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When Fitting Multifocal Contact Lenses, It’s the Ocular Surface that Counts

April 11, 2023

Imagine fitting a patient into multifocal contact lenses. The refraction, education, and lens selection are completed according to the patient’s lifestyle and needs. The patient is given ample time to settle, but it falls flat. The vision isn’t there, the comfort isn’t great, and everyone involved is underwhelmed. So, you move on to a different lens and design. You’re still implementing the same care and expertise, and you’re even following the recommended fit guides, but you still receive underwhelming results. Sound familiar?

Until these surface issues are resolved, this patient would not be a good fit for contact lenses.

Like Putting a New Shoe on a Sprained Ankle
When we fit multifocal contact lenses, or any contact lenses for that matter, we are trusting that the ocular surface is ready for the task. All the optics and design that go into the production of these lenses are based on the assumption of a healthy tear film and cornea. During the comprehensive eye exam, the anterior segment is evaluated and observed for any pathology because if we have learned anything about ocular surface disease it is that it isn’t so straightforward.

If a lens is put on an eye that is not ready for all the optics squeezed into a tiny piece of plastic, it is similar to putting a new shoe on a sprained ankle. The newer lens (or shoe) will perform better than what was previously used, but it won’t deliver optimal results until we resolve the underlying problems.

Multifocal Contact Lens Wearers Are Most Likely to Drop Out
Contact lens dropout remains a considerable problem with patients today. Even with the advent of more breathable materials, more frequent replacement, more parameters, and other features meant to decrease contact-lens-related dryness, the percentage of patients discontinuing lenses due to comfort and vision is consistent. Although today’s visual demands are far more challenging than 20 years ago, the materials and innovations have evolved with the times. So, the primary reasons patients discontinue lens wear remain the lens and surface interactions that translate to comfort and vision.

In clinical studies, dropout rates were higher in multifocal contact lens wearers compared to toric and spherical wearers. (Sulley, Young). In a natural history study of dry eye disease, patients who had ocular surface issues reported significantly more blurred vision than their control counterparts (McDonnell). Using this information along with aged-based findings, we expect multifocal contact lens wearers to be more challenging to the practitioner.

In other studies, ocular surface issues were found in 45% of pre-LASIK candidates (Zhao). These are otherwise healthy adults who have vision correction and are likely wearing contact lenses.

These Screening Tools Will Ensure the Ocular Surface Provides a Good Foundation
Because of these potential obstacles, it becomes more important to start with a good foundation for success. This includes a more in-depth look at the ocular surface and closely focusing on the questions for the case history. Having these as screening tools to ensure a healthy and properly functioning tear system is paramount to a good experience for the patient.

Using a questionnaire gives the practitioner the opportunity to get standardized answers and start the conversation. Giving the patient the chance to quantify their symptoms helps the doctor understand if there are already underlying issues with current wearers or neophytes to presbyopic correction. If the patient is already having an issue, proactively addressing any inefficiencies will help future success. We use a survey on all comprehensive eye exams, but doing so can be even more helpful for contact lens wearers when discussing new technologies and possible obstacles.

There is a multitude of validated surveys for dry eye and contact-lens-related dryness. Each has its own grading scale and correlation to possible ocular surface disease:

  1. Standard Patient Evaluation of Eye Dryness (SPEED)
  2. Contact Lens Dry Eye Questionnaire (CLDEQ)
  3. Contact Lens Discomfort Index (CLDI)
  4. Dry Eye Screening for Dry Eye Epidemiology Projects (DEEP)
  5. McMonnies Questionnaire
  6. Symptom Assessment in Dry Eye (SANDE)

(For more on dry eye questionnaires, click here: “How to Use Dry Eye Questionnaires in Your PracticeReview of Optometry May 15, 2022.)

Follow the “Look, Lift, Pull, and Push” Method
After having the patient complete the survey, prior to putting a lens on the eye, a thorough evaluation of the ocular surface is crucial. An easy way to evaluate is simplified in a pattern from ASCRS assessing for pre-operative complications. It’s the “Look, Lift, Pull, and Push” method (Starr).

Starting with Look, evaluate:

  • lids/adnexa for debris/blepharitis, teleangectasia, capped glands, saponification, thickening or other signs of inflammation
  • conjunctiva for hyperemia, concretions, papillae, and follicles
  • cornea for tear debris, presence of old scars, anterior basement membrane dystrophy, inflammation, or other keratopathies

Lift and Pull: Check under the superior lid for limbal issues such as SLK, while also looking at lid return to the globe to rule out floppy eyelid. Don’t forget to evert both upper and lower eyelids to look for abnormalities such as giant papillary conjunctivitis or conjunctival scarring.

Finally, gently Push on the meibomian glands to evaluate what comes out of the orifice in amount, color, turbidity, and ease of expression.

Everybody Wins When the Practitioner Fully Examines the Ocular Surface
If there are any abnormalities, even if the patient is currently successful in contact lens wear, there may be a chance of possible dropout or decreased performance in future modalities. By treating now, we improve outcomes and give the patient a great chance of success with more advanced technologies.

Educating the patient about what goes into the evaluation continues to build value in the services being provided. The patient witnesses a thorough process of ensuring not only satisfaction in current contact lens wear but also a lifetime of wearing. The patients want the luxury of choice, deciding whether contact lenses are right for them, not having the contact lenses decide for them.

When the practitioner fully examines the ocular surface specifically for the wearing of contact lenses, everybody wins. The patient gets the knowledge and satisfaction of a great experience, the practice gets a patient who is loyal to their efforts, and the doctor knows that the highest level of care has been provided.



  • 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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