Understanding Multifocals And Getting Them To Work
Understanding Multifocalsand getting them to workA number of factors contribute to the success of soft multifocalcontact lenses, Dr Trusit Dave examines the design principles andmaterial considerations behind current designs.Despite the increasing availability of multifocal contactlens options, presbyopes remain under-representedamong contact lens wearers. While in the five yearsfrom 2010 the number of multifocal contact lenswearers in the UK grew,1 they still represent a verysmall proportion of the total 3.7m contact lens wearermarket;2 just 4 per cent in volume terms.In other countries, uptake of multifocals is higher. InGermany, for instance, the proportion is 6 per cent andin France 8 per cent (Figure 1).3 In the US, 9 per cent oftotal lenses sold are multifocal, representing nearly 2mwearers. However, these data all identify the unmetneed for lens designs that effectively correct presbyopia.Figure 1: Proportion of multifocal contact lensessold compared to total sales 2010-2014Fitting data also reveal that only 15,000 UK fits wereswitched from single-vision to multifocal lenses in 2014and almost as many switched out of multifocals.1 Thishighlights a major opportunity, not just to increaseprescribing rates among new and existing wearers butalso to improve on success rates with current multifocals.KEY POINTS We all have spherical aberration; it isusually positive and pupil size is one ofthe factors that can affect SA Current soft multifocal contact lenses,whether centre near (CN) or centredistance (CD) in design generate sphericalaberration to give depth of focusTo achieve success with soft multifocalcontact lenses you need to consider: Pupil size varies with age and refractiveerror so choose a lens brand that takesthis into account Choose a lens design that provides goodon-eye centration to provide maximumvisual quality Use an optimal contact lens materialfor the ageing tear film (for good visualstability) Set positive, but realistic patientexpectations Daily disposability may be beneficial forthe presbyope, who for lifestyle reasonswants both spectacles and contactlenses
Table 1: Factors contributing to success with multifocal contact lensesEyeLensFittingPatientOptics;spherical aberrationCentre near/centre distancePowerselectionWho / when / wherePupil sizeBalanced designCentrationModalityCrystalline lens clarityOn-eye effectContact lens materialExpectationsDropout remains a major issue with multifocal lenses.The most recent study among new wearers showsa one-year retention rate of only 57 per cent amongmultifocal lens wearers compared with 78 per cent forspherical lenses.4 Discontinuation from multifocalsmay be due to dissatisfaction with vision but also toissues relating to the ageing eye, such as tear filmchanges and reduced comfort. Many presbyopic lenswearers are currently prescribed monovision, althoughthis form of correction has major limitations.5 Binocularhigh contrast visual acuity is lower with monovisioncompared to and stereopsis is also reduced.6,7 And whenwearers have experienced both modes of correction,most prefer multifocals to monovision (76 per cent vs24 per cent).7 Monovision offers a limited window ofopportunity for our patients. By the time wearers areready to move out of monovision, multifocal correctionis positioned later into presbyopia and medium to highadds are required. Ultimately this places more difficultadaptation conditions on patients, potentially loweringsuccess rates and increasing dropout. This article willexamine factors contributing to success with multifocalcontact lenses, as summarised in Table 1. It will describethe design principles and material considerationsincorporated in current lenses, including a new dailydisposable option: 1-DAY ACUVUE MOIST MULTIFOCAL.Eye factorsSpherical aberrationOf all the aberrations of the normal human eye,spherical aberration (SA) is the most relevant tomultifocal contact lens correction. We can measureocular aberrations using aberrometry. Qualitatively,this displays aberration data in wavefront error mapswhich provide information on the emergent wavefrontof an eye from a point source on the retina.8 While mostforms of aberration are, on average, close to zero, SAis the most significant.9 It is important to note that,between individuals, SA of the whole eye varies and,unlike other high order aberrations, is invariably positivein nature. With positive SA, marginal rays are focusedin front of the retina and paraxial rays near the opticalaxis are focused on the retina. In negative SA, marginalrays are focused behind the retina and central rays onthe retina. SA results in depth of focus at the retina; inobject space it results in depth of field (Figure 2).Whether positive or negative, both forms of SA providedepth of field and that is exactly what most currentsimultaneous vision multifocal lenses, whether centrenear (CN) or centre-distance (CD), exploit in order to giveclear vision over multiple distances.Figure 2: Spherical aberration results in depthof focus at the retinaSA, like other optical aberrations, is affected by pupilsize. The same aberration in the same eye with a 6mmpupil results in considerably greater defocus than witha 3mm pupil. This is a reason why a multifocal contactlens can perform very differently on the patient’s eyeand between patients.The optical system of the eye is principally composedof the cornea and lens. Corneal shape therefore alsoimpacts on the optical system. A spherical corneal shapewould have positive SA. Fortunately, the cornea has aprolate elliptical shape – flattening in the periphery –creating the eye’s own correction mechanism to reduceSA. ‘Optical coupling’ by the eye’s internal optics isa natural correction of the eye within itself wherebycorneal and lenticular aberrations partially compensatefor each other (Figure 3).10The result is that, in young eyes, higher orderaberrations of the whole eye are less than the sum oftheir parts, cancelling each other out to create a robustocular system.The aberrations of the internal eye increaseprogressively with age, due mainly to crystalline lenschanges; in fact, around 10X greater aberrations areinduced by the crystalline lens over time than by thecornea.10 Since SA increases and becomes increasinglymore positive in the ageing eye due to changes in thelens, depth of field is increased. If SA alone were toincrease, it would be quite an ingenious adaptation ofthe eye; however, along with increases in SA, there areincreases in other, unwanted aberrations.
Figure 3: Root mean square of the wave-frontaberration of the eye (squares), the cornea(circles), and the internal optics (triangles) forsix eyes after defocus was removed (adaptedfrom Artal et al10)1.4corneaRMS (microns)1.21.0internalFigure 5: Mean pupil diameter with refractivegroup in mesopic conditions (after Cakmak et al)11N 6Age 24 - 38Pupil 5.9mm0.80.60.40.2eye0.0subjectThe combination of the patient’s SA and the SA ofthe multifocal contact lens can explain some of thevariations in results (see On-eye effect). While it isimportant to understand how aspheric multifocalswork, and why they work better for some patientsthan others, remember that we cannot control SA inthe eye or in a given lens design. Other design featurestherefore need to be considered.Pupil sizePupil size is known to decrease with age, as well aswhen looking at near objects and, of course, underphotopic conditions. If a CN multifocal contact lensdesign is not optimised and has a fixed design for allreading additions, overall clarity or distance vision couldbe lost as the pupil size diminishes with age.Most, but not all, current multifocal designs (Figure 4)are adapted to reflect this age change as the readingaddition increases (if one makes the reasonableassumption that higher reading adds will be required forolder patients).Figure 4: Lens design modification for pupil sizechanges as the reading add increases, which ispresent in some multifocal optionsAlthough mean difference in pupil size betweenmyopes and hyperopes may seem small, it representsa difference in pupil area of as much as 24 per cent.Another study12 has recently confirmed this finding anddiscussed the implications for multifocal design.So, with a hyperopic group, although a multifocal contactlens may have a full range of powers – transitioningfrom near to intermediate to distance – if the design isnot optimised for refractive error (Figure 5) or age, theremay be reduced distance power over the pupil area. Ifdifferences in pupil size are not factored in, designing amultifocal for a myopic population would not lead to assuccessful a design for hyperopes, and vice versa.An opportunity therefore exists to optimise lens designnot just for age differences in pupil size but also fordistance refractive error. The new 1-DAY ACUVUE MOIST MULTIFOCAL has been designed to leveragemean differences in pupil between myopic and hyperopicgroups to help optimise multifocal correction withinthese refractive groups.Manufacturers need individually designed opticalprofiles across the prescription and reading additionrange to optimise optics in this way, but fortunatelythis is not a concern for practitioners who simply selectthe appropriate lens based on distance correction andaddition in the usual way.Lens clarityIn addition to SA and pupil size, crystalline lens claritycan also influence success with multifocal contactlenses. Multifocal intraocular lenses have a distinctadvantage over contact lens forms of correction in thatremoving the crystalline lens provides clear optics. It isimportant to check the clarity of the patients’ mediabefore fitting since this can impact on vision withmultifocals and may, in part, account for variation insuccess.However, a more recent finding is that not only doespupil size vary with age but refractive error may alsoinfluence pupil size, myopes tending to have larger pupilsize than hyperopes. Cakmak et al11 found that meanpupil diameter is larger in myopic eyes than in hyperopiceyes under mesopic conditions, and this difference isstatistically significant (Figure 5).Lens factorsCentre near / centre distanceCommon soft multifocal contact lenses utilise variousdesign concepts, the principal categories being CN or CDdesigns (Table 2).Power profiles of multifocal designs from differentmanufacturers show significant variations between lens
Table 2: Examples of some daily disposable and reusable multifocal soft contact lens designs(based on manufacturer details)Brand name(manufacturer)MaterialDaily wearmodalityPower range(D)Add powers (D)Aspheric CN 6.00 to-9.003 adds - low ( 0.75D to 1.25D); mid ( 1.50D to 1.75D) & high ( 2.00D to 2.50D)Aspheric CN 6.00 to-10.003 adds – low (to 1.25),med (to 2.00) & high (to 2.50)Design1-DAY ACUVUE MOISTMULTIFOCAL (Johnson &Johnson Vision Care)etafilcon A(hydrogel)Dailies AquaComfort PlusMultifocal (Alcon)nelfilcon A(hydrogel)Clariti 1day Multifocal(Sauflon)somofilcon A(SiH)Aspheric CN 5.00 to-6.002 adds - low (to 2.25);high (to 3.00)ACUVUE OASYS forPRESBYOPIA (Johnson &Johnson Vision Care)senofilcon A(SiH)Reusable –CD2-weeklyZonal asphereplacementric 6.00 to-9.003 adds – low (to 1.25),mid (to 1.75) & high (to 2.50)Air Optix Aqua Multifocal(Alcon)lotrafilcon B(SiH)Aspheric CN 6.00 to-10.003 adds – low (to 1.25),med (to 2.00) & high (to 2.50)Biofinity Multifocal(CooperVision)comfilcon A(SiH)CD or CN;multizonal 6.00 to-10.004 adds - 1.00, 1.50, 2.00, 2.50D lens, N lensPureVision Multifocal(Bausch Lomb)balafilcon ACN aspheric 6.00 to-10.002 adds – low (up to 1.50D) & high ( 1.75 to 2.50D)DailydisposableReusable– monthlyreplacementtypes. A recent study by Wagner et al13 found powerprofiles provided helpful information for prescribinglenses for presbyopes. These authors observed thatnegative SA occurred for most of the multifocal lensesthey tested and some (such as PureVision Multi-Focal,Bausch Lomb) seemed to rely predominantly on theSA component to provide the multifocal effect.Of the CN lenses, 1-DAY ACUVUE MOIST MULTIFOCAL(Johnson & Johnson Vision Care) and Air Optix AquaMultifocal (Alcon) are aspheric CN designs with threereading additions (low, medium and high). PureVisionMulti-Focal and SofLens Multi-Focal (Bausch Lomb),along with the Clariti Multifocal range (Sauflon), are alsoCN aspheric designs with two reading additions (low andhigh).Practitioners should note that with CN multifocals ofthe same distance and near prescription, the lens designdiffers not only between manufacturers but may alsodiffer between brands.Of the CD lenses, ACUVUE OASYS for PRESBYOPIA isa multi-zone multifocal or zonal aspheric optical designwith three reading additions (low, mid and high).Given these differences, having several multifocalsavailable in practice offers the opportunity to try morethan one type of design to meet the individual patient’sneeds. Where one design may not work in a givenpatient, another lens with a different design may besuccessful.Zonal aspheric designsThe reusable Proclear and Biofinity Multifocals(CooperVision) are aspheric lenses and come in four addpowers, with CN and CD options. With these lenses, theCN lens is fitted to the non-dominant eye and the CD tothe dominant eye.In these lenses, unlike other designs, the optics are notoptimised for age as the reading addition increases.With the Proclear Multifocal, for instance, the CN lenshas an approximately 2mm central spherical zonefollowed by an approximately 1mm transitional zonewhere the lens power transitions to the distanceprescription. Finally, there is the distance zone whichappears to have an aspheric surface.The CD lens has a central aspheric zone of approximately3mm and a steep transitional zone, with the peripheraloptics of the lens containing an aspheric nearprescription. Both CN and CD designs have fixed opticalzones regardless of add power.On-eye effectLens design cannot be considered in isolation from theoptics of the eye. The same powered multifocal lensfitted to eyes with the same optical prescription andpupil size may not result in the same vision.Bakaraju et al14 found that the image quality of modeleyes with greater positive spherical aberration wasgreater with a CN multifocal (which has negative SA);however, the depth of focus was reduced. In essence,eyes with greater positive SA will have improved acuityfor closer/intermediate vision, but less multifocal effectwhen wearing CN lenses (Figure 6).
Figure 6: Power profiles showing the on-eyeeffect of a centre-near multifocal on eyes withlow (left) and higher (right) spherical aberration(SA) on depth of field (DoF) and visual acuity(VA)Figure 7: Using elevation maps (difference fromsphere) to visualise the apex of the corneawith respect to the pupil centre. On this RE,the multifocal lens shows temporal, opticaldecentrationFittingPower selectionEye care practitioners will know from experiencethat very small changes in multifocal lens power,whether for distance or near, can make a markeddifference to a patient’s vision and visual comfort. Anextensive distance power range, with small incrementsthroughout the range, is therefore desirable, as is arange of reading additions. In daily disposable options,available powers have been somewhat limited to date.Very few multifocal toric soft lenses are as yet available,and none in a daily disposable modality. This is an areathat practitioners will be watching closely in futureas success rates with toric soft lenses and with softmultifocals improve.CentrationOf course placing a lens on a model eye does not reflectthe dynamic situation that exists when a lens is actuallyworn. A key fitting characteristic for all multifocal contactlenses is centration. If a multifocal lens decentres it willinduce unwanted aberrations (principally coma), thusreducing vision. Recently, Lampa et al15 proposed thatcorneal topography may be a useful method to evaluatelens centration and the authors recommended usingtangential (instantaneous curvature difference) maps toquantify centration.The author of this article, however, considers that abetter method to check optical centration may be to useelevation maps with the difference in height subtractedfrom a spherical or aspheric surface. This approachenables visualisation of the apex of the cornea (with orwithout the multifocal) with respect to the pupil centre(Figure 7).Being able to predict this effect from topographic mapsis an excellent method of objective assessment ofoptical centration to confirm subjective visual acuityfindings. In conjunction with this objective method canbe gaining feedback on subjective vision performance,by asking patients if they notice any doubling orsplitting of vision at distance or near.Lens materialChoice of material is a neglected factor in multifocalcontact lens prescribing. In fact material is almost asimportant as design, especially in presbyopic eyes sincetear stability reduces with age.16 Environmental factorssuch as increased use of computers also challengethe ageing eye. The aim is to select a material whichmaintains a stable tear film and thus provides moreconsistent vision as well as minimising symptomsof dryness and discomfort. Real-time topographicaberrometry of the pre-lens tear film is helpful inrevealing differences in tear film stability between lensmaterials. Koh et al17 investigated whether the polymercomposition of disposable soft contact lenses affectssequential changes in higher-order aberrations.
Table 3: Examples of managing expectations with multifocal wearersAvoidConsiderCompromiseBalance between distance and nearNot perfectAll-round visionNot as good as specsReduced dependence on reading glassesIn symptomatic daily disposable lens wearers, totalhigher order aberrations and subjective ocular drynesswith a lens with embedded polyvinyl pyrrollidone (PVP;1-DAY ACUVUE MOIST) were significantly decreasedwhen compared with a lens of the same materialwithout PVP.Patient factorsWho, when and whereAs well as choice of lens material, modality is akey consideration in multifocal prescribing. Dailydisposability offers particular advantages forpresbyopes who, for lifestyle reasons, may want to weara combination of spectacles and contact lenses.18Patients do want a choice. Low myopes, for instance,may function well without any correction in somesituations, such as indoors, but there may be otheroccasions when they want to have that multifocaleffect.Having experienced both progressive-additionspectacles and multifocal contact lenses, most patients(78 per cent) prefer a combination of both correctionmethods.19 Presbyopes may prefer progressive additionspectacles for stationary and solitary activities, butmultifocal contact lenses for social and active pursuitssince they provide a wider field of view and a morenatural vision experience. Patients perceive the benefitsof the two modalities as complimentary.A multifocal is ideal in a daily disposable modality sincepatients can wear the lenses part time if they wish;currently a third of multifocal wearers use their lenseson a part-time basis.20 However, once patients getstarted with multifocals they may organically grow intowearing them more often if they so choose. It is prudentto consider the applications for which patients will bewearing the lenses and use materials that performwell in those situations that can exacerbate drynesssymptoms, such as office environments.The advantages of daily disposability, along withthe increasing number of lens options available, arereflected in the uptake of multifocals in this modalityin the UK.3 Nearly one in four multifocals (22 per cent)sold here in 2014 were daily disposable lenses, comparedto 10 per cent in 2010. The current UK figure is alsomuch higher than in other countries such as Germany(8 per cent), and France and the US (both at 4 per cent),although daily disposable prescribing in multifocals hasincreased four-fold recently in both Germany and the US(from 2 per cent and less than 1 per cent respectively in2010).ExpectationsCommunication is the final consideration whendiscussing multifocals with presbyopes. Give patientsthe most positive impression of correcting theirpresbyopia but avoid over-technical terms. Use languagethat resonates with them and talks about theirexpectations. ‘Reducing your dependence on readinglenses’ is just one way of adapting your language tomanage patient expectations (Table 3).Other authors have suggested ways of opening adiscussion with long-term contact lens wearers abouthow their visual and lifestyle needs change over time.21,22ConclusionsMultifocal contact lenses all differ between lensmanufacturers and behave slightly differently on theeye. As a result, practitioners are advised to have anumber of different lens designs available within theirpractices.The question each practitioner must ask is: ‘What willbe my first-choice multifocal?’ The author recommendsthat the first-choice lens should be one that:1. Uses an optimal material for the ageing tear film(for good visual stability)2. Has pupil optics that are optimised both for age andrefractive error3. Provides good on-eye centration4. Offers flexibility and comes in a modality that is easyfor patients.There are several multifocal lens options with a numberof manufacturers offering centre-near lenses. Weoften see innovation in a crowded, technology-drivenmarketplace. Small steps in the development of opticaldesign and lens materials, when combined together,could well provide a first-choice lens that stands outfrom everything else.The arrival of 1-DAY ACUVUE MOIST MULTIFOCALfrom Johnson & Johnson Vision Care, with its enhancedmultifocal design and proven material properties,offers practitioners the potential for good successrates with multifocal contact lenses. Ultimately, clinicalperformance results and personal, hands-on experiencewill help practitioners decide if this is the multifocalcontact lens to choose as their first fit lens.
AcknowledgementThis article was originally published in Optician. Dave T.Understanding multifocals and getting them to work.Optician (2015); 249; 6505: 12-17About the AuthorOptometrist Dr Trusit Dave is founder and director ofOptimed. This article is based on a presentation at theJohnson & Johnson Vision Care 2015 Clinical Roadshow inthe UK, “A New View“References1. I nternal analysis based on independent third partydata, 2015.2. A ssociation of Contact Lens Manufacturers, 2014.3. J ohnson & Johnson Vision Care, Data on file; Internalanalysis based on independent 3rd party volumedata 2014 US, UK, France and Germany; and internalestimates annual consumption based on frequency,seasonality and compliance from Independent MRsurvey 2014, 7 markets across Europe and Russia viaonline questionnaire n 5,076 contact lens wearersaged 15 .4. S ulley A, Young G and Hunt C. Factors in the successof new contact lens wearers. Optom Vis Sci 2014E-abstract 1450205. E vans B. Monovision: a review. Ophthalmic PhysiolOpt 2007;27:5 417-39.6. Rajagopalan AS, Bennett ES and LakshminarayananV. Visual performance of subjects wearing presbyopiccontact lenses. Optom Vis Sci 2006;83:8 611-615.7. R ichdale K, Mitchell GL and Zadnick K. Comparisonof multifocal and monovision soft contact lenscorrections in patients with low-astigmaticpresbyopia. Optom Vis Sci 2006;83: 5 266-273.13. W agner S, Conrad F, Bakaraju RC et al. Power profilesof single vision and multifocal soft contact lenses.Cont Lens Anterior Eye 2015;38:1 2-14.14. Bakaraju RC, Ehrmann K, Ho A et al. Inherent ocularspherical aberration and multifocal contact lens opticalperformance. Optom Vis Sci 2010;87:12 1009-22.15. Lampa M, So K, Caroline P et al. Assessing multifocalsoft contact lens centration with the aid of cornealtopography. Poster presentation at Global SpecialityLens Symposium, January 2012.16. Patel S, Boyd KE and Burns J. Age, stability of theprecorneal tear film and the refractive index of tear.Cont Lens Anterior Eye 2000;23:2 44-7.17. Koh C, Maeda N, Hamano T et al. Effect of internallubricating agents of disposable soft contact lenseson higher-order aberrations after blinking.Eye Contact Lens 2008;34:2 100-5.18. Aslam A. Contact lenses and spectacles: a winningcombination. Optician 2013; 246:6425 26-28.19. Neadle S, Ivanova V and Hickson-Curran S. Dopresbyopes prefer progressive spectacles ormultifocal contact lenses? Cont Lens Ant Eye2010;33:262-263.20. Johnson & Johnson Vision Care. Data on file.Incidence study 2014, EMA.21. Bharuchi S and Donne S. Conversations inpractice: managing the long-term wearer. Optician2014;248:6472 23-30.22. Hudson C. How to succeed with multifocal contactlenses. Optometry Today 2011; February 11: 45-48.8. D ave T. Wavefront aberrometry. Part 1: Currenttheories and concepts. Optometry Today 2004;November 19: 41-45.9. P orter J, Guirao A, Cox IG et al. Monochromaticaberrations of the human eye in a large population. JOpt Soc Am A Opt Image Sci Vis 2001;18:8 1793-1803.10. Artal P, Guirao A, Berrio E et al. Compensation ofcorneal aberrations by the internal optics of thehuman eye. J Vis 2001;1 :1 1-8.11. Cakmak HB, Caqil N, Simavli H et al. Refractiveerror may influence mesopic pupil size. Curr Eye Res2010;35:2 130-6.12. Dumbleton K, Guillon M, Theodoratos P et al. Theeffects of age and refraction on pupil size and visualacuity: Implications for multifocal contact lens designand fitting. Presentation at British Contact LensAssociation Clinical Conference, May 2015.THE VISION CARE INSTITUTE , 1–DAY ACUVUE MOIST, ACUVUE OASYS are registered trademarks of Johnson & Johnson Medical Limited.Other brand names mentioned herein are the trademarks of their respective owners. Johnson & Johnson Medical Limited. 2015
contact lenses, Dr Trusit Dave examines the design principles and material considerations behind current designs. KEY POINTS We all have spherical aberration; it is usually positive and pupil size is one of the factors that can affect SA Current soft multifocal contact lenses, whether centre near (CN) or
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