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Troubleshooting in Multifocal Contact Lenses

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Photo Credit:Getty Images/Vetta

December 8, 2023

Roadblocks can occur when fitting patients with contact lenses even after you’re gone through all the necessary steps, including history, motivation, refractive status, education, expectations, ocular surface evaluation, lens selection, and all the other pieces to the puzzle. When the patient has finally gotten the lenses on the eye and had ample time to settle, something just ain’t right and the patient isn’t thrilled with their vision or comfort. Here are some ways to troubleshoot the multifocal lens process.

Follow the Fitting Guide
If you are a follower of this Contact Lens section of Review of Presbyopia and the Aging Eye, you’d notice we love a contact lens fitting guide. You should too as it is the best place to start. So, if you aren’t starting by following the manufacturer’s recommended place to start, we’d refer back to that for your initial lens selection. For the first enhancement, each process is different. Some start with adding +0.25/-0.25 flippers, some change add powers, some keep adding more plus to the equation, so make sure you’re fully versed on the appropriate steps.

One of the things we appreciate most about the newer technologies is that we see success come quicker. From research done by each manufacturer, we see high success rates with one or two lenses per eye. The flip side to this is that we also see failure come even quicker. If a patient isn’t somewhat functional at distance and near with the first lens, we can go ahead and switch designs because we need to start at a place of functionality. Now we’ve saved at least one or two more lenses, which can add up to 20 minutes of wasted time trying to make this lens work.

The Ghosting Phenomenon
Ghosting isn’t just something the kids do these days when they don’t text you back. Our multifocal lens wearers also complain of this. They may say “it looks 3D” or “the words are coming off the page” or any other fun descriptors we’ve heard over the years. But this is a phenomenon we see often in the clinic. Usually this means the optics aren’t working in your favor, and typically it’s too high an add power. In some lenses, we can split the add and go down in the dominant eye, which clears up the vision. In other lenses, we may have started in too much add and can go down while still achieving good near vision. The most common age demographic that we’ve seen have this complaint is the 49 to 54-year-old. They are typically given more plus in their spectacle prescription but may not need as much in a more dynamic visual correction such as contact lenses. They generally can handle a lower add in the contact lenses and still have great functional vision at distance and near.

Emmetropic and Low Hyperopic Expectations
The emmetropic or low hyperopic presbyope is another fun patient who wants to turn back time and see like they did at 20 or even 30 years old. They tend to have the highest expectations when it comes to contact lens wear. We like to start these patients in binocular multifocal wear, but sometimes it can be too much for their visual system. In these patients, we’ve had a lot of success wearing a multifocal contact lens in the non-dominant eye and creating a modified monovision setup where they still have great binocular distance vision.

Fluctuating or blurry vision is a hallmark in ocular surface disease. We’ve seen too many patients where we bumped up the add, but really what they needed was a better tear-surface interface. These patients with ocular surface issues will have complaints of blurry vision even though we’ve tweaked, changed, and explored all our options. Don’t be afraid to take a contact lens holiday to treat the surface in order to get the best vision and comfort possible.

These pearls have paid dividends for us and our patients over the years. They have helped to keep our patients happy in their lenses and given them plenty to rave about outside the exam lane. We hope this will be the missing piece to solve some of those conundrums we all face in our daily practice.



  • Mark Schaeffer, OD, FAAO

    Dr. Schaeffer serves as Clinical Field Manager at MyEyeDr in Birmingham, Alabama, where he practices full scope optometry. In addition to day-to-day patient care, he has run several clinical trials and is affiliated with multiple pharmaceutical companies in consulting for ocular disease and contact lenses. Dr. Schaeffer has appeared in various media as an author for publications, lecturer for continuing education, and advocate for the profession and patient care. He is a founding member of the Intrepid Eye Society, and he is a member of the Alabama and American Optometric Association, American Academy of Optometry, and the Contact Lens and Cornea Section. Dr. Schaeffer earned a Bachelor of Business Administration in Marketing from the University of Georgia, his Doctor of Optometry from Southern College of Optometry, and he completed a residency in Ocular Disease at Bascom Palmer Eye Institute in Miami, Florida. Email him at Mark@DrMESConsulting.com

  • Brooke Schaeffer Kaplan, OD

    Dr. Kaplan currently serves as Clinical Field Director at MyEyeDr in Birmingham, Alabama. In addition to seeing patients in the clinic, she supports 36 other optometrists throughout the state. Prior to this, she was Medical Director for Schaeffer Eye Center and its 18 locations. She is also on the faculty at UAB School of Optometry as a Clinical Assistant Professor in the Primary Care Service. She is a CooperVision CAST speaker and has served as a consultant for other companies in the optometric industry. She graduated from the University of Georgia with a Bachelor of Science in Genetics. She completed her Doctor of Optometry from the University of Alabama Birmingham. Email her at Brooke.Kaplan@MyEyeDr.com

  • David Schaeffer, OD, FAAO

    Dr. Schaeffer currently practices full scope optometry with MyEyeDr in Mountain Brook, Alabama, with an emphasis in specialty contact lenses and management of ocular disease. He received his undergraduate degrees in Microbiology and Psychology from the University of Georgia in 2012, and he graduated from the Illinois College of Optometry in 2017. In 2018, Dr. Schaeffer completed his residency in ocular disease at Bascom Palmer Eye Institute in Miami and is a fellow of the American Academy of Optometry. He currently speaks on behalf of CooperVision.

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