Consultants

The November ENYOS meeting was a round table discussion of the fitting techniques of the acuvue bifocal. This format, where several experienced practitioners discuss their philosophies, can be a very effective method for our members to sharpen their skills. As the meeting was sparsely attended, we will try to bring out the major points that were discussed to aid our members who could not make the meeting. 

My first experience with the lens left me feeling that it was another poor soft bifocal lens attempt.  My patient’s were complaining about distance blur that I didn’t expect due to the pre-launch information I received by the sales rep.  However, due to the great demand that Vistakon’s advertisements and the brochures in the waiting area generated, I had no choice but to make another attempt.  Patient feedback guided me into a fairly successful fitting pattern. 

The acuvue bifocal does not give perfect distance and near acuity.  We still must select the appropriate candidates based largely on their motivation to be free from glasses. I think the most important aspect of being successful is preparing the patient for the mild decrease in acuity that they will experience. I tell the patient that a contact which is dedicated solely to distance acuity will be virtually 100% clear and the bifocal contact has central annular rings which allow them to focus at near. I appeal to their logic that, obviously, this lens will therefore have a slightly reduced distance acuity due to these central near zones. Thus, when they put the contact on their responses are “the vision isn’t THAT bad”.  I explain that even though it is not as perfect for distance as a distance contact it does allow them to see at near. Ed Alexander noted that they may not think it is worth it until they go back to the DV contacts and then see that they don’t see squat at near.  I find this to be absolutely true. Thus, I don’t find myself apologizing for the DV blur but rather recognizing that it is a natural and expected fact of life.  Much as bifocal eyeglass lenses blur the ground as we look down.  The availability of the fitting set right in the office makes adjusting of the powers very easy.  A major reason why I stayed away from promoting bifocal contacts was the hassle and time my staff spent on returning lenses, credit memos, etc.  I used to fit patient which regular bifocal contacts and after the patient was relatively happy, I would make them sign a non-disclosure agreement not to tell their friends where they got them.

It was generally agreed that we all use a form of modified monovision where we decrease the add power of the dominant eye so as to blur the DV as little as possible. This, I found to be the key to my increase in patient satisfaction.  If my patient needs a +1.75 add, I put a +100 add on the dominant eye and a +1.50 on the non-dominant eye. If they need more at near I would raise the +1.50 add to +2.00, depending on their reaction, I may or may not raise the dominant eye to +1.50.  It was generally agreed that the +2.50 D adds caused significant DV blur and were seldom used binocularly.  A clinical pearl from Vistakon is to add a -0.25 D to the distance power when using the higher adds. I made the point that even though the DV or NV acuity may not be adequate for a particular patient’s job, ie. Truck driver or CPA, they still may wish to use them part time for going out to dinner. Thus, don’t make any assumptions for the patient. I tried to do this myself when I tried a pair on the office manager at the Lion’s Eye Institute who has a plano OU rx with 20/15 acuity. She complained that the DV was not good for driving and I responded, “oh, well it was a shot”, and she said, “so what, I just take them off before I drive home!”.

The comfort of the lens is excellent although it is thin and somewhat difficult to handle.  The 1-2-3 inversion mark is very difficult to see and we were informed that Vistakon is considering other avenues.  As the age of these wearers is over 40, complaints of dry eye are going to be common. Remember to try a collagen punctal implant to see the effectiveness of punctal occlusion in relieving these symptoms.  I have a good supply of collagen sleeves samples that I would be happy to send out to members wishing to try this. Any member of ENYOS who wishes to learn punctal occlusion is welcome to come to my office for personal instruction. 

We discussed the new acuvue 2 contact lens and agreed that it is an extraordinary product. The comfort and handling were excellent. I don’t think it fills a void as much as the AV bifocal but it is still a good product especially in the low minus range. 

Roy Kline and Carolee Boyd reported that they have had significant success with the AV bifocal. They reported that for people with astigmatism, the toric Westcon lens works great, maybe better than a spherical fit. This surprised me as I never even tried it on a patient, assuming it couldn’t possibly work. They, also, told the panel that the Lifestyle RGP provided excellent results for patients who are in rigid lenses. Roy suggested that these lenses must be fit steep to provide good centration and function. Their favorite multi-focal RGP, however,  is the Boston Multivision, especially in adds less than +1.50 D.  Roy and Carolee suggested using the direct ophthalmoscope, with a +8 lens,  to see the central zone of the lens and if you can’t get good centration, forget it. These are great clinical pearls that I took away from the meeting.  

This open panel discussion format worked pretty well and each of us took away good clinical information. The next meeting will be in January and will be held at 7 PM at the Lion’s Eye Institute, 35 Hackett Blvd. The meeting will be in the first floor conference room. I will be presenting information about the new mast cell stabilizer, Zaditor, from Ciba Vision Ophthalmics. I have already used this on half a dozen patients, even though we are not in allergy season, and it has been very effective. Sai Gandham MD and Reza Mozayeni MD will each present a few cases which we have seen and found to be interesting and instructive.  Pizza and soda will be provided. Please RSVP, if you can, to Maureen at 262-2540 so that we can provide enough food.

Al Morier OD