BCLA CLEAR Presbyopia: Management with Contact Lenses

LEARNING OBJECTIVES

On completion of this CPD activity, participants should:

1. Be aware of the history of presbyopia correcting contact lenses,

2. Realise the many different CL designs available to correct presbyopia,

3. Understand the evidence behind comparative performance, and

4. Be able to advise patients on aftercare for their contact lenses.

Nearly two billion people worldwide are currently presbyopic, and this number is expected to rise as individuals continue to live longer. At the same time, many individuals are working later into life, and modern society, with the widespread use of digital devices, is placing increasingly complex visual demands on them. In this context, achieving optimal correction of presbyopia is crucial for maintaining quality of life.

History

Scleral lenses were the first type of contact lens to be fitted, with their initial use dating back to 1888.² However, it was not until nearly 50 years later that the concept of bifocal contact lenses was introduced. In 1936, United States optometrist William Feinbloom proposed in his patent, titled ‘Contact Lens’, the creation of “… contact lenses whose corneal sections are made with two or more different refractive powers”. While the patent was awarded in 1938, there is no evidence to suggest that Feinbloom ever successfully manufactured or fitted these lenses.³

It remains unclear who performed the first successful fitting of bifocal scleral contact lenses, as several names have been associated with their early development. Among these are Frederick Williamson-Noble and Josef Dallos, prominent ophthalmologists working in the United Kingdom during the 1950s. The same uncertainty applies to rigid bifocal corneal lenses. George Tsuetaki, Richard Camp, and John de Carle were significant pioneers in this field.⁴

The concept of monovision correction for presbyopia – where one eye is corrected for distance vision and the other for near vision – was first proposed by US ophthalmologist Richard Westsmith in 1958.⁵ Westsmith, who was emmetropic, reported difficulty adapting to bifocal spectacle lenses. As a solution, he fitted a +1.50D rigid contact lens to his left eye. He successfully wore the lens for one month, achieving good near vision, and was not bothered by the slight blur in his left eye for distance vision.

During the 1970s, many small custom laboratories emerged around the world, which could generate novel designs by lathe-cutting xerogels in any form, prior to hydration and forming a hydrogel lens.

In 1977, KL Rowley in the UK reportedly designed and fitted a truncated soft translational bifocal lens with prism ballast.⁵ In 1980, Hirst published the first report on soft bifocal contact lenses.⁶ The first soft bifocal contact lenses approved by the US Food and Drug Administration in 1981 were the spin-cast aspheric bifocal soft contact lens and the Wesley-Jessen Durasoft bifocal contact lens. In June 1982, the Bi-Soft lens – a bifocal soft contact lens – was launched by CibaVision.

In 1982, Pilkington introduced the Diffrax rigid corneal bifocal contact lens with a simultaneous-focus bifocal design, and in 1989, Hydron developed a hydrogel version of this lens, called the Echelon Diffractive bifocal contact lens.⁷

A more recent innovation in contact lens correction for presbyopia is the extended depth of focus (EDOF) lens. First described in the Griffin patent granted in 2002,⁸ and later detailed by Zlotnik et al. in 2009,⁹ this design involves creating an optical construct on the front surface of a contact lens. The design extends the lens’ depth of focus by 3.00D, enabling good visual acuity and contrast sensitivity for both distance and near vision.

The report provides a historical overview of the major pioneering developments in multifocal contact lenses, focussing on contact lens materials (soft/rigid), forms (scleral/corneal), and optical principles. At the time of publication, there are 101 different multifocal contact lenses available across a wide range of brands, optical and physical designs, materials, and replacement schedules. These include 12 soft daily disposable lenses, 42 soft reusable spherical lenses, 12 soft reusable toric lenses, 31 rigid lenses, and four hybrid lenses featuring a rigid centre with a soft skirt.

Fitting Trends

Surveys on contact lens prescribing from the late 20th and early 21st centuries highlight initial eye care professional (ECP) engagement in fitting presbyopes with early-generation soft multifocal lenses. Contemporary data on presbyopic contact lens prescribing is obtained from annual surveys initiated in the UK in 1996, later expanded globally in 1998, and supported by the International Contact Lens Prescribing Survey Consortium, a network of 97 academics, industry representatives, and ECPs who manage the survey in their country or geographic region.¹⁰

In various countries each year, up to 5,000 ECPs (optical dispensers, optometrists and/or ophthalmologists) receive paper or electronic surveys. The most recent survey found contact lens fitting trends recorded for presbyopia (≥ 45 years of age) in 47 countries from 2018 to 2022 comprised of 21,326 fits. From these surveys we know that most contact lens fits for presbyopia are multifocal (44%), and the most popular material selection overall is silicone hydrogel (63%). Figure 1 provides a more comprehensive breakdown.

Of all presbyopes who wear contact lenses, nearly half (46%) are still being fitted with a ‘non-presbyopic fit’ (usually distance correction only) and are likely relying upon supplementary reading spectacles for close work intermittently; this has been fairly consistent over the past 30 years. However, there has been a steady increase in contact lenses, with most of this upsurge in activity attributed to soft multifocal lens fits.

ECPS can be reluctant to prescribe contact lenses to correct presbyopia in patients over 45 years for several reasons. Limited fitting skills, technical knowledge, or product awareness can diminish the confidence of ECPs. Some might view the perceptual compromises associated with multifocal contact lenses as too significant, potentially leading to unsuccessful patient experiences with this type of lens.

Finally, the lack of a ‘perfect’ multifocal contact lens, which provides uncompromised simultaneous optical imagery for all distances and excellent comfort, may discourage ECPs from fitting contact lenses for presbyopia.

Such perceptions can be conquered by an increase in professional education in contact lens fitting for presbyopia. Additionally, continued research and development is necessitated to develop optimised multifocal contact lens designs.

Preliminary Clinical Exams

Patient education about presbyopia and available correction options is pertinent. Typically, pre-presbyopic and presbyopic patients are not familiar with the word ‘presbyopia’ and do not comprehend its meaning. The necessity for presbyopic correction is usually viewed negatively, as a sign of decline or of old age.

Individuals not yet requiring presbyopic correction are described as sceptical, reluctant, or concerned about needing to correct for presbyopia. Commonly, presbyopes are aware of their visual symptoms for a period before seeking advice from an ECP. Ideally, the ECP should aim to achieve optimal contact lens comfort, vision, convenience, and cost, with little impact on ocular physiology. There is often a disconnect when it comes to the importance of cost to patients. ECPs are more likely to focus on the clinical, anatomical, cost, and technical aspects of the decision-making process, while patients are more concerned about convenience, comfort, and value for money. Patients prefer to be more involved in decision making around their choice of correction type; some believe they do not receive ample information for making informed decisions.

Patients who do not wear contact lenses prior to becoming presbyopic typically do not consider contact lenses and tend to be less receptive when an ECP offers them as an option. However, those who wear contact lenses that correct for distance vision tend to be more enthusiastic about contact lenses that correct for presbyopia.

It is helpful to determine the amount of motivation for presbyopic contact lens correction. The main points are to determine how patients spend their time each day, which distances are the most critical, the primary type of visual tasks, and the time spent undertaking these tasks.

Prior to fitting contact lenses, a clinical examination is needed. Key history and symptoms questions (Figure 2) include:  presenting symptoms, ocular health and patient history, current eyewear, visual status, general health, occupation, lifestyle, and hobbies.

Baseline measurement considerations include: horizontal visible iris diameter, white-to-white, and visible palpebral aperture or vertical visible iris diameter, lid tension and lid pressure, corneal shape, pupil size, ocular dominance, stereopsis, slit lamp examination, and tear film assessment.

Soft Lenses

Soft contact lenses for presbyopia are typically simultaneous image optical, which have two or more optical powers to enable clear vision at both near and far distances when placed in front of the entrance pupil of the eye. As well as being used for presbyopia, theses lenses are increasingly used for myopia control. However, these lenses are pupil-dependent, placing multiple optical zones in front of the eye, with various focal properties of light entering the pupil. Pupil size is dynamic and changes in pupil size can affect visual performance. These changes in pupil size are influenced by many factors including age, binocularity, the flux density at the cornea (field illuminance x area subtense), target distance, and emotional state. Various lens designs, such as concentric zones and EDOF principles, aim to address these challenges. During fitting, wearers are often advised about potential visual complications. Evidence of the neuroadaptation process suggests these complications are limited over time. In some cases, wearers experience temporary occurrences of ghosting and haloes during the initial adjustment period.

Most contemporary presbyopic contact lenses use a centre-near design with an aspheric power profile (Figure 3), providing a smooth transition between near, intermediate, and far vision. Multifocal lenses, available in daily disposable and reusable options, are widely offered by manufacturers, including toric versions for astigmatic prescriptions. Less commonly prescribed are centre-distance lenses, which are sometimes paired with centre-near lenses in a hybrid approach to maximise distance and near vision. Other advanced designs include multizone lenses consisting of a series of concentric rings of varying power, which are less affected by pupil size; diffractive lenses that use phase plates for multifocality; and EDOF lenses, which provide a continuous range of vision across multiple working distances.

The only current design that allows true single vision at both distance and near is the translating contact lens, which depends on lower lid tension to support the lens with eye rotation.

Rigid Lenses

Rigid corneal multifocal lenses exhibit reduced flexure during blinking, with the post-lens tear film layer aiding in the correction of corneal astigmatism. This offers distinct optical advantages compared to soft lenses, providing better visual outcomes and comparable to progressive addition spectacles. These lenses are ideal for patients with unstable vision in soft toric multifocal lenses, habitual rigid lens wearers, or new wearers seeking spectacle independence for complex astigmatic prescriptions. Multifocal rigid contact lenses are characteristically from either simultaneous imaging or translating designs. The fitting process is similar for both designs and a 15 to 20-minute settling period is recommended before evaluating the fit. The patient should be encouraged to view various distances and simulate daily visual activities, such as looking at their phone, reading a book, and observing distant objects. Corneal topography of a corneal contact lens on the eye can help assess lens centration effectively.

Rigid multifocal contact lenses are based on two primary design principles: translating and simultaneous images. A translating image happens when a movement of the contact lens in a downward gaze results in viewing through an area with a different refractive power.

Simultaneous imaging lenses provide a range of powers within the optic zone, with their effectiveness largely influenced by pupil size, ideally less than 6 mm under standard room lighting. Aspheric progressive lens designs come in three variations: back-surface aspheric, front-surface aspheric, and dual-aspheric configurations.

Translating (also referred to as ‘segmented’) lenses are a beneficial option for individuals with high visual demands or larger pupils. In the primary gaze, the distance zone of the lens is aligned with the pupil, while in a downward gaze, the lower lid pushes the near segment of the lens upward to align with the pupil.

Hybrid contact lenses, consisting of a rigid centre combined with a soft hydrogel or silicone hydrogel skirt, offer the optical benefits of a corneal contact lens with the comfort of a soft lens. Compared to standard corneal lenses, they provide improved comfort, easier adaptation, and more consistent visual quality. They also correct anterior corneal higher order aberrations more effectively than soft toric lenses, are simpler to handle than piggyback or scleral lenses, and do not have post-lens tear reservoir fogging compared to scleral contact lenses.

For eyes that are unsuccessful with conventional contact lens options, scleral lenses offer an excellent alternative for vision correction. Modern scleral lenses are also used to correct simple refractive errors, including presbyopia, particularly when other modalities fail due to vision or comfort issues, and for dry eye patients. Advancements in manufacturing processes, lens designs, lens materials, and an increased understanding of scleral anatomy have significantly improved scleral lens fitting.

Key considerations for rigid contact lens materials include oxygen permeability, resistance to flexure, scratch resistance, and surface wettability. Additional factors, such as wearing modality (daily or overnight), refractive error, and ocular surface disease, also influence material selection. For corneal lenses intended for daily wear, a Dk/t value of at least 20 × 10⁻⁹ units is recommended to prevent corneal oedema. Highly oxygen-permeable rigid materials (Dk > 100 units) allow increased oxygen transmission, reduce the risk of hypoxic complications, and do not enhance bacterial adhesion during overnight wear. Factors influencing wettability include manufacturing residues, tear film chemistry, blinking efficiency, and lens material. Plasma treatment improves lens wettability by ionising the surface, though its effects diminish after weeks of use. Alternatively, polyethylene glycol (PEG) polymer coatings, applied post-plasma treatment, can improve wettability by 50%, reduce deposits, and enhance comfort while maintaining optical properties. Modern PEG coatings are covalently bonded for long-lasting benefits.

Monovision

Monovision is an optical correction method for presbyopia in which one eye is optimally corrected for distance vision and the other for near tasks. While it is a well-known strategy for presbyopia correction, it is almost exclusively used with contact lenses, and to a lesser extent with spectacles, refractive surgery, and intraocular lenses.¹ The key advantages and disadvantages of monovision are summarised in Table 1. Table 2 presents the key considerations for fitting monovision contact lenses.

 

The success rate for experienced contact lens wearers with presbyopia trying monovision ranges between 67 to 80%,^11,12 however drops to only 8% when a neophyte tries monovision,¹¹ most likely due to the loss of binocularity.

In conventional practice, the dominant eye is typically corrected for distance vision, while the non-dominant eye is corrected for near work. It’s also essential to fully correct low levels of astigmatism to maximise distance visual acuity. Most literature indicates that tests of sensory dominance and blur suppression are the most relevant.

Comparative Performance

The BCLA CLEAR article found that the majority of studies comparing contact lenses for presbyopia have evaluated single vision distance, monovision, multifocals, and progressive addition spectacle lenses, as well as different multifocal contact lens designs. These studies typically assess visual performance, including visual acuity at various distances, subjective vision performance, preference, stereoacuity, accommodation, contrast sensitivity, glare, ghosting, light disturbances, and reading speeds. It found that some studies also consider wearer preference and willingness to purchase.

Since the early 1990s, research has evolved, initially comparing monovision with early soft multifocal contact lenses. Early findings indicated that while objective performance was often similar, multifocal lenses provided better subjective performance, stereopsis, and stereoacuity. Refitting monovision wearers into multifocal lenses proved successful, with better real-world functional vision and preference for multifocals. It was noted that a period of adaptation might be needed, including for light disturbances.

When comparing progressive addition spectacle lenses with multifocal contact lenses, a pattern of preference for the functional vision provided by contact lenses was identified, although discrepancies exist. Vision performance with progressive addition lenses is similar to rigid contact lens multifocals, which are superior to soft multifocal designs and monovision. Improvements in both objective and subjective vision performance have been noted over time, with different soft multifocal lens designs. Some studies reported differences between multifocal lens types in terms of vision performance and stereoacuity, with some designs no longer commercially available.

Comparisons of various soft multifocal contact lenses and monovision revealed minor differences, although certain lenses outperformed monovision, even in early presbyopes. Studies comparing EDOF with other multifocal lenses showed similar overall performance, with some improvements in intermediate and near vision, and overall satisfaction.

Improved vision performance with specific multifocal designs can result from multiple power zones and optimised pupil coverage. Disability glare varies between different multifocal contact lenses. Studies comparing daily disposable multifocals demonstrated overall good performance, with minor differences between designs. Aberrations have been shown to affect vision performance in presbyopes when comparing different multifocal designs. Monofocal correction provided better performance under low light conditions compared to multifocals.

Overall, these studies suggest ongoing improvements in multifocal contact lens design are needed to enhance performance, particularly for higher addition powers. Research continues to refine lens designs to improve visual outcomes and wearer satisfaction.

Aftercare

As with any contact lens wearer, presbyopic patients typically attend regular clinical examinations known as ‘aftercare visits’. These assessments aim to: 1) preserve ocular health, 2) maintain vision, 3) optimise comfort, and 4) ensure a satisfactory lens fit.

The recommended frequency of aftercare visits is every two years for soft daily disposable lenses, and annually for soft reusable and rigid daily wear lenses. However, the intervals between visits may be shortened if the ECP anticipates frequent changes or identifies a need for increased monitoring. Given the progressive loss of accommodation and the resulting reduction in near vision quality, and with advancing presbyopia, annual check-ups may be beneficial, with recall frequency based on the ECP’s professional judgment. The general considerations for regular aftercare visits are detailed in Table 3.¹³

The primary reasons for contact lens discontinuation among presbyopes tend to be discomfort, dryness, or poor visual performance, though maintenance costs and lens handling issues may also contribute. Encouragingly, a study of lapsed contact lens wearers found that 76% of presbyopes could be successfully refitted, with at least one month of wear. However, factors such as higher levels of astigmatism or more advanced presbyopia were associated with lower chances of successful refitting.

Future Directions

Several innovative technologies for ‘accommodating’ or ‘focussable’ contact lenses for presbyopia correction have been proposed. These lenses aim to adjust focus between near and distance, based on the wearer’s viewing direction, providing an additional +2.00D for near vision. Another proposed approach involves mechanically accommodating lenses, where the lenses are moulded and/or altered by the pressure from the eyelids, resulting in a change in dioptric power. Alternatively, microelectronics can be incorporated into a contact lens controlled by a capacitive sensor to monitor the gaze direction of the cornea based on capacitance variations. Liquid crystal technology is also promising, where liquid crystals are embedded between two layers of electrodes, directing the reorientation of naturally occurring rods in the crystals. This results in the alteration of the refractive index of the material, consequently changing the optical power of the contact lens.

While some of these ideas are ambitious, the principles and technologies behind them are unique and will underpin the development of these novel contact lens designs. There is likely to be significant interest in these approaches among researchers and the contact lens industry, potentially leading to novel developments in presbyopia management in the coming years.

In conclusion, contact lenses for individuals with presbyopia are effective and should be considered as part of the management options. Daily preferences regarding whether to wear spectacles or contact lenses can vary depending on mood, activities, and other factors. Therefore, offering tailored recommendations for both options, with the flexibility to alternate between them, and ensuring clear communication, is vitally important.

Five Tips for Managing Presbyopia with Contact Lenses

1. Obtain relevant patient history and clinical data (including ocular dominance, motivation, daily visual demands, and lifestyle information). 2. Make tailored recommendations involving the patient in the decision-making process and ensure expectations are realistic. 3. Avoid making presumptions; the individual’s preference may be to alternate between spectacle and contact lens wear. 4. Multifocal contact lenses are usually considered the first choice, and fitting guides are not always interchangeable, partly due to differing optical designs. 5. For success, provide general advice (including on lighting), use real world assessments (PROMs), with regular reviews to address their evolving needs.

BCLA CLEAR Presbyopia was facilitated by the British Contact Lens Association (BCLA), with financial support by way of educational grants for collaboration, publication, and dissemination provided by Alcon, Bausch and Lomb, CooperVision, EssilorLuxottica, and Johnson and Johnson Vision.

The editors for this article series are Neil Retallic and Dr Debarun Dutta.

Acknowledgement and recognition to the authors of the original paper: Philip B Morgan, Nathan Efron, Eric Papas, Melissa Barnett, Nicole Carnt, Debarun Dutta, Andy Hepworth, Julie-Anne Little, Manbir Nagra, Heiko Pult, Helmer Schweizer, Bridgitte Shen Lee, Lakshman N Subbaraman, Anna Sulley, Alicia Thompson, Alexandra Webster, and Maria Markoulli.

The full report, BCLA CLEAR Presbyopia: Management with contact lenses and spectacles, can be accessed at: pubmed.ncbi.nlm.nih.gov/38631935.

Dr Melissa Barnett OD FAAO FSLS FBCLA is a world-renowned key opinion leader recognised for her expertise in dry eye disease, specialty and scleral lenses, keratoconus, and presbyopia. She has authored more than 300 articles and books, delivered over 450 lectures, is a board member and founding member of Intrepid Eye Society and serves on several industry boards. Dr Barnett has been recognised with the Scleral Lens Practitioner of the Year Award from the Scleral Lens Education Society, the inaugural Theia Award for Excellence for Mentoring by Women In Optometry, and the Most Influential Women in Optical from Vision Monday. She is the Director of Optometry at the University of California, Davis, and is the host of the Clearly KC podcast.

 

 

 

Dr Debarun Dutta PhD MCOptom FIACLE FHEA FAAO FBCLA is a senior lecturer and lead for contact lens education at the School of Optometry at Aston University, UK. He is an Academic Chair and Trustee of the BCLA, responsible for both excellence in research and education, and is involved in didactic and clinical face-to-face training at Aston University. Dr Dutta’s research interests include contact lenses, dry eye, ocular infections and antimicrobial strategies, including supervision for PhD, Post-doctoral and Professional Doctorate students. He has published more than 50 peer-reviewed articles, dozens of professional education articles, and two book chapters. He has presented worldwide at various conferences.

 

 

 

References

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