Contact Lens 1-2: Presbyopic SCL Fitting

Question 1

What is the largest untapped segment of the CL market?

a. Why?

Answer 1

Presbyopia

a. Steady increase in peeps over 60. 8% in 1950; 11% in 2009; and expected to hit 22% in 2050

Question 2

3 Options for Presbyopes

Answer 2

1. Distance SCL w/Reading Glasses
2. Monovision SCL
3. Multifocal SCL

Question 3

Distance SCL w/Reading Glasses

1. Number of Focal points?
2. Best for what type of wearers?
3. Con?
4. Pro?
5. What options are there?
6. Pt stay Binocular or Monocular?

Answer 3

1. 2
2. Bifocal wearers or those w/o Significant Intermediate Needs
3. Doesn’t get rid of the need for Glasses
4. Easy Fit
5. Toric Options
6. Pt stays Binocular

Question 4

Monovision SCL

1. What is it?
2. Visual System can alternate what?

Answer 4

1. Correction of 1 eye for DISTANCE and the other for NEAR

2. Central Suppression as needed

Question 5

How does monovision work?

1. Which eye is fit for Distance?
2. Which is fit for near?
3. How does it work?

Answer 5

1. Dominant Eye usually
2. Non-Dominant (Distance Rx + Near Add)
3. a. Interocular Blur Suppression
   b. Pt Learns which eye to use for which task (“brain”)
   c. Suppresses Dominant Eye when reading
   d. Suppresses Non-Dominant Eye when viewing at distance

Question 6

Acuity In Monovision

1. What happens to it?
2. What is lost?

Answer 6

1. about 1 letter loss in Binocular DVA per DIOPTER of ADD POWER
2. Loss in Stereoacuity DIrectly Proportional w/Increasing Add Power

Question 7

Drawback to Monovision

1. 3 drawbacks?
2. Success rate?

Answer 7

1. a. Stereopsis reduced
   b. Contrast loss and difficulty suppressing bright images against a dark background
   c. Glare
2. varies from 67-86%

Question 8

Approach to Monovision

1. 2 ways to determine Dominant eye?
   a. When determining Dominance, what needs to be done?

Answer 8

1. Triangle Test and Swinging Plus Test

a. Pt HAS to be FULLY corrected for Distance

Question 9

Triangle Test

1. How is it done?

Answer 9

1. Hold hands at arm’s length; form triangle w/thumbs at the bottom; Center 20/30-20/40 letter at distance; Close 1 eye then the other; and the eye that can STILL SEE THE TARGET when the other is closed is the DOMINANT EYE!

Question 10

Swinging Plus Test

1. How is it done?
2. How do you tell which eye is MORE DOMINANT?

Answer 10

1. Use 20/30 to 20/40 letter at distance then Swing +2.00 DS trial lens back and forth from right to left eye
2. Eye that’s MOST BLURRED from the +2.00 DS loose lens being in front of it is the DOMINANT EYE

Question 11

What other ways are there to determine Ocular dominance?

Answer 11

1. Eye you put up to a camera
2. Eye you Shoot with
3. If you have unequal BCVA, the eye w/better BCVA is the dominant.

Question 12

Near Eye Selection

1. % of cases where near eye is the Non-dominant Eye?
2. Start w/which eye as the NEAR EYE?
3. When do we consider switching?

Answer 12

1. 95%
2. Non-dominant
3. when adaptation is difficult

Question 13

Adaptation to Monovision

1. How long does Full adaptation usually take?
2. May take as long as…?
3. Difficulties may include what 3 things?

Answer 13

1. 2-3 wks (counsel on activities that should be initially avoided)
2. 4-6 wks
3. Blur, Eyestrain, Headaches

Question 14

Over-Refraction in Monovision SCL

1. 2 things that you can use…?

Answer 14

1. Trial Lenses or Flippers

Question 15

Over-Refraction in Monovision

1. Check vision how?
   a. What do we expect to see reduced?
2. How do we over-refract?

Answer 15

1. At DISTANCE and NEAR Monocularly AND Binocularly
   a. reduced Monocular DVA in non-Dominant Eye and reduced Monocular NVA in Dominant Eye
2. In Free space and Over-refract MONOCULARLY (Present Lenses to DOMINANT EYE for Distance…and Non-Dominant eye for NEAR)

Question 16

Verifying Whether a Change Needs to be Made

1. Depends on Patient’s what?
   a. Incorporating what?
   b. ANY CHANGES TO BE MADE SHOULD BE VERIFIED at what?

Answer 16

1. visual needs (Prioritization)
   a. a +0.50 over-refraction into the Non-dominant eye’s SCL Rx
   b. at BOTH DISTANCE and NEAR

Question 17

To Determine a Patient’s Effective Add

1. Effective Add: What is it?
2. Over-refract which eye?

Answer 17

1. The amt of reading add that the patient is getting in their lenses
2. the NON-DOMINANT eye MONOCULARLY at DISTANCE!

(I.e. if patient takes a -1.00 DS over their non-dominant eye MONOCULARLY to get from 20/40 to 20/20 at distance, their effective add is a +1.00 w/their current SCL)

Question 18

Should Pilots wear Monovision CLs?

Answer 18

1. NO! It’s PROHIBITED by the FAA

Question 19

Depth Perception with Monovision

1. Decrease in Stereopsis: By how much?
2. Decrease in Stereo increases with what?
3. % of monovision patients that report problems with night driving?
4. Who is a Liability to fit in Monovision?

Answer 19

1. b/w 37-150 seconds of arc
2. with Increasing Add Power
3. 80%
4. Anyone w/Critical Depth Perception Requirements

Question 20

What 3 things need to be done and Documented in regards to Monovision SCL Wearers?

Answer 20

1. Educate pt on Adaptation Period to Monovision
2. Educate on Loss of Contract Sensitivity, decrease in Depth Perception and increase in glare at night
3. Prescribe a Pair of Glasses to wear over the CL for driving when finalizing the CLRx

Question 21

Multifocal/Bifocal SCL

1. Most are of what design?
   a. What does this mean?
   b. They can be 1 of 2 things?
2. There’s also an ALTERNATING VISION (TRANSLATING) design: what is it?

Answer 21

1. SIMULTANEOUS VISION Design
   a. there’s a focused image and an out-of-focus image on the retina at one time.
   b. Center distance or Center Near
2. Only a Focused image on the Retina at one time.

Question 22

Multifocal SCL

1. 4 Types

Answer 22

1. Concentric
2. Aspheric
3. Combo Concentric/Aspheric
4. Diffractive (None on the market today)

Question 23

Aspheric Designs

1. How are they centered?

Answer 23

1. Can be DISTANCE or NEAR Centered; depends on brand…some use 1 over the other, and some use both

Question 24

Aspheric Designs that use BOTH Distance and Near Lenses

1. What are they?

Answer 24

1. Proclear Multifocal

2. Biofinity Multifocal

Question 25

Near-Centered Aspheric Designs only 1. What are the 2?

Answer 25

1. Air Optix Aqua Multifocal | 2. Purevision 2 Multifocal

Question 26

Biofinity Multifocal Fitting Guide 1. Add Power a. +1 b. +1.50 c. +2.00 d. +2.50

Answer 26

1. Dominant/Non-Dominant Eye a. D/D b. D/D c. D/N d. D/N

Question 27

Air Optix Multifocal Fitting Guide 1. Select Initial Lenses a. Then determine what things? b. Choose Add based on what?

Answer 27

1. a. Vertex-corrected, Least minus/most plus, spherical equivalent distance Rx b. Lo, MED, HI based on chart: over BOTH EYES Lo: Up to +1.25 MED: 1.50 to 2.00 HIGH: 2.25 to 2.50

Question 28

Concentric/Aspheric Design 1. What is it? 2. What company makes it?

Answer 28

1. Hybrid of the 2 designs | 2. Acuvue Oasys for Presbyopia

Question 29

Simultaneous Vision Design * Regardless of whether they're concentric, aspheric or combination concentric/aspheric can be the following: 1. Center Distance (3) 2. Center Near (4)

Answer 29

1. a. Acuvue Oasys fro Presbyopia (Vistakon) b. Biofinity Multifocal D Lens (Coopervision) c. Proclear Multifocal D Lens (Coopervision) 2. a. Air Optic Multifocal (Ciba/Alcon) b. Purevision 2 Multifocal (Bausch + Lomb) c. Proclear Multifocal N Lens (Coopervision) d. Biofinity Multifocal N Lens (Coopervision)

Question 30

Challenging Multifocal SCL Patients 1. Pupils smaller than what? 2. What other 2?

Answer 30

1. smaller than 3 mm | 2. Emmetropes and Peeps who don't want to Compromise any of their distance vision

Question 31

What about Astigmatism? 1. Most designs Can't be used for patients with more than what? 2. Only 1 Toric Multifocal SCL on the Market: What is it? 3. Custom ones?

Answer 31

1. with > 1.00 DC 2. Proclear Multifocal Toric (Coopervision) 3. Custom Toric Multifocal SCL Available

Question 32

Multifocal/Bifocal SCL 1. Most are SIMULTANEOUS VISION design: What 3 things? 2. There are also what designs?

Answer 32

1. Aspheric, Concentric, and Combo Concentric/Aspheric | 2. Alternating Vision (Translating) Designs

Question 33

What's the Alternating Vision Design? What is it?

Answer 33

Distance at top half of CL and Near at bottom half. (Only 1 Translating SCL on the Market) *Primary Gaze uses DISTANCE and DOWN GAZE uses Near

Question 34

Translating CLs 1. Good for what kind of patients? 2. Who shouldn't use them? a. Which LID has the MOST EFFECT on TRANSLATION?

Answer 34

1. w/Lower Lid position below the Limbus and/or Loose lids are not good candidates 2. Loose lids don't allow a lens to translate a. UPPER LID; Lower lid accounts for 1mm of the total translation

Question 35

Multifocal SCL: 2 groups

Answer 35

1. Simultaneous Vision a. Aspheric (Center distance or Center Near) b. Concentric (Center Distance or Center Near) c. Diffractive 2. Alternating Vision/Translating

Question 36

Fitting Multifocal SCL 1. How is it done?

Answer 36

1. Choose Lenses according to manufacturer's fitting guide; 2. Place diagnostic Lenses on Patient's Eyes 3. Let the Lenses Settle 4. Check Vision/Over-Refraction 5. Check Fit

Question 37

Simultaneous Multifocal SCL Vision 1. Check vision how?

Answer 37

1. At Distance and Near Monocularly and Binocularly * May have reduced mono distance vision in eye w/HIGHER ADD POWER or Center-Near Design and in Near Vision in eye with LOWER ADD POWER or Center-Distance Design

Question 38

Over-Refracting in Multifocal SCL 1. Over-Refract how? 2. Some designs call for Over-Refraction how? 3. Any changes to be made should be verified how?

Answer 38

1. in FREE SPACE!! 2. BI-OCULARLY at distance and near Separately (Bi-ocularly --> Both eyes are open but loose lenses or flippers are presented over one eye only) 3. Both at DISTANCE and NEAR

Question 39

Refracting Bi-Ocularly 1. How is it done?

Answer 39

1. Both Eyes Open; Loose Lens or Flipper over ONE EYE ONLY!!

Question 40

Verifying whether a Change needs to be made 1. Assess what? 2. Most important vision is what?

Answer 40

1. Patient's Visual Priorities 2. is OU VISION (e. g. Incorporating a -0.50 over-refraction into the dominant eye's SCL Rx to improve distance)

Question 41

Trouble Shooting 1. Poor Distance Vision a. Check for what? 2. Poor Near Vision a. Do what?

Answer 41

1. a. Check for Underminusing at distance (esp in DOMINANT EYE) b. Reduce Add in Dominant Eye c. Uncorrected Cyl?? 2. a. Push PLUS at distance (esp. in non-dominant eye) b. Increase the add in the non-dominant eye c. Uncorrected Cyl?

Question 42

* Language...Use what terms? | 2. Avoid what terms?

Answer 42

1. Balance and Prioritizing | 2. Compromise or Sacrifice

Question 43

Creative Combinations 1. Modified Monovision 2. What else?

Answer 43

1. Single vision SCL in dominant Eye and Multifocal SCL in non-dominant eye; Fitting monovision by correcting dominant eye for distance and the non-dominant eye for intermediate 2. a. Fitting a different brand of multifocal SCL in each eye b. Only wearing a lens in 1 eye (Multifocal or single vision) c. Distance SCL w/Intermediate Glasses d. Distance SCL w/"Computer PAL"

Question 44

Presbyopic Correction Success? (3)

Answer 44

1. Cosmesis is an issue 2. Spectacles are bothersome 3. Visual demands are not very critical

Question 45

1. Monovision: Pros/Cons

Answer 45

1. Decreased Stereo a. Not for every occupation b. Always Prescribe Overglasses for Driving

Question 46

1. Multifocal: Pros/Cons

Answer 46

1. Better stereo but depends on lens design a. Flexible patient b. Determine Patient's primary visual demand

Question 47

Distance SCL w/Overglasses: Pros/Cons

Answer 47

1. No intermediate with NVO 2. Taking glasses on and off 3. For patients w/critical visual demands and no cosmetic concern