10/22/14 Multifocal Contact Lenses New
Thoughts New Understandings
Please complete your session evaluation
using EyeMAP™ online at http://
eyemap.cistems.net
Matthew Lampa, OD, FAAO
Disclosure Statement:
•  Alcon
•  Bausch + Lomb
•  SpecialEyes
•  Valley Contax
•  Vistakon
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Simultaneous Image Designs
Near and Intermediate Vision
Multifocal Soft Contact Lenses
> 70%
50%
of presbyopic patients cite the need for good near and
intermediate vision as a priority for their work.2
of these patients say they often have difficulty
with their near or intermediate vision at work.2
contact lenses
2. Kadence International. PureVision®2 For Presbyopia Quantitative Testing. July 2012.
Simultaneous Image
•  Distance, intermediate and near images
of equal intensity are simultaneously
presented to the retina.
•  At a given distance, the brain selects
the appropriate image.
[3]
Soft Multifocal Lens Designs
Aspheric Center
Near Design
Aspheric Center
Distance Design
Multizone
Design
1 10/22/14 Prefitting Considerations
The Balancing Act
•  Distance and near vision often conflict
•  Practitioner must break with spectacle
prescribing habits
•  Unequal adds
•  Lower adds
•  Goal - CL should work for 75% of tasks
•  SV Readers or SV Distance over-Specs
•  Visual needs
•  Anatomical considerations
•  Patient expectations
Soft Multifocal Lenses
General Tips
Outcome influenced by:
•  Lens de-centration
•  Pupil size
•  Amount of refractive
astigmatism
•  Patients age and their ability
to interpret blurred images
if the lenses are fitted with
•  Start with the fitting guide
•  Allow all lenses to settle 10-15 minutes
•  Be prepared to utilize a modified
monovision approach
Modified Monovision
Determining the Near Eye
• 
• 
• 
• 
Non-dominant eye
Specific occupational requirements
Specific recreational requirements
Sighting vs. sensory dominance
–  “Swinging plus test” & “Hole in Hand”
+1
.5
0
Soft Multifocal Lens Designs
Aspheric Center
Near Design
Aspheric Center
Distance Design
E
HP
EVO
TZVECL
EHPNTOH
Multizone
Design
2 10/22/14 Simultaneous Image CL’s
Concentric Multifocals
Bifocal Lenses
•  Available in center/near or center/distance
Multifocal Lenses
•  Dedicated distance and near power zones
•  ‘3D-effect’ for near-vision
•  Ghosting or doubling of images
POWER DISTRIBUTION
Near
Near
Near
N
TA
CE
NE
AR
DIS
E
Power correction
Distance
Image intensity
Distance
Distance
Image intensity
Distance
•  Pupil size dependent
•  Reduced contrast sensitivity
: DISADVANTAGES :
POWER DISTRIBUTION
Distance
Near
•  Progressive power effect
•  No compromise to intermediate vision
: ADVANTAGES :
Near
DISTANCE VISION
N
TA
CE
DIS
E
IN
R
TE
ED
TE
IA
M
AR
NE
Power correction
NEAR VISION
Center Near
SIMULATED NEAR VISION
Center Distance
2.6 mm Pupil
N
4.5 mm Pupil
D
5.6 mm Pupil
Pupil Size and Age
Age
(Years)
20
40
50
60
70
80
Daylight Nighttime
Diameter Diameter
5.0
8.0
4.0
6.0
3.5
5.5
3.0
4.25
2.5
3.0
2.0
2.5
The Effect of Sagittal Height
4.0 mm Pupil
10.2 mm
13.0 mm
3.5 mm
3 10/22/14 Vision Evaluation
Corneal Mapping over
the Contact Lens
•  Acuity
–  Distance
•  Snellen
–  Near
•  Snellen
•  Real world
•  Over Refraction
–  Unilateral
–  Bilateral
–  Demonstration
Corneal Mapping over
Corneal Mapping over
Air Optix MF 8.6/14.2 -3.00 (High Add)
Purevision MF 8.6/14.0 -3.00 (High Add)
Corneal Mapping over
Corneal Mapping over
Acuvue Oasys MF 8.4/14.3 -3.00 (High Add)
Proclear MF 8.7/14.4 -3.00 (+2.50 Add)
4 10/22/14 Proclear MF 8.7/14.4 -3.00 (+2.50 Add)
Corneal Mapping over
Proclear MF 8.4/14.4 -3.00 (+2.50 Add)
Proclear MF 8.4/14.4 -3.00 (+2.50 Add)
Further Investigation
Angle Lambda and Multifocals
•  Fovea is decentered temporal
•  Visual axis passes through the lens 1
to 9 degrees nasal to center
5 10/22/14 Corneal Mapping over
Corneal Mapping over
Air Optix Aqua 8.6/14.2 -3.00 (High Add)
Purevision MF 8.6/14.0 -3.00 (High Add)
Corneal Mapping over
Corneal Mapping over
Acuvue Oasys MF 8.4/14.3 -3.00 (High Add)
Biofinity MF 8.7/14.4 -3.00 (+2.50 Add) D
Corneal Mapping over
Study – What is Normal?
Biofinity MF 8.7/14.4 -3.00 (+2.50 Add) N
•  Subjects = 18
•  Enrolled based on:
–  Central K 43.00 D
–  <1.00 D corneal toricity
–  Visible Iris Diameter 11.8mm +/- 0.2mm
•  5 Commercially available multifocals
chosen
•  Lenses allowed to settle centration
verified
•  Over topography performed
6 10/22/14 Study
•  Mismatch always temporal
•  Mismatch range = 0 – 1.25mm
•  Mismatch average = 0.50mm
Line of Sight
+
CL Optic
Decenter the Optics
Decenter the Lens
+
Multifocals
• 
• 
• 
• 
• 
Centration is critical (over line of sight)
Alter base curve or diameter
Consider other lens design
Consider custom multifocal
Consider monovision
Robert B. Mandel
Observation
Why do soft contact lenses frequently
decenter temporally???
Observation
Scleral lenses frequently decenter temporally
7 10/22/14 Temporal
Nasal
Clinical Observations
“Vision is clear, but seems a bit off”
Temporal
Nasal
“My eyes feel strained with the lenses
on”
“I can’t explain...something just doesn’t
seem right”
Temporal
Nasal
330 um
460 um
210 um
250 micron
difference
Right Eye Scleral Height
Left Eye Scleral Height
T N N
Horizontal 15.0 mm Chord N = 18
OD Average 173 um Higher Nasally
Horizontal 20.0 mm Chord N = 18
OD Average 838 um Higher Nasally
T
Horizontal 15.0 mm Chord N = 18
OS Average 2 um Higher Nasally
Horizontal 20.0 mm Chord N = 18
OS Average 659 um Higher Nasally
8 10/22/14 Nasal – Temporal
Comparative Results
Right Eye
Average Height Difference Between Nasal & Temporal Sclera
Chord
OD
OS
15 mm
173 um
2 um
20 mm
838 um
659 um
N
At 15.0 mm: nasal higher by 210 um
At 20.0 mm: nasal higher by 1,060 um
SA Right Eye 3,650 um
Left Eye
N
T
Right Eye
T
Left Eye
At 15.0 mm: temporal higher by 50 um
At 20.0 mm: nasal higher by 490 um
Right Eye Left Eye
9 10/22/14 Applications
•  Scleral lenses
–  Ortho K
–  Multifocal
•  Soft contact lenses
–  Multifocal
–  Toric
–  Specialty soft for irregular corneas
–  Higher order aberration correction
Decenter the Optics
Decenter the Lens
Line of Sight
+
+
CL Optic
Robert B. Mandel
Translating Soft Contact Lenses
Lower Lid Control
SCL Translation
Traditional Ballasted Design
10 10/22/14 SCL Translation
Modified Ballasted Design
The Tear Film
Surface Quality
(TFSQ) Index
Alternating Image SCL Designs
Traditional Ballasted Design
Modified Ballasted Design
The topographer
captures and
analyzes a
placido image
every second for
30 seconds.
Medmont Corneal
Topographer
The height of the
tear film is
measured and
recorded as the
Tear Film Surface
Quality (TFSQ)
0.0 sec
6.8 sec
Dry Eye Patient
0 Seconds
5 Seconds
Post Blink
TFSQ Index 0.025
TFSQ Index 0.103
11 10/22/14 Soft Contact Lens
Materials
On-Eye
Material Surface
Wetting
Properties
Three Different Brands -3.00 D. SCL’s
Same Patient, Same Eye
Lens #1
0 Seconds
Lens #2
0 Seconds
Lens #3
0 Seconds
Lens #1
5 Seconds
Lens #2
5 Seconds
Lens #3
5 Seconds
‘
Rigid Contact Lenses
Materials
‘
12