When it comes to a contact lens fit for presbyopia, a little bit of education and discussion goes a long way. I approach these fits by first identifying the patient’s visual goal with contact lens use. We then discuss the contact lens options for presbyopia correction, such as distance correction with reading glasses, monovision, and multifocal. This approach has been successful in that it includes the patient in the decision-making process and sets the expectation from the start. Similar to a cataract surgery candidate choosing their intraocular lens type and refractive target, we are able to customize their vision correction based on individual ocular health, lifestyle, and visual needs. 

Once we have determined the patient’s visual goal, I start the fitting process with an updated most-plus refraction and identify eye dominance. These 2 steps are critical to ensure a successful presbyopia-correcting contact lens fit, and they save substantial chair time. 

The contact lens options for presbyopia are greater than ever. Our industry partners offer multifocal soft contact lenses in daily, biweekly, and monthly disposable modalities (Table 1; this table is a summary and may not include all soft contact lens options for presbyopia). We also have the option to prescribe conventional multifocal soft contact lenses for high refractive errors beyond +/- 6.00 D and astigmatic correction around the clock. In the scenario in which a conventional soft contact lens parameter is not available, custom soft multifocal and corneal and scleral rigid gas permeable options are available.

Table 1. Contact Lens Options For Presbyopia

A tip for a successful multifocal contact lens fit is to always choose your first lens option based on the fit guide. Contact lens manufacturers invest substantial time and resources in determining the most efficient and successful way to fit their lens before releasing it. From the initial lens choice, we can make an adjustment to suit each patient’s individual needs. Keep in mind that it is no longer necessary to maintain a folder of all fit guides. Many of the contact lens manufacturers have apps that allow fitters to input refractive error, add power, and eye dominance. The calculations, including vertex distance, are completed, and the best first lens choice is identified.

Once that first lens is identified, I allow the lens to settle for approximately 10 minutes before assessing vision. I typically have people wait in the waiting area to provide a real-life visual setting, rather than the exam room. After the lens is settled, I check binocular visual acuity at distance and reading first and then monocular visual acuities. For reading, I prefer a reading material such as a cell phone or magazine. Make sure to educate the patient about appropriate working distance and to provide adequate overhead lighting. I explain that multifocal lenses work best in those settings.

When prescribing multifocal or monovision contact lenses for the first time, it is important to explain the adaptation period. Specifically, in cases of monovision, it is often necessary to advise the patient on its reduced stereopsis. 

Once we achieve good vision at distance and reading, fit, and comfort, the patient can go home for a 1- or 2-week trial period. After this trial period, I always follow up in the office to ensure stability and make fine-tuned adjustments before finalizing a prescription. In an instance of difficult adaptation, it may be useful to trial modified monovision, in which the dominant eye is set for distance and the nondominant eye is given a multifocal contact lens. This choice maintains binocularity while also providing near function. In instances in which a patient is happy with distance vision and most near tasks but spends hours per day on a computer, reading or doing detailed, close work, it may be beneficial to supplement with a pair of reading glasses over their contact lenses. Keep in mind that each individual’s visual demands and needs vary, but we are more equipped than ever to provide clear vision at distance and reading for our patients with presbyopia. 

Micaela Crowley, OD, provides comprehensive eye care at Lexington Eye Associates, a tertiary care group in Massachusetts. In addition to optometric care, she is director of dry eye and professional practice liaison.