GP lens eye Rounds

PRESBYOPIA: Adult Hybrid Multifocal Case

Deepa Chandrasekaran MS, OD, FAAO, FIACLE

History

• HPI: 67-year-old Caucasian-American male came to the Contact Lens (CL) clinic to try multifocal CLs again as he was unsuccessful with the soft multifocal CLs he had tried in the past and wanted greater stability with his vision. He wanted to know his options as he hated wearing his glasses full-time, especially for sports. He was told that he has astigmatism in both eyes.
• CC: Patient would like to be free of glasses for the majority of the work day and be able to wear CLs for sports and special occasions without experiencing any fluctuations in vision.
• Modifying factors: He had symptoms of occasional eye dryness with soft CLs and, therefore, his vision was not very clear with them.

Examination

• Entering visual acuities (with current spectacle Rx):

OD: 20/30
OS: 20/25+2
Near VA: 0.50M binoc

• Current spectacle Rx (four months old; Rxed by an outside provider):

OD: -1.50 +1.25 X 175
OS: -1.50 +1.25 X 160
Add: +2.50D

• Manifest Refraction:

OD: -0.25 +1.75 X 175 (20/25)
OS: -1.50 +1.25 X 160 (20/25)
Add: +2.50D (0.50M binoc)

• Slit Lamp Examination (OD & OS):

• Manual Keratometry:

OD: 44.87 @180/43.00 @ 090
OS: 44.75 @180/44.00 @ 090

• Left eye tested dominant.
• HVID: 11 mm OD & OS
• Pupil size: 3 mm OD & OS in photopic illumination and 5 mm OD & OS in scotopic illumination

Decision-Making Process

• It was suggested for him to try hybrid MF CLs this time as he desired to wear these lenses for work and for sporting activities too.
• We discussed gas permeable (GP) multifocal CLs but given that he exercised every day and was an active sports person, he felt that hybrid CLs would give him the best comfort and stability in his vision.
• Given the occasional eye dryness, he was advised to use OTC PF Refresh eye drops four times a day until his new contact lenses arrived, for better comfort.

Fitting and Evaluation

• New hybrid CLs were ordered empirically based on manifest refraction, keratometry and pupil size.

OD: Duette progressive 7.7/FLT (8.4)/+0.75/+2.50 (CN-center near)
OS: Duette progressive 7.6/FLT (8.4)/-0.75/+2.50 (CN-center near)

These lens parameters were determined using the Duette calculator (based on the fitting guide; the initial base curve selection should be 0.50 to 0.75 D steeper than flat “K”, for up to 2.00 D of corneal astigmatism; the progressive design (center distance or center near) is determined based on spectacle add power; the skirt curve is based on HVID, and the add power of the Duette lenses is selected based on patient’s age and refraction).

• First dispense: Both hybrid lenses were applied with fluorescein in the bowl of the lenses and the fit and vision with them were assessed after ten minutes of application. Both lenses exhibited uniform clearance underneath the gas permeable portion of the lens. The lenses had ~1 mm movement with blink and centered well on both eyes. Vision was 20/25+2 binocularly at distance and 0.63M binocularly at near (with no over-refraction at distance and near). He was comfortable with the lenses and happy with his vision in-office. He was able to see the computer screen and read the messages on his phone at a comfortable distance. He was taught application and removal of the hybrid lenses along with how to care for them (replacing them every six months and using ClearCare solution for cleaning and storing the CLs.
• Two-week follow-up visit: He was very happy with the fit and the vision with the hybrid CLs. The hybrid lenses fit the same as before with the same level of vision as before (with no over-refraction at distance and near). Plan: Lenses were finalized. He was advised to return in one year for a hybrid CL recheck.
• One-year follow-up evaluation: Patient returned in one year for CL check with his hybrid CLs. He was continuing to wear them every day for work and for sports. He continued to have good vision with them and was happy with the comfort of the CLs. His refraction did not change much and, therefore, the CL Rx was also kept the same as before and new hybrid CLs with the same parameters were ordered for the patient.

Clinical Pearls

• Hybrid multifocal contact lenses offer the optics of a GP lens and the comfort of a soft lens and are a great option for presbyopic patients who are actively involved in sports.
• Hybrid contact lens fitting is made easier with fitting guides from manufacturers and the more experience a contact lens fitter gains with fitting these lenses on patients, the easier they are to fit and troubleshoot, and the less chair-time spent with a patient.
• Duette progressive hybrid lenses are a great choice for patients with astigmatism who are presbyopic as they are available as a center-distance or a center-near design depending on the power of the spectacle add needed for the patient. Given the availability of different base curves and skirt curves in the Duette progressive design, making changes depending on the fit of the lenses is simple.