Meeting the needs of presbyopic patients with multifocal contact lenses

In partnership with Alcon, OT spoke with four practitioners in a discussion that addressed the often specific needs of this patient group, the concerns that can arise, and how Alcon’s Total1 and Total30 multifocal contact lenses can assist the presbyope who presents in High Street practice. 

Opportunity and empathy with presbyopic patients

OT is interested in how the panel would define the presbyopic patient group, and what effect or opportunity an ageing population might be having on their practices.

Ian Chalmers, senior contact lens optician and owner at Chalmers Optician, identifies presbyopes as an exciting and growing area for his practice, and one that offers a different optical challenge for his team.

Along with daily disposables, “it is now multifocals where we’re doing more new fits,” he shared.

Kieran Minshull, director at LK Leon Opticians, agrees that this demographic presents an opportunity for his practice.

“The presbyopic demographic is really important,” he said. “If we have successful contact lens wearers, over the years, they’re going to start struggling. If we don’t give them alternatives, if we don’t find solutions for them, they’re going to look elsewhere. We need to educate them on what’s available, what’s on the market, and what solutions we have for their presbyopic situation.”

Minshull added: “It’s a big market. Most contact lens wearers won’t just wear contact lenses – they will also wear varifocal spectacles. So, there will be an additional profitability aspect for the practice.”

It is not only about problem solving, Minshull believes: “It’s alerting them and educating them to what’s happening with their eyes, and that there are solutions.”

A growing market might present a clinical challenge and a commercial opportunity, but that is likely to come with its own challenges – something that David Gould, optician and director at David Gould Opticians, is quick to identify.

“The biggest challenge with presbyopes is always managing expectations,” he said. “Most of them want the vision they had when they were 25. We need to find a way of explaining that that’s not always going to be possible.”

Being presbyopic himself allows for a high level of empathy and understanding, Gould explained.

He added: “I think empathy is really important. People come in wanting to be able to see the grain on the paper, not just the smallest print that we have. People are expecting six/four vision, as good as their glasses.

“We need to find a way of toning those expectations down and making things realistic, and then when they do manage to get six/five, they are usually pleased. Managing expectations is always the key with this.”

Minshull advised explaining to the patient that their vision, even with correction, will never be as good as it was 10 or 15 years ago.

“If you’re managing expectations, and if you over deliver on the lens, patients are happy,” he added. “Before they put the lens on, they’re already primed to know that this isn’t going to be the silver bullet. That’s the key, I think, to multifocal lens fitting.”

Michelle Beach, optometrist director at Park Vision Opticians, noted that, if the patient is a long-term contact lens or varifocal wearer, they are likely to believe that their vision will be the same with a multifocal lens.

“The concern I have is trying to convey that it will not be the same,” she said. “They think it’s going to be a varifocal lens that they are now putting on their eye, but it doesn’t work the same. So, the conversations must be about explaining how that lens works.”

One particular challenge comes from toric patients, Beach said.

She explained: “If they’re going into a daily multifocal, you’ve suddenly got to explain to them that they cannot have that toric element fitted. You have to have the conversation about them wearing a monthly lens. Obviously, a lot of them love the daily lens.”

Emphasising that there is a compromise and that their vision may not be the same is important, Beach added.

She also raised the fact that some of these patients might be living with dry eye, caused by hormones replacement treatment or other medication. They might also be time-poor, and used to having a one-stop solution for their eye care needs – something that is unlikely to be possible when dealing with various levels of eye dominance.

“I try and explain to them that a multifocal is not one hit and go,” Beach said.

She added: “It might be multiple visits until we do hit the holy grail, where they feel their distance and near vision is the best we can make it.”

Explaining her own situation – that she can ski, do yoga and walk the dog in the rain in her one-day multifocal contact lenses, but that she cannot work in them – is helpful, Beach said.

She added: “I do often try and explain that this isn’t a one fit – it may be that we need to get you back and refine your vision. A 0.25 adjustment in a non-dominant eye can make quite a big difference to them gaining another line in reading. All the way through, [it is about] expectation, balance, and time.”

“They need to understand that it is not exactly the same as putting varifocal glasses on,” Beach emphasised.

She also recognises that vision problems might be new to some members of this demographic, and that this might lead to frustration.

These patients need to be managed differently to those who are used to living with vision correction, Beach said: “It’s about managing that slightly different group.”

Discussing what he looks for from a multifocal contact lens for this patient group, Chalmers explained that, when it comes to dry eye, comfort is key, as is stabilisation – that the lens is always sitting centrally on the eye.

He will also ask patients to rate their vision out of 10, as “it’s a good way of monitoring how your what success you’re getting out of the lens,” he said.

The key to this is ensuring that the patient knows what to expect from the lens, whether they are used to contact lenses or brand new to them, Chalmers believes.

If a patient understands what to expect, monitoring their progress with the lens will be easier, he said.

“We want comfort, stability, handling, and vision quality. Vision quality is the main thing that, obviously, you need to look at and manage,” he added. “You just want the patient to be happy at the end of the day.”

If you’re managing expectations, and if you over deliver on the lens, patients are happy

The wow factor

Moving on to discuss the practitioners’ experiences of Alcon’s Total1 and Total30 Multifocal specifically, Minshull explained that almost all of his patients wear daily disposable contact lenses.

He has been fitting the Total1 for years, while the first patient he had fitted with Total30 was due to pick them up the day after our conversation.

The majority of presbyopic patients will have some level of dry eye, Minshull has found.

Comfort is an important factor, he said, because patients want to wear their lenses all day, “but they are potentially marginal dry eye patients.”

"When we started fitting the Total1 Multifocal, the wow factor with patients was how long they could wear them for. These guys could put them in in the morning and take them out late in the afternoon,” he said.

He highlighted, however, that some patients have trouble with lens removal, so communication around this is vital.

“We had a couple of issues with patients who loved the lens: it was comfortable, they could wear it all day, but they really struggled at the point where they were taking them out,” Minshull said. 

He added: “It’s important to advise them that they need to wash their hands with soap and water, and thoroughly dry them before they attempt to take the lens out. If they’ve got any sort of cream or moisture or water, or even tears, on their fingers, their fingers will just slip off the lens.”

It’s about “guiding them in the right direction,” and providing them with what he believes is the best material on the market, Minshull said.

He added: “It’s super comfortable. Most patients are unaware that they’re actually wearing it, once it is in – they don’t feel the lens. We want to get them into a situation where it’s feel-free – they’re able to see distance, and their reading, and they’re unaware of the lens, even if their eyes are marginally dry.

“It ticks all the boxes there, and that’s why we go predominantly to Total1 Multifocal as our first choice of multifocal lens.”

Gould also identified comfort and vision quality as key positives that have stood out in his patients’ experiences of these lenses.

He noted that, when using the slit lamp, practitioners can often see if an eye is very dry – and that this is never the case with the Total1.

“They retain the vision comfort as well as the physical comfort,” he said, adding: “People who have worn other lenses before, who try this product, are always more comfortable with it. It works brilliantly.”

Gould explained that he has not come across a better material in the 11 years that he has been using the Total1 single vision lens, and that the release of the Total30 will increase the choice that he is able to offer his patients.

The improved tear film over the surface of the single vision lens led some patients to believe that their prescription had been changed, Minshull revealed.

“It wasn’t breaking down as quickly as it was with so many other lenses, so the vision was more stable, giving the patient the impression that they had HD vision. It was so much clearer, even though the prescription hadn’t changed,” he said. 

Beach, whose practice is similarly 95% daily contact lens-led, agrees that the technology has been well received by patients, but acknowledges that the lens is slippery.

“I find the fit is excellent. It’s usually very stable, and it has a wow factor because they really can’t feel it,” she said.

Patients worrying that they might not be able to remove the lens is alleviated by a supportive teach and a buddy system, Beach revealed.

“Once you decide you’re going to wear lenses, you have your contact lens buddy who is your go-to teacher,” she said, adding: “Your presbyopic patient, who maybe hasn’t tried lenses, is used to achieving, and they don’t like thinking that they’re going to fail at something.”

Beach noted that, “when people are wearing the lens, they want to wear it for long periods of time. I do think this is a comfortable lens to wear.”

Chalmers emphasised that adequate chair time and his own confidence in the lens contribute towards a successful fit.

“I feel confident from the very first time I select the lens for them, in what I’m going to have to offer,” he said.

Minshull revealed that he has a patient who has been waiting for 18 months for the Total30 to come onto the market, and that she is booked in to pick it up the day after our conversation.

“Tomorrow, I’m hoping she leaves the practice singing and dancing. This is the lens she has been waiting for for a long time,” he said.

For patients who have never worn contact lenses there is an assumption that they might hurt or take a long time to adapt to, but Minshull explained that this is not the case with the Total1.

“When you put the lens in, they are amazed at how comfortable the lens is. You do not feel it, and that’s partly because of the water surface,” he said.

Chalmers added that “that wow factor is so much the case, all the way through, right from the very start.”

Beach also revealed that the ability to wear the Total30 for a longer period of time is likely to be a strong draw for her patients, many of whom are environmentally conscious and do not feel comfortable throwing away a contact lens after only an hour or two of wear.

People who have worn other lenses before, who try this product, are always more comfortable with it. It works brilliantly

 

Utilising the practice team for patient education

When it comes to the questions patients ask around contact lens wear, Chalmers explained that nerves around potential discomfort are common.

“There is still a high percentage of people who have never tried contact lenses, because they’re wary about putting something on the surface of their eye,” he said.

There may be different points in the practice journey when patients ask about lenses, Chalmers said, and that this should be noted by practice staff.

“During an eye examination, there is only X amount of time that you can have with the patient. To go into absolutely everything you can offer them is impossible,” he said. “It can be picked up with somebody else.”

Minshull has found that discussing contact lens wear with early presbyopes, whether they are existing wearers or not, can make them easier patients to manage in the long run.

Mentioning presbyopia to those in their mid-30s, and emphasising that it is nothing serious and that “we will cross that bridge when we come to it,” can ensure that they are primed when the time comes, Minshull said.

“It’s so important to have that early discussion, so they know what’s coming down the road. They might actually pre-empt it and say, ‘Can we try these things now? I’m struggling a little bit.’ The team needs to be aware as well.”

He reiterated how important it is to follow the fitting guide when looking for new contact lens options for patients, and how vital it is to make sure the conversation is adapted to every individual.

Gould also emphasised that his entire practice team takes part in contact lens conversations.

Currently he is spending time at the front of his practice, “going back to my roots as a dispensing optician.” It is a position that allows him to have the contact lens conversations that he wants to be having from the beginning of the patient interaction.

Speaking about the practice team, Beach said: “I think it’s really important. Everybody has to talk the same language.”

She added: “I don’t know any presbyopes these days who are sitting knitting in a chair or smoking a pipe. These days, presbyopes are active: they’re playing tennis, they’re skiing, they’re travelling. They want to do things, and everybody knows that there is a time when your glasses are a pain in the neck, and you do not want them.”

Beach recalled a conversation that she regularly has with her presbyopic female patients, who often struggle to put on their make-up. Some carry a magnifying mirror with them for this reason, she revealed.

“Presbyopic ladies absolutely love the fact that they can put their make-up on and see their eyebrows,” she said.

“I can’t tell you how many patients, with the daily Total1 multifocal, say, ‘Goodness, I can put my make-up on now, and actually know what I look like.’ That is quite life changing for a patient.”

There is opportunity for contact lenses with every patient

She added: “This is a frustration to presbyopia, that you realise hits you as you get older. Not being able to see your face close-up in a mirror is quite big. That’s one thing that they love. It’s freedom.

“To be able to go out without trying to fit your reading glasses in your clutch bag or in your pocket, and to be able to read a menu, makes you feel young, and it makes you feel happy.”

It is about changing the conversation and the communication to being positive around the possibilities than a lens could offer, Beach said.

“There is opportunity for contact lenses with every patient,” she believes.

When it comes to the role of the practice team on the patient contact lens journey, Chalmers highlights the importance of having a point of contact should any issues arise.

“I remember years ago, it being said that there was a precipice that sometimes patients could fall off in that trial month. It could be about comfort, or vision, or something silly, like they had damaged or lost the lens, and they didn’t want to bother you because they felt awkward,” he said.

That the whole practice team is positive and enthusiastic about lenses from the first point a patient walks into the practice, right to their follow-up appointments, is key, Chalmers believes.

It is important that practice team members do not just take the easy option, he said, because “it is not dispensing [just] for spectacles – it is dispensing for a visual correction, so they should always be talking about contact lenses as well as the glasses.”

“You need to get everybody enthusiastic and on board,” he said.

Find out more about the Total1 and Total30 online.

The participants are paid consultants of Alcon, and their opinions are their own.