Today’s disposable bifocal contact lenses return binocular vision to presbyopes

Issue: September 2000

The phrase “specialty contact lenses” has meant different things over the years to practitioners and patients alike as contact lenses have evolved. What once was included in the specialty lens category, in some instances, has become the norm. Today, the term includes disposable bifocal contact lenses, a new type of rigid gas-permeable lens and overnight orthokeratology lenses.

As more and more baby boomers become presbyopic, more disposable bifocal contact lenses are entering the marketplace, and these types of lenses are being requested more often as well. Patients have various disposable bifocal contact lenses to choose from today, including the Acuvue Bifocal (Vistakon), Focus Progressives (CIBA Vision) and FreshLook Progressive Bifocal (Wesley Jessen).

The Acuvue Bifocal: fitting tips

The Acuvue Bifocal is offered to most of the presbyopes who come into the Eye Centers of Doctors Davis and Morris, said Robert Davis, OD. “It’s our lens of choice for the presbyopic population,” Dr. Davis told Primary Care Optometry News. “We’re returning binocular vision to these patients. They’re seeing comfortably at distance and near with bifocal contact lenses.”

The computer-generated separation between distance and near zones is so precise that visual aberrations are reduced, Dr. Davis noted. “You don’t get the haloing or the glare at night that you get with some of the other products because of the precise lens design,” he said. “The optics of the lenses are very good, and once you get the correct prescription, patients seem very happy with distance and near vision.”

Prepare the patient

Dr. Davis said that presenting the patient with proper expectations for the bifocal contact lens is essential to its success. “You should tell patients that it will solve 95% to 98% of their visual needs,” he said. “They won’t see the way they did with glasses in some cases, but they’ll certainly be more comfortable with these lenses. We also explain to patients that it might take more than one visit to complete the fitting process. We tell them that they’ll have to go through some adaptation to adjust to what is called simultaneous vision.”

Explaining the concept of simultaneous vision in advance helps patients prepare for their new vision, he said. Dr. Davis also suggested allowing the lens to “settle” on the eye for 10 to 15 minutes before evaluating the fit.

“We like to evaluate binocular near vision first, because it seems that patients do better initially up close than they do at a distance,” he said. “For the most part, if everything looks good at that visit, we’ll send them home with a pair of trial lenses. That is nice, because we have the lenses in stock so patients can actually try them. That’s the beauty of disposables: we don’t have to order them and we don’t have to wait for them. If we want to make changes, it’s very easy because we have all of these trial lenses at our disposal.”

Modify the dominant eye

The lenses can often be fit within two visits, said Dr. Davis, who suggested increasing or reducing the power in the dominant eye by no more than 0.25 D or 0.50 D to improve distance vision, using flippers to make the adjustments. To improve near vision, Dr. Davis suggests increasing the distance portion of the nondominant eye by + .50 D before increasing anything else. “The more separation between the distance and the near, the harder it is for a patient to adjust to simultaneous vision,” he said. “When I adjust powers, I liked to adjust the distance part of the lens rather than increase adds in bifocals if I can help it.”

If that does not work, Dr. Davis recommended a modified monovision technique, “whereby we fit the dominant eye with a single vision distance lens and the non-dominant eye with an Acuvue Bifocal,” he said. “But you want to keep the difference between the distance and the near prescription powers of the lens as close together as possible.”

Finally, Dr. Davis said, if you are receiving positive feedback, stay with the lens. If the patient is reporting negatively to both distance and near vision, he said, consider changing that patient’s vision correction. “That’s very rare, so stop there and cut your losses,” he advised. “Go to another bifocal or another form of correction. Once you do 25 or 30 of these fits, it becomes easy to tell which patients are going to be successful and which patients are not.”

Working with Focus Progressives

The Focus Progressives lens was launched in select U.S. markets in September 1999 and rolled out nationwide July 31, 2000. Recommended for 1- to 2-week or monthly replacement, the lens is a center near-intermediate design, surrounded by a large distance zone.

Richard Noyes, OD, participated in early investigations of the lens and has been successfully fitting it for more than a year. “This is probably the simplest of the bifocal contact lenses to use and the easiest to figure out whether it’s going to work or not. So, from a practitioner’s standpoint it’s a very time-efficient and effective lens to use,” he said. “The success rate runs about 70% in our practice.”

A critical first step in successfully fitting a Progressives lens is making an accurate sphere-cylinder refraction, Dr. Noyes said. As little as a 0.5-D error could make a big difference in a patient’s success. “It’s really a lens that needs to be right on,” he said.

When using the Progressives lens, Dr. Noyes said, the practitioner must take into account the two time periods in which the vision will improve — after 10 minutes and over a 72-hour period. “We will look at the patient’s corneal curvature, get an accurate sphere-cylinder refraction, select a lens that is the vertex adjusted spherical equivalent plus 50% of the add, put the lens on the patient and then check him or her in about 10 minutes,” he said “But it’s so easy to learn to use, we can try it on patients very quickly.”

The 20/40 target

Once the patient is in the exam room, said Dr. Noyes, he or she is presented with a 20/40 target, which helps determine the success of the lens. “If you’re not able to get the patient to 20/40, he or she will probably not be a successful candidate,” he said. “Tell these patients that the technology is just not right for them. However, we really don’t trust the acuity on that first day.”

Therefore, he said, bring the patient back into the office within 1 week, preferably in 3 days. “If you bring patients back in 3 days, they usually can tolerate the lenses; you can make an adjustment, if necessary, and turn it into a success,” he said. “This lens is known best for extreme ease of fit, very low chair time and a strong, positive response from patients both in comfort and vision.”

Dr. Noyes recommends the Focus Progressives over other bifocal contact lenses. “These lenses have a high success rate,” he said. “I tell patients that this is not a home run – it’s a triple. However, not a lot of triples are hit in the big leagues, so it’s pretty exciting. It is our first-choice bifocal contact lens nowadays. This is a whole new venue for most of us.”

Fitting the FreshLook

Wesley Jessen’s FreshLook Progressive Bifocal is a center-near design with an aspheric zone designed to ease the transition from distance to near as well as provide intermediate vision. Rex Ghormley, OD, in private group practice in St. Louis, said that the lens does especially well from a comfort standpoint.

“Some of my patients have stated that it is one of the most comfortable lenses they have had on their eyes,” he said. “One of the strengths of this lens is the fact that distance vision for most patients has proven to be very good, and with some of the other bifocal lenses, the patient really has a distance vision compromise.”

Dr. Ghormley noted that, like other bifocal lenses, the FreshLook produces simultaneous vision, which may take a period of time for the patient to adapt to because of reduced contrast sensitivity. However, he recommends it highly for the emerging presbyope.

“This is one of the first bifocals that I have been able to use for the young presbyope — someone who is +1.00 or +1.50,” he said. “I don’t use many of the lenses that come with those adds very often because I find patients have difficulty adapting to them. Some younger presbyopes have done very well with the FreshLook bifocal. That is a real plus.”

Do not start with monovision

Practitioners should resist the urge to put presbyopes into monovision immediately, said Dr. Ghormley. “I think that is a mistake,” he said. “The last thing you should do is fit them with monovision; you should start with a bifocal lens instead of using it to bail yourself out, which is what is happening right now. I’d like to see practitioners fit people with bifocal lenses, and if patients can’t adapt, then maybe go to monovision to bail them out with those particular patients. I think we have enough choices now that we can do that.”

Proper patient selection, of course, aids in the success of a lens, he noted. Patience and motivation on the patient’s part help bifocal contact lenses become a recipe for success. “The patients who want to have immediate success and want to see exactly like they do with their glasses may have difficulty,” he said. “The patients who are really motivated and really want to work with you to achieve success have a greater chance of achieving it with this particular type of lens.”

Fitting in real-life conditions

The best way to see how well a patient will fare in his or her new bifocal contact lenses is to have the patient wear them in natural surroundings, said Dr. Ghormley.

“Everybody looks at computers nowadays,” he said. “In our office, we have terminals in every examination room, so quite frequently I’ll have the patient sit down in front of the terminal to make sure it looks clear. Many times, if I’m going to refine the prescription, I’ll do it looking right at that computer screen as opposed to some artificial near point.” The same principle applies to using sheet music for a music teacher, he said, or real estate listings from a newspaper for a real estate agent.

“Don’t get hung up on having patients just sit in the chair and look at the near-point card that everyone uses,” he stressed. “Very small changes make a huge difference. Having patients look at a computer screen is far more effective than putting them behind the phoropter and checking the binocular vision in an artificial visual environment.”

replacement schedule

No matter which bifocal contact lens a practitioner prescribes for a presbyope, the replacement schedule should be dictated by the patient’s best interest rather than the company that manufactures the lens, said Dr. Ghormley. When determining the best frequency of replacement for a patient, the practitioner should take into account such factors as the patient’s financial situation, environment and ocular health, he said.

“You need to determine if the patient can afford a new pair of lenses every 2 weeks or every 4 weeks,” Dr. Ghormley said. “Also, you have to look at the person’s environment. If the patient is a construction worker or someone who works outside in a dirty environment, he or she may need to replace the lenses more frequently.”

A patient’s ocular health also encompasses any allergy or dryness problems, he said. “If a patient is on allergy medication, you’ll probably want to replace the lenses every 2 weeks as opposed to every 4 weeks,” he suggested. “If the patient has a dry eye, you’ll want to keep a fresh, clean lens on the eye, and you may want to lean toward replacing the lenses a little bit more frequently.”

Are disposable bifocals affordable?

Presbyopes may question whether or not making the leap to disposable bifocal contact lenses will be worth it financially. One reason to answer “yes” is the lower cost when a lens needs to be replaced, said Dr. Davis.

“The nice thing about disposable lenses is that patients have extras, so if they lose or tear a lens, they can put another one on immediately,” he said. “Each lens is really not very expensive. The financial burden isn’t there. It’s so much easier to wear a disposable lens than a daily-wear lens, which can cost between $75 and $125 to replace.”

Improved quality, reproducibility

Because of advances in technology, the quality of disposable lenses has improved and, therefore, keeps the expense down, said Dr. Ghormley. “Lenses today are manufactured faster, cheaper and a lot more accurately,” he said.

“Also, reproducibility is a big issue. When bifocal lenses were strictly lathe cut, it would be extremely difficult to replace a lens because it was basically custom-made for that particular patient,” Dr. Ghormley continued. “We also were dealing with lenses that often cost $100 or more apiece to the doctor, so the doctor had to charge more than that to the patient. So whether it was a prescription change or a lost, torn or damaged lens, replacement would be costly to the patient. Today, if you look at what people were paying for a pair of conventional bifocal lenses compared to what people are paying for disposable bifocal lenses, there’s not a big difference for a year’s supply.”

For Your Information:

Robert Davis, OD, is in a group primary care practice. He may be reached at The Eye Centers of Doctors Davis and Morris, 1732 University Dr., Pembroke Pines, FL 33024; (954) 432-7711; fax: (954) 432-8017. Dr. Davis has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Richard Noyes, OD, is in private group practice. He may be reached at Iowa Eye Care, 1065 E Post Rd., Marion, IA 52302-5214; (319) 377-2222; fax: (319) 377-2967. Dr. Noyes has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Rex Ghormley, OD, is in private group practice. He may be reached at Vision Care Consultants, 12121 Tesson Ferry Professional Center, St. Louis, MO 63128; (314) 843-5700, ext. 216; fax: (314) 843-1353. Dr. Ghormley has no direct financial interest in the products mentioned in this article. He is a member of the Wesley Jessen advisory board.

The Acuvue Bifocal is available from Vistakon, Johnson & Johnson Vision Care, Inc., 7500 Centurion Pkwy., Jacksonville, FL 32256; (800) 874-5278.

Focus Progressives are available from CIBA Vision, 11460 Johns Creek Pkwy., Duluth, GA 30097; (800) 241-7468; fax: (678) 415-3151.

The FreshLook Progressive Bifocal is available from Wesley Jessen, 333 East Howard Ave., Des Plaines, IL 60018; (800) 348-9595; (847) 294-3000; fax: (847) 294-3962.