an inferiorly positioned lid)
  • Segmented, Translating Designs
    • Translating designs provide excellent distance and near as any add power can be incorporated into the lens and make a good option for moderate-to-advanced presbyopes, especially if the patient is unable to achieve satisfactory vision with an aspheric lens design.
    • These lenses utilize prism or truncation to use the lower lid such that when the patient looks inferiorly to read, the lens is pushed up so that the patient is viewing through the reading add power of the lens.
    • The segments are available in executive, crescent, and D-shaped. They are fit on flat or flatter than “K” to allow the lower lid to interact with the lens during downward gaze. The best anatomical traits for these lenses are:
      • An upper lid that just covers the upper limbus or is above the upper limbus so that there is limited upper lid interaction.
      • A lower lid 1mm to 1.5mm below or tangent to the limbus with a tight lower lid tension.
      • Any pupil size but a smaller pupil is preferred to avoid high segment heights, excessive translation, or a decentered corneal apex.

GP Material

  • A minimum of 400-700 cells/mm2 is needed to maintain a clear cornea.2 Therefore, it is vital to choose a lens material with a high oxygen permeability, especially as multifocal contact lenses are thicker by design, especially translating contact lenses that are prism-ballasted.

Clinical Pearls/Conclusion

  • There is a huge presbyopic population, and eye care practitioners must understand the options for treating and managing presbyopia.
  • It is important to understand the pros and cons of each modality to meet every patient’s needs. These include soft, gas permeable, hybrid, and scleral lenses, and understanding monovision, modified monovision, bifocals/ multifocals, aspheric bifocals, and translating gas permeable bifocals.
  • Prescribing well-fitted gas-permeable lenses will lead to loyal patients with excellent comfort, vision, and eye health, which is both professionally and financially rewarding.

Sources

  1. Bennett ES, Henry VA, Richdale K, Benoit DP. Multifocal Contact Lenses. In Bennett ES, Henry VA. Clinical Manual of Contact Lenses (5th Ed.). Philadelphia, Wolters Kluwer. 2020:440-491.
  2. Rosado-Adames N, Afshari NA. The changing fate of the corneal endothelium in cataract surgery. Curr Opinion Ophthalmol, 2012 Jan;23(1):3-6.
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