About a decade ago, the Vision Council and the American Optometric Association launched a public awareness campaign called “Think About Your Eyes,” with the goal of encouraging individuals to undergo an annual eye examination.¹ The campaign has grown over the years to include partnerships with celebrities, such as boxer Laila Ali and actress Gwyneth Paltrow. Although the campaign continues to be successful—more than two-thirds of adults who see an ad schedule an eye examination for themselves or a family member—patients want the opposite of what it advocates for. They don’t want to have to think about their vision; they just want to see clearly.

Luckily, there is much that we can do to minimize the impact of poor vision and help keep patients from having to think about it, such as prescribing glasses, contact lenses, and presbyopia drops. In particular, by getting to know our patients, asking them the right questions, and looking at their ocular surfaces, we can help a wide range of individuals with presbyopia to benefit from multifocal contact lenses. It is important to remember that this option may not be right for every patient, and that it’s okay for patients to have concerns or say no. For many patients, a main worry is ocular comfort. This concern becomes an increasing issue in the aging eye.

Understanding The Aging Eye

As the population ages, the number of people with presbyopia is increasing. Globally, more than half of people older than 30 are presbyopic.² Multifocal contact lenses are an increasingly important tool for presbyopia correction. It is imperative, however, to consider the physiological impact of multifocal contact lenses on the delicate ocular surface.

Several ocular surface changes are associated with the aging eye. Within the meibomian gland, keratinization of the ducts, atrophy, and alteration in the character of lipid secretions can occur.³ Additionally, lacrimal gland secretions may change and diminish, gland inflammation and ductal fibrosis can occur, and levels of lactoferrin and lysozyme decrease.^4-6

Alterations to one or more functions of the ocular surface cause disruptions of the tear film that can lead to dry eye disease (DED), decreased visual acuity, and inflammation.³ These side effects are more prevalent today, as people spend more time on screens. As a result, there is a higher rate of meibomian gland dysfunction and tear film evaporation, often leading to ocular discomfort, eye fatigue and strain, and fluctuating vision. Symptoms such as burning, itching, watering, and redness also play roles in the aging eye, often dissuading patients from contact lens use. Contact lenses, however, are a phenomenal option for patients who want to have functional vision without worrying about their glasses fogging up or slipping.

Addressing Ocular Surface Issues

Ocular surface health is key to a successful patient journey with multifocal contact lenses. For those with preexisting DED, the ocular surface must be optimized before initiating lens wear. This optimization includes achieving an intricate balance among the lipid, aqueous, and mucin layers of the tear film and ensuring proper lubrication with blinking.⁷

If the ocular surface isn’t performing the way it should, further degradation of homeostasis can leave the conjunctiva and cornea vulnerable to desiccating stress, potentially impeding the efficacy and comfort of the contact lens on the eye. Additionally, decreased blink rates due to screen use may compound the difficulties of maintaining moisture on the contact lens.⁸ Most patients list decreased vision and comfort as the 2 main reasons for discontinued contact lens use. Both tie into having an intact and properly functioning ocular surface.

Advances In Lens Materials

Recent data from the Contact Lens Institute show that fewer than 10% of patients in the presbyopia age range are counseled about multifocal contact lenses.⁹ As a result, patients may not be aware that innovations in lens materials, such as water gradient technology and osmoprotectants embedded within the lens, can help maintain homeostasis and improve the wearing experience.

We have experience with several advanced multifocal contact lens designs, and our recommendations depend on patient preference. The proprietary blend of electrolytes, osmoprotectants, and moisturizers retained in the Infuse One-Day Multifocal contact lenses (Bausch + Lomb) help minimize dryness and discomfort, optimize the wearing experience, and reduce the impact of lens wear on ocular surface homeostasis. Additionally, the silicone hydrogel material delivers more oxygen to the front of the eye and has a high water content, which is a unique combination. 

Other contemporary multifocal contact lenses also have excellent designs that can support ocular-surface health. The Dailies Total1 contact lenses (Alcon) feature a Precision Profile lens design and permanent water surface technology that helps more moisture interact with both the ocular surface and the eyelid, and the Acuvue Oasys Max 1-Day Multifocal (Johnson & Johnson Vision) has OptiBlue technology to help maintain moisture throughout the day and a blue light filter that helps with eye fatigue. The MyDay Multifocal (CooperVision) includes Aquaform Technology, which is a long-chain silicone hydrogel built into the material so that moisture doesn’t decrease throughout the day. 

In our experience, with today’s daily disposable multifocal lenses, few patients complain of comfort issues, and most have a positive overall experience. They may still need tweaks in their prescriptions to help them achieve crisp, clear vision, but we can achieve that goal by trialing different lenses. Comfort, which is more difficult to modulate with any individual lens material, is generally less of an issue for patients (see Case in Point).

In our practice, anyone older than 40 is asked whether they would like to try multifocal contact lenses. We discuss the importance of binocularity and explain that multifocal contacts are designed to use both eyes at the same time for both distance and near vision. We also explain that daily disposables are the least likely to cause eye infection or adverse effects and are best for the ocular surface. 

Conclusion

Integrating multifocal contact lenses into an optometric practice model requires a holistic approach to patient care, including prioritizing the health of the ocular surface and engaging new, experienced, and former contact lens wearers. Advances in multifocal contact lens materials, such as water gradient technology and the incorporation of osmoprotectant ingredients, can help patients achieve comfortable wear while enhancing their range of vision and overall satisfaction. 

References

1. Think About Your Eyes’ data shows eye care message received. American Optometric Association website. Published June 24, 2019. Accessed April 12, 2024. https://www.aoa.org/news/inside-optometry/aoa-news/think-about-your-eyes-data-shows-eye-care-message-received?sso=y

2. Patel I, West SK. Presbyopia: prevalence, impact, and interventions. Community Eye Health. 2007;20(63):40-41.

3. Gipson IK. Age-related changes and diseases of the ocular surface and cornea. Invest Ophthalmol Vis Sci. 2013;54(14):ORSF48-ORSF53.

4. Obata H. Anatomy and histopathology of the human lacrimal gland. Cornea. 2006;25(10 Suppl 1):S82-S89. 

5. Research in dry eye: report of the Research Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):179-193.

6. McGill JI, Liakos GM, Goulding N, Seal DV. Normal tear protein profiles and age-related changes. Br J Ophthalmol. 1984;68(5):316-320.

7. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II definition and classification report. Ocul Surf. 2017;15(3):276-283.

8. Al-Mohtaseb Z, Schachter S, Shen Lee B, Garlich J, Trattler W. The relationship between dry eye disease and digital screen use. Clin Ophthalmol. 2021;15:3811-3820.

9. Simple communications: adjustments could supercharge contact lens adoption, according to new research. Contact Lens Institute website. Published March 14, 2024. Accessed: April 24, 2024. https://www.contactlensinstitute.org/news/attvee24prev/

Disclosures

Dr. Kaplan reports a financial relationship with CooperVision.

Dr. Schaeffer reports financial relationships with Allergan, Bausch + Lomb, Alcon, CooperVision, Harrow, Tarsus, and TearScience.

MARK E. SCHAEFFER, OD practices at MyEyeDr in Birmingham, AL. He is a founding member of the Intrepid Eye Society and a member of the Alabama Optometric Association, the American Optometric Association, and the American Academy of Optometry.

Brooke Kaplan, OD practices at MyEyeDr in Birmingham, AL. She is a member of the American Optometric Association and the Alabama Optometric Association.