Lots of contact lens patients start to lose interest in contacts when Presbyopia (a loss of ability to focus the eyes on near objects) starts to take away their up-close vision.
But wait! There are now excellent MULTIFOCAL CONTACTS available that allow patients over age 40 to wear contacts and be able to see both far away, up close, and at an intermediate distance so crucial for computer users.
Since our Seattle patients live in an urban area, pretty much all of us are computer users at some level. But that intermediate distance is also key for lots of other things, such as seeing the person across the table from you. I would like to state that I would be doing a disservice to the profession of optometry if I did not mention that fitting multifocal contacts can be rather challenging. Follow-ups are more likely than with other fits, so you should expect fitting fees to be a bit higher for multifocals.
Not all patients will be successful (for example, patients with more than one diopter of astigmatism often need expensive specialty “multifocal toric” lenses). But for a large majority of patients in their 40s and beyond, multifocal contacts can be a real game changer.
If you are reading this article about multifocal contact lenses and how they work, you are most likely over 40 years old. In Our forties we all begin to need help focusing on near objects such as smartphones and documents.
If you needed glasses or contacts before age 40, you’re probably already using multifocal (progressive) glasses. Many other patients are familiar with monovision contacts (one for distance, one for near) but have not yet had the opportunity to try multifocal contact lenses.
There are many 40-something patients who have worn distance-only contacts for numerous years with great success, yet they are gradually encountering increasing frustration with their near vision. Typically, these patients buy some reading glasses and find great relief.
With the satisfaction of excellent up-close vision comes the frustration of knowing they need readers in addition to their distance-only contacts for more than half of the day. Many patients ask us “what the point of wearing contacts” if they need reading glasses over top for much of their day.
Whenever I fit patients in multifocal contacts, I like to discuss the 80% rule with them. This rule is really about setting expectations at the right level.
Basically, it boils down to this: if you expect perfection in multifocal contacts, we should not even try them. They are not perfect.
When our optometrists hear that the patient is happy 80% (or more) of the time without supplemental reading glasses, then that is a successful fit. There is always some level of compromise. The modern multifocal lenses are WAY better than the contacts we had just a handful of years ago.
Things got much better when the Air Optix Multifocal and Biofinity Multifocal were released. Now is a good time to need multifocals; modern contact lens technology is impressive. The latest crop of daily disposable multifocals such as Dailies Total-1 multifocal and MyDay multifocal lenses are also excellent.
Often when one of the doctors at Cannon EyeCare in Seattle fits a patient in Multifocals, they can see 20/20 in the distance, and 20/20 or close to that at near. But they often tell us that their vision is not perfect. I had a patient report that they could see the street signs about as early as anybody else in the car, but there is a little fuzziness or “ghosting” on the street signs due to their multifocal contacts.
Patients tell us it is almost like a shadow or ghost image next to the letters. But many of them also say their vision is “awesome” because they can see nearly everything they need to see, all day long, without pulling out reading glasses. Good functional vision is achievable for the vast majority who try multifocals. This assumes that the doctor doing the fit is experienced and takes the time to fine tune the lens powers.
Again the 80% rule says that if you are happy 80% of the time, and able to do 80% of the things you’d like to be able to do without putting on readers, then that is a successful fit. Sometimes I’ll have patients come in and tell me that they are happy 90% of the time with their contacts. When I have patients come in telling me that they are happy with their contacts 85 or 90% of the time, I feel like I’ve hit a home run. Again, if you expect perfection, we should not even try.
Like most types of contacts, multifocals are now available in monthly replacement and daily disposable modalities. Dailies may make good sense for you if you are new to contacts, or only wear them a few times a week. Often monthlies make more sense for patients who wear contacts 5+ days a week due to cost considerations. If you wear daily disposable lenses every day, that’s 730 lenses for a year. Even if they’re only $1 per lens, that adds up quickly.
One final note: these lenses require good lighting to perform up close. You can therefore expect them to underperform in your favorite dimly-lit Italian restaurant.
The multifocal vs bifocal discussion comes up in glasses too. I’ll briefly describe that setup to set the stage for an informed discussion of how things work with contacts. First, let’s start with some root words. ‘Bi’ means two.
With bi-cycles, we are talking about two wheels. In bi-focal glasses, we are talking about a lens with two distinct focal powers. The old-school lined bifocal has two distinct working distances that will be in focus if the prescription is right: far away and at about 16”/ 40 cm. There are bifocal glasses lenses available in the market, but they are the lined bifocals that your grandma and grandpa wore.
For glasses, about 95% of our patients over age 40 prefer multifocal “progressive” lenses in their glasses. Progressives are also sometimes called ‘no-line bifocals,’ but that’s not technically correct, because there are more than two powers. Multifocal glasses do not have a visible line, so they look like regular glasses, which is nice. They are also more functional, which is great.
Progressive (multifocal) glasses will cover the distance, right up close (approximately 40 cm of 16”) and everything in the middle. That is the beauty of multifocal glasses AND multifocal contacts – you get good, functional distance, near, and intermediate vision.
Multifocal contacts have many different powers in different parts of the lens. A good way to think of it is the concentric rings that result after a stone is thrown into a calm pond. Each of these rings indicates a different diameter from the center. Multifocal contacts have different powers in different diameters of the lens. Most modern multifocal contacts are set up to have near vision focused in the center of the lens, which ideally will be centered over your pupil.
The concentric diameters of the lens become more and more focused on distance vision as we approach the edge of the contact lens. The lens design takes advantage of the fact that our pupils constrict when we read. Likewise, the pupils dilate slightly when we look into the distance.
One important consideration when weighing the plusses and minuses of Multifocal Contacts is the cost. At the time of this post edit (January 2023) the MSRP for a year supply of the Air Optix Multifocal lenses (with Hydraglyde) is 66% higher than the cost of a year supply of the simpler Air Optix plus Hydraglyde (a single focus lens). In other product lines, the premium is closer to a 30% increase. Compare that to the annual cost of your over-the-counter reader glasses. Then consider how much money you’re willing to spend for freedom from readers in the vast majority of situations.
Are there cheaper alternatives to Multifocal Contact Lenses?
One strategy that can work well – and cost less – is Monovision contact lenses. In this strategy, the patient’s dominant eye is set up to see well for distance. The other eye is focused for either arm’s length (computer distance) or at about 16″/40cm. It sounds crazy but you don’t have to shut one eye to drive and cover the other eye to read. When set up properly, your brain should figure out how to see pretty well at both distances. Not everyone can adapt to Monovision though; nor is everyone a good candidate. The eye doctor needs to weigh many factors when sorting out which strategy is likely to work best for you. But seriously though, if the cost of Multifocal lenses is burdensome for you, talk to your eye doctor about Monovision.
One important downside to Monovision contacts is a slight loss of depth perception. As a result the doctors at Cannon EyeCare never suggest monovision for dentists or surgeons. It turns out they need very precise depth perception.
It does take time for most patients’ eyes (and brains) to adjust to multifocal contacts. There is a bit of a learning curve. Some patients have glasses prescriptions are less than ideal, which can make the adjustment harder. Most people will adjust to their new multifocal contacts within a week if they are worn daily.
People who have had a significant glasses prescription are more likely to appreciate the many benefits of multifocal contacts. Other patients who have seen well until their 40s hit and can get by with over-the-counter readers often are the hardest to fit in multifocal contacts. Patients who are used to seeing really well in the distance without contacts or glasses often have a harder time with the inherent compromise to distance vision.
If you give it a good college try and you are not happy, then you are not likely to adapt to that particular lens and prescription combination. If you’re not happy about 80% of the time or more without having to put on readers, it’s time to try a tweak to the prescription. We would suggest that you set up a “contact lens followup” with the same clinic you worked with originally.
There are, of course, some patients who never adjust to multifocal contacts. This is a small percentage, only about 10% these days. Some of these patients drop out of lens wear because they have untreated or under-treated dry eye syndrome. These patients can’t stand the feeling of contact in their eyes. Dry eye disease can also cause constant or intermittent blur. So, sometimes underlying ocular health issues are to blame for low satisfaction. Patients who have significant cataracts or macular degenerations are also less likely to adapt to multifocals.
One of the most frequently asked questions in the clinic is why multifocal contacts are blurry in the distance. There is a little give and take that happens with the physics of bending light here. Multifocals essentially take away a bit of your distance clarity to allow you to see well up close.
While ‘perfectly functional vision’ is not anything a doctor’s office would guarantee, many of our patients leave our office with a prescription for contacts that provides them with REALLY functional vision. Some even achieve 20/20 in the distance and 20/20 or nearly 20/20 up close. Computer working distances are often even better.
Still, even with these REALLY functional patients, there is a bit of blur. I had a patient a few years back tell me a story about driving at night with his multifocal contacts on. He said that he could see the street signs and read them about as early as his passenger, but for him, each of the letters had a little shadow. That shadowing corresponds to the part of the lens that is focused on near work. If you can accept a little shadowing, you’ll likely be happy in multifocal contacts. If you expect perfection all the time, you really shouldn’t even try multifocals.
The vast majority of patients are successful in multifocal contact lenses. There is definitely a small percentage of patients who will never adapt. Yet, with proper patient education and lens selection, we see greater than 90% multifocal contact lens fitting success in our Seattle WA optometry practice. Your mileage may vary.
It can be hard to get used to multifocal contact lenses. Kind of like when you got your first pair of glasses or your first pair of glasses, there is an adaptation period.
There is a concept that optometrists and other eye doctors talk about: ‘Blur Interpretation.’ This is a good term to describe a process through which patients learn how to see with their new contact lenses. It typically takes 3-7 days to get through this process. Ideally, the patient wears their new multifocal lenses 4-10 hours of each day during the adaptation period.
It’s also good to know that the one situation where we expect these lenses to underperform is in dimly lit near work /reading situations. Good lighting is necessary for good near vision. The increased lighting constricts your pupils. This in turn means that you will be looking through the center of the lens, which is optimized for near vision.
If you wear multifocal glasses most of the day every day and want a way to see well without glasses, the odds are we can fit you in multifocal contacts. Some patients have been told in the past that they can’t wear contacts if they have severe astigmatism, but new lens technology is always emerging. Now, fitting specialty toric-multifocal lenses is an option in many optometry practices.
You also have to be OK with touching your eye repeatedly. Some patients can’t get over this hurdle. Also, the ocular surface and lids have to be sufficiently healthy. Patients with dry eye or other ocular surface diseases typically do not do well in contact lenses. Many of our patients come in unable to tolerate contacts for years. After we treat their dry eye for a few weeks or months, they can often return to contact with great success.
Many users ask why multifocal lenses are so much more expensive than mono-focal contacts. Based on our 2023 price sheets, multifocal sell for a 30-66% premium over their single-vision versions. That is certainly a significant bump in price. So what gives?
Well, it’s kind of analogous to a base model of a car vs the top of the line. They charge a premium at the dealer largely because all the premium equipment on the best version of that car costs more to make. Likewise, the lens manufacturers have to spend millions of dollars developing multifocal lens technology. Then there is the cost of building the machines that mass-produce the lenses. It is a more challenging lens to design and build, so it costs more.
Sincerely, Dr. Mark J Cannon, OD @ Cannon EyeCare, Seattle