can we solve the presbyopia dilemma? the successful contact lens

2/5/2015
Financial Disclosures
CAN WE SOLVE THE PRESBYOPIA DILEMMA?
ED BENNETT O.D., F.A.A.O. (Dipl), F.S.L.S. MSEd
AMY DINARDO O.D., M.B.S., F.A.A.O.
STEPHANIE WOO O.D., F.A.A.O., F.S.L.S.
THE SUCCESSFUL CONTACT LENS WEARER IN 2015
AMY DINARDO O.D., M.B.S., F.A.A.O.
• Dr. Dinardo
• Dr. Woo is a paid consultant for Alcon, SpecialEyes, Biotissue, Blanchard Contact Lens, and X‐cel Contacts
• Dr. Bennett is a consultant for Contact Lens Manufacturers Association
NEW AND SUCCESSFUL MULTIFOCAL DESIGNS
STEPHANIE WOO O.D., F.A.A.O., F.S.L.S.
Hybrid Multifocals
Clear GP vision with
soft lens comfort
Hybrid lenses can correct astigmatism WITHOUT toric ballast system
1
2/5/2015
Patient Candidates for Hybrid Multifocals
• Astigmatic presbyopes
• Soft multifocal patients seeking to eliminate their readers
• Soft multifocal patients with astigmatism
– Great option since soft multifocals for astigmats is limited
• Soft toric monovision patients that want better vision
• Patients desiring better overall vision
• Patients wanting to try the latest technology
Getting patients to try hybrids
• If patients are unsatisfied with their current vision (whether it be glasses or contacts), explain this rather new technology
• Explain how custom it is
– “The lens is created based on the exact shape of your eye and your exact prescription”
• Tell them about the warranty
– Patients are more likely to try something new if they know they can always go back to what they were in before and can get their money back. Troubleshooting Hybrid Multifocals
• Patient education before the dispense is highly important!
– Make sure the patient is prepared for what they might encounter
– “These lenses are different that your last lenses, so they might feel a little different on your eyes. The more you wear them, the more comfortable they will become.”
– “The distance vision and near vision may be strange, or have a 3‐D or shadow effect. This is normal and usually becomes less noticeable.”
• DO NOT see the patient back before 2 weeks!
Poor Candidates for Hybrid Multifocals
•
•
•
•
•
Patients with severe dye eye or OSD
Patients with dry eye with all soft contact lenses
Patients with lenticular cylinder
Patients with very high expectations for vision
Patients unmotivated to try a different lens modality
Patient ready to try hybrid multifocals?
• Empirical vs diagnostic fitting
• Empirical is recommended
– Information needed:
– Manifest refraction
– Keratometry values
– Add power
– Dominant eye
Troubleshooting Multifocal Hybrids
• Most common problems:
• 1. Decreased wear time:
– Observe the fit. Hybrids should exhibit movement similar to a soft lens. If the lens hardly moves, flatten the skirt. If the patient is already in the flat skirt, flatten the BC of the lens.
• 2. Distance vision unacceptable
Distance Vision not 20/25 Confirm distance power is ‐0.50 to ‐1.50 more than manifest
Adjust base curve so power falls in this range
2
2/5/2015
Troubleshooting Multifocal Hybrids
• Most common problems
• 3. Lens Dryness
Change solution Flatten skirt
Flatten BC
Good Candidates for Scleral Multifocals
• Patients with irregular corneas, desiring more freedom from glasses
• Patients with REGULAR corneas
– Offering the best of both worlds: Great vision and great comfort
• Patients with dry eye symptoms
• Post refractive surgery patients (RK, LASIK, etc)
– These patients never wanted to wear glasses anyway!
– Usually more motivated!
Scleral Multifocal Designs
Scleral Lens
• Larger than corneal GPs
• More stability and centration
• Increased comfort due to reduced lid interaction
• Tear reservoir between the contact lens and the cornea can help with dry eye
• Many sclerals vault the cornea completely, taking the cornea out of the fitting process
Poor Candidates for Scleral Multifocals
• Those with high/unreal expectations
• Patients with significant vision loss
• Patients with corneal scarring may have problems with glare/haloes/decreased vision
• Patients with significant high order aberrations • Patients unwilling to learn a new modality of insertion and removal • Patients who want to walk away with a multifocal TODAY
Advantages to Scleral Multifocals
• Can fit REGULAR as well as IRREGULAR corneas
• No translation required • Most are concentric or aspheric designs
• Many scleral MF are center near, which have a similar design to other soft or GP designs
• Very customizable!
– Changing diameter, base curve: no problem!
– Some designs can adjust add power and zone size – Some designs available in toric or quadrant specific designs. Wow how custom is that?!
– Sclerals for everyone!
• Allows any good candidate more freedom from glasses
• Great comfort and great vision
• Highly customizable, so patient is likely to achieve good functional vision
• Patient will not likely get this type of CL fit anywhere else – This can be extremely valuable for patient retention and referrals!
3
2/5/2015
Disadvantages to Scleral Multifocals
• Fitting fee is usually quite high compared to corneal GPs and soft lenses
• Fitting process – This will take a few visits so the doctor AND the patients need to discuss this prior to fitting
• New lens modality
– If they have never worn sclerals: insertion, removal, and lens care will need to be reviewed
• Troubleshooting can be tedious and time consuming
– Both the doctor and patient may start to get discouraged
Fitting Scleral Multifocals
• Patient not wearing sclerals?
• Fitting is highly recommended
• Although there are a few scleral designs which offer empirical ordering, fitting the patient with a diagnostic set is recommended to ensure proper fit and vision
Fitting Scleral Multifocals
Patient wearing sclerals
currently
Determine add power over scleral lenses
Call the lab and report results
Diagnostic fitting
• Use a diagnostic scleral lens set to fit the patient
• After determining a lens with the proper fit, over refract at distance and near.
• Determine eye dominancy (optional) • Report results to the lab
– They will create a lens they feel will work best
– Add power, zone sizes, lens diameter, etc can be modified with many different designs
Troubleshooting Scleral Multifocals
• Insertion and removal are one of the main reasons patients get discouraged easily
– Dropout 
• Be sure to review the techniques thoroughly at dispense
– In depth application/removal training
– Video?
– Patient handouts and resources
4
2/5/2015
Troubleshooting Scleral Multifocals
Tear Film Debris
• Problems with distance or near vision
– First assess their vision OU at distance and near
– If they are seeing relatively well (ex: 20/40 at near), patient education on expectations of vision
• If their vision is poor, perform over‐refraction at distance and near
– Best to report the results to a lab consultant
– Since the designs are highly customizable, they will be able to assist in appropriate design changes
Photo courtesy of Dr. Jason Jedlicka
Tear Film Debris
• Many scleral lens wearers remove their lenses at least once a day to clean the lens and refill due to tear film debris
• New research has determined that patients with dry eye, excessive central clearance, and tight edges are more likely to suffer from tear debris.*
Tear Film Debris
Dry Eye management
• Ocular hygiene
• Adding artificial tears
Excessive clearance
• Decrease sagittal depth of lens
• Flatten edges (may decrease sag)
Edge too tight
• Flatten edges
• Decrease sag
* Hot topics in scleral lenses. Paper. AAO, 2013
Final Thoughts
• Hybrid Multifocals and Scleral Multifocals are a great option for patients looking to decrease their dependency on glasses
• These designs may provide better vision that your patient’s current form of vision correction
• Patients know you are on the cutting edge of technology
• Patients CANNOT order these online or through other mass distributors
WHAT IS THE FUTURE IN MULTIFOCAL CONTACT LENSES?
ED BENNETT O.D., F.A.A.O. (Dipl), F.S.L.S. MSEd
5
2/5/2015
DIFFRACTIVE LENSES: The Past is the Future?
2010: What will occur in five years???
TYPE OF DESIGN
•
•
•
•
•
2014 Annual Report (Nichols J, CLS 1/15)
• Survey via Jeff Johnson OD (Vice-President, Robert
W. Baird & Co.)
• For presbyopes wearing CLs, practitioner preference
was:
– Multifocal lenses: 70% (59% in 2008)
– Monovision: 22% (27% in 2008)
– Over-spectacles: 8% (14% in 2008)
“ , , , new technologies in multifocal lens designs
would lead to the slight rise in fitting multifocal
contact lenses compared to monovision. . .”
ON THE MARKET
Refractive Surgery Multifocal
Hybrid Multifocal
High Add/Front Surface Aspheric Yes
Empirical Segmented Bi/Trifocal Yes
Scleral Multifocals
Yes
Yes
Yes
THE FUTURE IS EXCITING
• Greatest potential to build a practice: the contact lens correction of the presbyope
• Morgan et al, 2011: “Despite apparent improvements in MF design & increase in available MF options in recent years, practitioners are still under‐prescribing . . . CLs for the correction of presbyopia”
• Presbyopes have a more active lifestyle than in the past (exercise, social activities), with greater variance in vision demands – notably cell phones – and they often would prefer NOT to have to use an ancillary correction (i.e., reading glasses)
6
2/5/2015
I HATE MY GLASSES !!!!!
The next 2 – 5 years should bring
•
•
•
•
Improvements in multifocal lens design
Expanded lens parameters
Sclerals into the mainstream
Corneal Reshaping
With simultaneous vision designs, consider the ocular components
With simultaneous vision designs, consider the ocular components
• Charman(2013): The quality of the retinal image – even for a well‐centered lens‐ results from interaction of lens power profile, pupil diameter, amount of residual ocular accommodation, and ocular spherical aberration. Lens decentration and other aberrations of the lens and the eye may further complicate issue. . . . . Improved knowledge of lens power profiles, consideration of aberration and pupil characteristics of individual eye = better match between lens, individual and visual performance.
Brujic M. How important is optical placement in multifocal lenses? GSLS, 2015
• Kollbaum (2014): “Because all presbyopic eyes may have significant positive spherical aberration, consider using an aspheric center‐distance design to add extra positive spherical aberration to the eye. With this small amount of added positive spherical aberration, we aim to reduce the sensitivity to lens decentration while still providing expansion of their depth of focus.”
7
2/5/2015
The next 2 – 5 years should bring
BOTTOM LINE
• Newer simultaneous designs can consider:
– Line of sight considerations/decentration
– Pupil diameter
– Aberrations
•
•
•
•
• Resulting designs can:
– Position optical center of lenses aligned with line of sight
– Customized options that consider pupil size influences
– Wavefront correction can further optimize acuity
The next 2 – 5 years should bring
Expanded Lens Parameters
• Daily disposable silicone‐hydrogel multifocals with expanded parameters
• Higher add powers via the use of balanced progressive‐based lenses that have specifically designed optics for each eye combined with slight‐under‐correction in Si‐Hy materials.
• Greater number of options in disposable/planned replacement soft toric multifocal lens designs
• Custom single use lenses such that patients can change lenses from day time to night time
• Greater expansion of hybrid multifocal lens parameters
Improvements in multifocal lens design
Expanded lens parameters
Sclerals into the mainstream
Corneal Reshaping
•
•
•
•
SCLERALS INTO THE FUTURE
• Poll of GPLI Advisory Board: 26% feel sclerals will have moderate to mainstream use; 61% mild use
• Although typically center‐near, they can be preferable to soft MFs due to optical quality
• Need to develop designs that optimize alignment with pupil to compensate for decentration
• Potentially a viable option for irregular cornea patients Improvements in multifocal lens design
Expanded lens parameters
Sclerals into the mainstream
Corneal Reshaping
The next 2 – 5 years should bring
•
•
•
•
Improvements in multifocal lens design
Expanded lens parameters
Sclerals into the mainstream
Corneal Reshaping
8
2/5/2015
CORNEAL RESHAPING
• Thought of almost an exclusive myopia control device, there is potential for presbyopic use
• “I have many patients in the 40‐75 year old range ecstatic that my multifocal Orthok provides them everything they visually need without relying on glasses for anything. In the Orthok circles, multifocal Orthok is just at the budding stage right now, so I think we will see much growth here as more docs start to embrace Orthok and are more comfortable with it.” (Dr. Ken Maller)
Decline in CL options; increase in surgery‐
mediated options
LOOKING FURTHER AHEAD
MULTIFOCAL ELECTRONICS
• The age of accommodating multifocal lenses should be present within 5 – 10 years
• They will change refractive error based upon the task. • These so‐called “Smart Lenses”(google/Novartis) restore eye’s ability to autofocus
ACKNOWLEDGEMENTS
•
•
•
•
•
•
•
•
•
•
•
Josh Adams
Arthur Back
Melissa Barnett
Doug Benoit
Mile Brujic
Rob Davis
Tim Edrington
Barry Eiden
Jason Jedlicka
Michael Lipson
Ken Maller
Robert Maynard
Langis Michaud
Bruce Morgan
Clarke Newman
Renee Reeder
Muriel Schornack
Jeff Sonsino
Jan Svochak
Harvard Sylvan
Eef van der Worp
Stephanie Woo
9
The Successful Mul,focal Lens Wearer: 2015 The successful multifocal lens wearer in 2015 Amy Dinardo, OD, MBA, FAAO
International Prescribing Trends (2014)
Contact Lens Patients Over 45 years old
Monovision
9%
Other
46%
Multifocal
45%
Morgan PB, et al. International Contact Lens Prescribing in 2014. Contact Lens Spectrum 2015;30:22-­‐‑27.
U.S. Prescribing Trends (2014)
Contact Lens-­‐‑Wearing Presbyopes
Other
18%
Monovision
36%
Multifocal
46%
Where is the disconnect?
•  7/10 patients prefer multifocal lenses to
other forms of correction1,2,3…
•  7/10 eyecare practitioners prefer to
multifocal lenses for their patients4,5….
•  Less than 5/10 patients are wearing
multifocal contact lenses4,6….
•  More than half are in another form of
correction4…
Nichols, J. International Contact Lenses 2014. Contact Lens Spectrum January 2015.
1.7 Billion Presbyopes Worldwide
AllAboutVision.com
•  ~10,000 unique page views per month
Amy Dinardo, OD, MBA, FAAO and Michigan College of Optometry/Vision Research Ins,tute Page # 1 Source: Alcon Data on file, 2012 Census Data
The Successful Mul,focal Lens Wearer: 2015 Myths
Distance Acuity
•  “Multifocal lenses do not work”
•  “Multifocal lenses are not worth the chair
time”
•  “Monovision works better”
•  “Multifocal Lenses do not meet patient
expectations”
Acuity with LogMAR
contacts (OU)
Dinardo et al (2014)
Dinardo et al (2014)
0.12 +/-­‐‑0.12
0.25 +/-­‐‑ 0.07 20/35
Situ et al2 0.11 +/-­‐‑ 0.08 6pt print (+/-­‐‑2) at 43cm (+/-­‐‑ 8cm)
0.27 +/-­‐‑ 0.1120/40
Richdale et al3 (2006)
-­‐‑0.12 +/-­‐‑ 0.09
0.08 +/-­‐‑ 0.15)
(2003)
Approxi
mate Snellen Equivale
nt
20/25 (6 pt print at habitual test distance)
Category
Dinardo et al J. Woods et al (2014) (2009)1
*Scale 1-­‐‑100 *Scale 1-­‐‑100
Distance 4.30 +/-­‐‑ 0.83 92.2 +/-­‐‑ 11.7
Vision Rating Intermediate 4.31 +/-­‐‑0.55
Vision Rating 20/20
0.33 +/-­‐‑ 0.11
20/40
Situ et al2 (2003)
20/25
0.29 +/-­‐‑ 0.08
20/40
20/20
0.21 +/-­‐‑ 0.14
20/32
Richdale et al3 0.01 +/-­‐‑ 0.12
(2006)
20/15
20/25
Subjective Ratings
J. Woods et al1 -­‐‑0.01 +/-­‐‑0.12
(2009)
0.12 +/-­‐‑ 0.08
-­‐‑.036 +/-­‐‑.06 20/18
J. Woods et -­‐‑.030 +/-­‐‑ .07 20/18
al (2009)1
Near Acuity
LogMAR at Approximate LogMAR at high contrast Snellen low contrast
Equivalent Approxima LogMAR at Approxima
te Snellen low te Snellen Equivalent Contrast
equivalent
Near Vision Rating Situ et al (2003)2 *Scale 1-­‐‑100
Richdale et al (2006)3
*Scale 1-­‐‑100
80.6 +/-­‐‑ 22.9
78.1 +/-­‐‑ 16.1
82.2 +/-­‐‑ 20.4
70.9 +/-­‐‑ 18.2
93.8 +/-­‐‑ 10.7
3.89 +/-­‐‑ 0.83
Night Driving 4.05 +/-­‐‑ .70
(Glare/Halos)
88.8 +/-­‐‑ 11.7
73.6 +/-­‐‑ 26.6
67.4 +/-­‐‑ 30.4
Overall Satisfaction
88.7 +/-­‐‑ 12.8
79.5 +/-­‐‑ 17.4
64.7 +/-­‐‑ 20.0
MCO-­‐‑VRI Pilot Study
•  Examined commonalities between
“successful” and “unsuccessful” GP
and soft multifocal lens patients
•  20 “successful” and 12 “unsuccessful”
•  “Is your multifocal lens use meeting
your expectations for success?”
Amy Dinardo, OD, MBA, FAAO and Michigan College of Optometry/Vision Research Ins,tute Page # 2 The Successful Mul,focal Lens Wearer: 2015 “Unsatisfied Patients”
Simultaneous Vision Optics
•  #1 Reason: Vision
-  Near: 92%
-  Distance: 50%
-  Intermediate: 33%
•  #2 Reason Discomfort
Pupil-­‐‑size Dependency
-+
- ++ - - ++++ - - - - ++++++++ - - - - ++++ - - ++ +
--
-+
- ++ - - ++++ - - - - ++++++++ - - - - ++++ - - ++ +
--
Center Center Concentric
Distance Near Rings
Pupil Size and Induced Aberration
Category Mesopic Pupil Diameter* (mm) Photopic Pupil Diameter* (mm) Satisfied Sta&s&cal Dissa&sfied Significance 5.0 5.5 p < .01 3.4 3.9 p <.001 * As measured by the Nidek OPD Scan III
•  Negative correlation between pupil size and near vision ratings. (r2= 0.25)
•  Positive correlation between pupil size and near visual acuity. (r2= 0.26)
Amy Dinardo, OD, MBA, FAAO and Michigan College of Optometry/Vision Research Ins,tute Page # 3 The Successful Mul,focal Lens Wearer: 2015 Eye without contact lens (posi,ve SA) Eye without contact lens (posi,ve SA) 0
000
0000
00000000
00000
000
0
Reading Glasses
•  25% of satisfied patients still wore reading
glasses on occasion with multifocal contacts
(and they were okay with that!)
•  53% of unsatisfied patients expressed
moderate-frequent use of reading glasses
(more often then they would have liked)
1. 
Spherical Aberration
•  Positive correlation between subjects’ spherical
aberration and near visual acuity (r2= 0.44)
•  Negative correlation between subjects’ spherical
aberration and near visual acuity ratings (r2 =0.20)
•  No significant correlation
between spherical aberration
and distance and intermediate
visual performance (r2 =0.03-0.06)
Near Visual Acuity (LogMAR)
_
___
_____
_________
_____
___
_
+
+++
++++++
+++++++++++
++++++
+++
+
Spherical Aberration
Conclusion
•  Multifocal lenses can be effective at correcting
presbyopia
•  There are limitations in some lens designs, making
them suboptimal for certain categories of patients
•  There are solutions:
o  GP Lenses, especially translating designs
o  Center-Distance Lenses
o  Custom Multifocal Lenses
References
Woods J, Woods CA, Fonn D. Early symptomatic presbyopes —what
correction modality works best? Eye & Contact Lens. 2009;35:221-226.
2.  Situ P, Du Toit R, Fonn D, Simpson T. Successful monovision contact lens
wearers refitted with bifocal contact lenses. Eye Contact Lens 2003; 29: 181–4.
3.  Richdale K, Mitchell GL, Zadnik K. Comparison of multifocal and monovision
soft contact lens corrections in patients with low-astigmatic presbyopia.
Optom Vis Sci 2006 May;83(5):266-73.
4.  Morgan PB, et al. International Contact Lens Prescribing in 2014. Contact Lens
Spectrum 2015;30:22-27.
5.  AOA Cornea and Contact Lens Section (2014)
6.  Nichols, J. International Contact Lenses 2014. Contact Lens Spectrum January
2015.
7.  Kollbaum M, Bradley A. Clear View of Multifocal Lens Optics. Review of
Cornea and Contact Lenses. November 2014; 8-11
8.  Bakaraju R, Ehrmann K, Ho A, Papas E. Inherent Ocular Spherical Aberration
and Multifocal Contact Lens Optical Performance. Optom Vis Sci. 87(12):
1009–1022
9.  Montes-Mico R, Madrid-Costa D, Dominguez-Vincent A, Belda-Salmeron L,
Ferrer-Blasco T. In vitro power profiles of multifocal simultaneous vision
contact lenses. Contact Lens and Anterior Eye. 37: 162-167.
10.  Planis S, Ntzilepis G, Atchinson D, Charman N. Through-focus performance
with multifocal contact lenses: Ophthalmic Physiol Opt 2013, 33, 42–50.
Amy Dinardo, OD, MBA, FAAO and Michigan College of Optometry/Vision Research Ins,tute Page # 4