(1) Investigate the patient's environment: check their systemic health, medications (Rx and OTC). Most of these patients can be fit if they are under control systemically.

(2) Investigate patient's visual needs: if they use a computer 30% or more in a day for work or leisure, then use an aspheric design to enhance the mid range.

(3) Calculate and predict the refractive success with the corneal measurements and the refraction.

• If the refractive correction and the corneal toricity are close or similar, then use an aspheric design (VFL 3, Essential, Multivision, Multifocal, etc.).
• If the refractive correction and the corneal toricity are different, then use a translating lens with a capability for front toric design (decentered De Carle, etc.).

(4) Use corneal topography to assess total cornea.

• If the highest peak of the cornea is positioned nasally, temporally, superiorly, or centrally, then use a simultaneous design.
• If the highest peak of the cornea is positioned inferiorly, then use a translating lens (decentered De Carle, Solution, Annular, Presbylite, etc.).

(5) Astigmatism Prediction

• If there is more than .75D residual astigmatism predicted, then use a translating design.
• Presbyopic patients are more sensitive to residual astigmatism, especially for near vision.

(6) Don't fit translating designs when the lower lid is below the limbus. There is not the lid support for the translating movement.

(7) Carefully assess the physical characteristics of the patient, including VID, palpebral aperture measurement, lid tonicity and position, Cj artifacts such as pinqueculae, pterygiums, etc., corneal measurements with a CT, corneal artifacts, meibomian gland evaluation, and tear assessment.

(8) Pupil Assessment

• Measure the size with mesopic and scotopic environment.
• Use translating designs with larger pupils.
• Use simultaneous and aspheric designs with smaller pupils.

(9) All bifocals and multifocals need to translate.

• Fit aspheric lenses with centration and minimal movement to allow translation into the near add.
• Fit translating lenses with alignment.
• Keep translating segments below lower pupillary margin.

(10) Charge fees appropriate with your expertise, time needed to fit, and materials involved. DON'T UNDER-SELL YOURSELF!! YOU'RE WORTH IT!! This truly is a specialty area with great benefit for the patient.

(11) Always review patient expectations.

• Will the patient accept some compromises?
• Do they expect perfect vision at all distances?
• Do they expect to see better than with spectacles?

(12) Always test for marginal dry eye signs

• Do TBU test for tear quality.
• Look closely at the lid margins.

(13) Look at the patient's refractive needs.

• Distance Rx should be at least 1.00 D.
• Near add should be at least +1.00 D.

(14) Develop a definite presentation when discussing presbyopic options.

• Always place bifocal contact lens options at the top of your list.
• Be prepared to discuss different types/designs.
• Understand that patients gain confidence in a procedure when you educate them about their range of options.
• Take advantage of literature that is provided by your local laboratory that discusses various bifocal lens designs.
• Utilize the GPLI brochure that discuses presbyopia.

(15) Utilize diagnostic bifocal contact lenses in your work-up procedure.

• Have at least one each of an aspheric multifocal and one translating multifocal design that you can utilize in a bifocal contact lens work-up.
• Always review the fitting guides for tips when evaluating a new patient.
• Take advantage of consulting services that your local lab offers when a challenging case presents some concerns.

(16) When first evaluating a diagnostic or a new bifocal lens on the eye, always allow for it to stabilize before making a decision to change the fit.

• Wait at least 10 minutes before evaluating the performance.
• Never measure the visual acuity until you are certain the lens is stable on the eye.

(17) Discuss with the patient what they should expect when wearing the new lens design.

• Night driving
• Extensive computer sessions

(18) Know when to change designs.

• When design doesn't work, change to alternate design.
• Always consider modified bifocal.
• Consider modified monovision.

(19) Know when to discontinue fitting.

• Always review progress at reasonable point in fitting.
• Always review goals of fitting and other options.

(20) Always charge a fee that represents a specialty service.

• Consider the time to deliver this advanced care.
• Consider the additional material cost for specialty lens designs.
• Remember, your patients realize this is truly an advanced procedure and there are additional costs. DO NOT GIVE AWAY YOUR EXPERTISE. The appropriate fee reinforces the value of your expert care!!!!!!
   

MM (WF 60 yrs old)

• 40+yrs PMMA - GP cls SV to Bif cls
   
• Because of congential blepharochalasia and ptosis, and the hyperopic prescription, I used an Annular style design.
   
• Health: neg
   
• Meds: Premarin, Ca++, Fosomax, vits
   
• Rx:    OD +2.75 +.75 x 65 = +2.50    OS +3.75 +.75 x 120 = +2.50
   
• K:    OD 42.00/41.50 @103    OS 42.00/43.25 @130
   
• Physical Measurements:
  Pupil size:    3.0 mm Mesopic OU    4.0 mm Scotopic OU
  Corneal VID: 10.5 mm OU
  Palpebral aperture: 7.0 mm OU
   
• Analytical Exam: good alignment of the eyes horizontally and vertically both far and near performed with Risley Prisms
   
• Goldmann AP: 10mm of Hg OU
   
• Corneal topography below. Note lid scotoma on OS especially.

Philosophy: Fit a lens that accommodates the small palpebral aperture, provides translation of the lens into the different zones, and gives good visual acuity.

Former BIF cl: Bivision (annular)
    OD 698/784 +4.50/-3.00 9.5 diam +2.50 add 12.25/ 9.00 PPO2 material
    OS 780/699 +4.75/-2.75 9.5 diam +2.50 add 12.25/ 9.00 PPO2 material

Because of slight dry eyes and losing comfort I switched to an aspheric design. Larger diameter assisted the bleph probs and the position of the lenses.
Universal Multifocal CD - CL parameters:
    OD 738 -.75 FV 9.8 Diam 8.4 OZ 9.00 .5/ 11.50
    OS 728 +.50 FV 9.8 Diam 8.4 OZ 9.00 .5/ 11.50
    +2.50 add FL30

Achieved 20/20- 20/20 J1 OU
  

CASE STUDY - Dr. Baker

LS ( WF 59 yrs old)

• 33 yrs of rigid wear + GP monovision for 5 yrs
   
• Difficulty with monovision when reading and doing bookkeeping (16 hrs/wk)
   
• Health: Hx is unremarkable
   
• Meds: Premarin
   
• SRx:
      OD -0.50 -1.00 x 010 20/20
      OS -1.00 -0.50 x015 20/20
      Add + 2.00, OU
   
• Keratometry:
      OD 41.75 / 42.75 @ 90
      OS 41.75 / 43.00 @ 95
   
• Physical:
      Pupils: 3.5 mm OU / 4.5 OU dim light
      VID: 11.50, OU
      Palpebral Aperture: 8.50, OU
   
• Ocular Health: Unremarkable, some complaints of dry eye symptoms.

Fitting Philosophy: Patient needs improved near to mid range vision. Refit with high add aspheric in high Dk/t material with good wetting characteristics.

Lens Design Used: Essentials III in Boston XO material
    OD 7.90 -1.75 9.80 8.30 Cap + 2.50 Add .23 ct
    OS 7.90 -1.50 9.80 8.30 Cap + 2.50 Add .22 ct

Visual Acuity
    Distance: 20/20, OD, OS & OU
    Near: 20/25 OD, 20/20 OS & OU