AS WE AGE ALONG WITH OUR patients, we share very similar journeys in life. One is the presbyopia journey. When I interact with my patients, I often share my own experiences with various modalities of vision correction through the decades, particularly with advancing presbyopia. My desire to stay in contact lenses as I age is the same desire and expectation of the patients I see, but we know many people stop wearing contacts when they face the twin challenges of presbyopia and drier eyes. How can we bridge this gap and meet our patients’ expectations?

My Long Goodbye to Monovision

In my 20s, I enjoyed the freedom of contact lenses, but I dropped out in my 30s as dry eyes caused so much discomfort and blurry vision. The change didn’t matter much to me (I love all my beautiful glasses!), and I continued to wear contacts occasionally for tennis and social functions.

When I entered my 40s, I needed a little more help up close. Despite the fact that I fit multifocal contact lenses on my patients regularly, I struggled with fitting them for myself. I began with the same expectations I set for my patients: “Multifocal contact lenses will satisfy about 80% to 85% of your visual needs. It’s part of putting the multifocal design into a small zone of vision in a contact lens—we give up something to gain something. Our goal is to create a balance at near and distance.” Still, I wasn’t satisfied because I couldn’t see well under different lighting conditions (for example, comfortably playing tennis outdoors vs indoors with artificial lighting).

I settled on monovision lenses for sports and special occasions and had progressive lenses made in a variety of designer glasses for my workwear. At that point, I had about a 0.75 ADD power, and that disparity between my eyes was acceptable.

As I progressed through my 40s, my presbyopia progressed too. The disparity between my distance and reading vision began to widen, requiring more power for reading. I continued to attempt monovision, but binocular inhibition became a problem, as my brain couldn’t reconcile the conflicting visual information. One interesting sign was that my ability to park my car became obviously challenged! I couldn’t judge depth, so I was parking 3-4 feet from the front of the space. Even my kids noticed! Realizing that the disparity in vision was too great for me to continue with monovision correction, I started wearing progressive glasses more and more.

Returning to Contact Lenses After 15 Years

I was approaching 50 and wearing progressive glasses in 2020 when COVID hit. Glasses and a mask, sometimes combined with a shield or magnifying loupes, proved very frustrating. I wanted to try multifocal contact lenses again, but I stuck with glasses because they gave me more reliably clear vision.

In 2022, I learned about a new pupil-optimized multifocal design (Acuvue Oasys MAX 1-Day Multifocal, Johnson & Johnson Vision), and I thought that this unique lens might deliver better vision at variable distances. The design accounts for pupil size variation and age-related pupil changes. With that knowledge, pupil optimization lays out 183 different power profiles to optimize visual clarity. The fitting protocol includes a unique fit guide and easy-to-use online multifocal calculator that offers a first set of parameters to fit the patient, as well as 2 next-step options if the patient wants to enhance either distance or near vision. The lenses can also filter 60% of blue light.¹

I chose to enhance my distance vision for playing tennis, and the Oasys MAX 1-Day Multifocal gave me great clarity at work and at play, easier night driving, and less screen-time fatigue. It also helped me to overcome the dryness that drove me out of contact lenses 15 years ago because it retains moisture to help maintain a stable tear film.^1-3

Now I comfortably wear my contacts from 6 a.m. to 10 p.m. The journey from failure to success with multifocal contact lenses wasn’t just a matter of finding the right lens. I learned some lessons about fitting that I continue to use for my patients.

Lessons Learned From Fitting My Multifocals

The experience fitting my own multifocal lenses taught me some lessons that have improved how I fit my patients.

1. Red-green balance is important. When I was in school, red-green balance was just a theory of how light focuses. After nearly 20 years in practice, I rarely felt the need to perform a binocular balance on my patients. But I’ve found strong value in the red-green balance in fitting patients with multifocal contact lenses. I perform this monocularly and leave each eye at equal clarity or last red. This ensures that I leave my patient at the most plus acceptance and not over-minused, which can decrease success.
2. Sensory dominance plays a significant role in multifocals. For multifocals, it’s best to indicate the sensory dominant eye, rather than the sight dominant eye. About 20% to 40% of patients are sight dominant in one eye and sensory dominant in the other.⁴ I’m one of them (a fact that contributed to problems with my earlier multifocal fittings). The pupil-optimized lens calculator asks for the sensory dominant eye, so I’ve followed that approach with great success.
3. Functional ADD power should be adjusted to age-related norms. I’m in my early 50s, with an age-related ADD power of about 1.75. In glasses, 2.50 makes me happy, but that’s not practical for contact lens fitting. Instead, I adjust the ADD power toward age-related norms for fitting my multifocals and my patients’. The pupil-optimized design fitting guide recommends ADD powers that work very well. I start patients in their 40s with LOW ADDs in both eyes, I use MED ADDs for both eyes for patients in their 50s, and for patients who are 60+, I use a MED ADD in the sensory dominant eye and HIGH ADD in the fellow eye.

The final lesson from my experience isn’t a tip for fitting, but it’s equally important: address dry eye! Dry eye is a top reason for dropout, and the risk for dry eye is higher among people with presbyopia.⁵ About 75% to 80% of my patients have dry eyes. I’m one of them, but with management, the difference is amazing. I proactively manage my patients’ dry eye so they can have the same opportunity as I do for clear vision, comfort, and remaining in contact lenses as long as they want.

Cases: Putting My Lessons Into Practice

When Rosie, a 55-year-old nurse, came to our practice for the first time, she was struggling to adapt to progressive glasses. She was juggling 2 pairs of glasses while helping patients. She also suffered from dry, itchy eyes, which was why she had dropped out of contact lenses in her early 40s.

Objective evaluation – Rosie’s refraction was -3.00 -0.75 x 080 OS and -2.75 -0.50 x 090 OD, with an ADD of +1.75. She was sensory dominant OD. The slit lamp exam showed decreased tear breakup time (TBUT) (5 seconds), conjunctival injection, heavy biofilm on her upper and lower lid margins, collarettes, and Meibomian gland dysfunction. Her SPEED score was 17/28.

Addressing dry eye disease – Management of Rosie’s ocular surface disease started in-office with lid exfoliation (Blephex, Scope), demodex cleanser (Oust, The Dry Eye Shop), and thermal pulsation (LipiFlow, Johnson & Johnson). She took doxycycline for 30 days and continues to take omega 3 supplements. I have her using lid scrubs once daily (Cliradex, Bio-Tissue) and a hypochlorous acid spray (Avenova, Avenova Eyecare) twice per day. At a follow-up visit 5 weeks later, Rosie’s eye fatigue and itchiness were much improved. Her SPEED score was 8/28, and her TBUT was 11 seconds.

Fitting multifocal contact lenses – Given Rosie’s visual complaints and dry eye disease, I chose to fit her in the Oasys MAX 1-Day Multifocal (OD: 8.4 -3.25 MID; OS: 8.4 -2.75 MID). We made a 1-step adjustment to her nondominant eye for better near vision at work. Her final acuities were OU distance 20/20 and OU near J3. Rosie is happy as can be and continues to see us for regular dry eye management follow up.

After years without contact lenses, I’m happy that the experience of fitting myself for multifocals has yielded lessons that help my patients like Rosie. We’ll continue to age together—hopefully wearing multifocal lenses for many years. ■

References

1. JJV Data on File 2022. TearStable™ Technology Definition.
2. JJV Data on File 2022. Effect on Tear Film and Evaluation of Visual Artifacts of ACUVUE® OASYS MAX 1-Day Family with TearStable™ Technology.
3. JJV Data on File 2022. Material Properties: 1-DAY ACUVUE® MOIST, 1-DAY ACUVUE® TruEye, ACUVUE® OASYS 1-Day with HydraLuxe™ Technology and ACUVUE® OASYS MAX 1-Day with TearStable™ Technology Brand contact lenses and other daily disposable contact lens brands.
4. Lopes-Ferreira D, Neves H, Queiros A, Faria-Ribeiro M, Peixoto-de-Matos SC, González-Méijome JM. Ocular dominance and visual function testing. Biomed Res Int. 2013;2013:238943.
5. Mostafa Y, Saif M, Saeed M, ElSaadany S. The effect of age and gender on tear film breakup time. Egyptian J Med Res. 2021;2(2):137-148.

Dr. Pham-Murphy is president of Visions Optometry in Sacramento, CA; vice president at EyeDesigns Optometry; and clinical director of Opening Eyes at Special Olympics Northern California and Nevada.

Disclosure
Dr. Pham-Murphy is a consultant for Johnson & Johnson Vision.