C L I N I C A L A N D E X P E R I M E N TA L

REVIEW

Soft multifocal simultaneous image contact lenses: a review

Clin Exp Optom 2017; 100: 107127 DOI:10.1111/cxo.12488

Roque Prez-Prados* OD MSc
David P Piero PhD
Rafael J Prez-Cambrod PhD
David Madrid-Costa PhD
*Centro ptico Benala, Alicante, Spain
Soft multifocal simultaneous image contact lenses have boomed in recent years due to
the growing number of presbyopic patients demanding visual solutions, allowing them to
maintain their current standard of living. The concept of simultaneous image is based
on blur interpretation and/or blur tolerance of superimposed multiple images on the
retina formed by various powers of a contact lens. This is the basis for a specic type of

Department of Optics, Pharmacology and Anatomy, multifocal contact lens developed for the compensation of presbyopia. Manufacturers
University of Alicante, Alicante, Spain
have released a great variety of soft simultaneous image lens designs to meet different
Department of Ophthalmology (Oftalmar),
Medimar International Hospital, Alicante, Spain patient needs but their tting is still unsatisfactory in some cases. Some presbyopes discon-

Foundation for the Visual Quality (FUNCAVIS, tinue wearing contact lenses due to some limitations in visual quality and comfort that
Fundacin para la Calidad Visual), Alicante, Spain can be overcome with an appropriate contact lens selection based on a comprehensive

Faculty of Optics and Optometry, Complutense pre-tting evaluation. This paper aims to review the different types of soft multifocal con-
University of Madrid, Madrid, Spain
E-mail: david.pinyero@ua.es
tact lenses that are currently available for presbyopic correction and to dene the steps
and factors crucial for their tting, such as pupil, aberrations, accommodation and cen-
tring. A discussion about useful tools to achieve a customised tting leading to a successful
Submitted: 14 January 2016
outcome, such as the defocus curve, power prole and questionnaires, is performed.
Revised: 27 April 2016
Accepted for publication: 12 June 2016

Key words: defocus curve, multifocal, power prole, pupil, questionnaires, spherical aberration

The age-dependent loss of the ability of the
crystalline lens to accommodate, named
presbyopia, is primarily attributed to a
decrease in lens elasticity.1 Other possible
causal factors for presbyopia include the
increase in equatorial diameter of the lens,
loss of elasticity of Bruchs membrane and
reduced mobility of the ciliary muscle.2
Human accommodative amplitude declines
progressively with age, beginning in the
second decade of life or perhaps earlier.
Presbyopia usually begins between the ages
of 38 and 45 and the prevalence is virtually
100 per cent by 50 to 52 years of age.3
Over the last two decades, there has
been a slow but progressive increase in the
presbyopic population in Europe. According
to Eurostat, 18.9 per cent of the European
population in 2009 was aged between
50 and 65, reecting a 2.3 per cent increase
from 1998 in the same age interval.4 Over-
all, since 1950, the proportion of older per-
sons (over 60 years) has been rising steadily,
passing from eight per cent in 1950 to
11 per cent in 2009 and it is expected to
reach 22 per cent in 2050.5 Better health
and increased vitality during the middle
years of life alter the range of activities
undertaken by the presbyopic population
and their attitudes toward physical appear-
ance have changed substantially over the
last two to three decades.6
The number of multifocal contact lens
users has also experienced a signicant
growth in recent years, although only about
10 per cent of UK contact wearers received
a correction for presbyopia in 2008.8
Figure 1 shows the distribution of lens
wearers stratied by sex and age.7 Similarly,
a recent international survey has revealed a
considerable variance among countries
with respect to contact lens tting for pres-
byopia, ranging from 79 per cent of all soft
lens tting to patients older than 45 years
in Portugal to zero in Singapore.7 Interest-
ingly, the same survey revealed that 63 per
cent of presbyopes were tted with non-
presbyopic corrections, with the remaining
29 and eight per cent of presbyopes being
corrected with multifocal or monovision t-
ting philosophies, respectively9 (Figure 2).
The overall low rate (37 per cent) of pres-
byopic contact lens prescribing to those
45 years and older suggests that the major-
ity of presbyopic contact lens wearers are
being tted with a distance prescription
and supplementary reading spectacles for
close work.7
Many contact lens wearers stop using
their contact lenses at the onset of presbyo-
pia. The primary reason for the low rate of
prescribing monovision or multifocal con-
tact lenses is likely to be a combination of
lack of tting skills,7 a view by practitioners
that perceptual compromises of currently
available options are too great10,11 and
an absence of availability of a perfect mul-
tifocal contact lens that provides good com-
fort and uncompromised simultaneous
optical imagery for all distances.7 Training
of contact lens practitioners in presbyopic
contact lens tting and clinical and labora-
tory research in this eld should be accel-
erated worldwide to fully meet the needs of
presbyopic contact lens wearers.7
PRESBYOPIC CORRECTION WITH
CONTACT LENSES
Currently, presbyopic patients have a vari-
ety of options for correcting their refractive
error with contact lenses. These options
can be grouped into three main categories:
supplemental spectacle correction over
contact lenses, monovision and multifocal
contact lenses.1214 Supplemental spectacle
correction implies reading glasses on top of

2016 Optometry Australia Clinical and Experimental Optometry 100.2 March 2017
107
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa

Males compromise in which depth of focus for

>75
high-contrast targets is gained at the
Females
6574 expense of glare and losses in retinal
image contrast, particularly when the tar-
5564 get contrast is low.23 Superimposition of
Age (years)

images produces a contrast sensitivity

4554
reduction that improves signicantly with
3544
time.24 The problem is acute in low light-
ing conditions and particularly affects near
2534 vision.25
Simultaneous vision is not a phenome-
1524 non that occurs with multifocal contact
lenses.26 As images provided by multifocal
014
or bifocal contact lenses are integrated into
the visual system to achieve the nal out-
0 10 20 30 40
come of a clear single vision, clinicians
Number of lens fittings (1,000) should refer to this phenomenon as simul-
taneous image. In the ISO (International
Figure 1. Contact lens wearers stratied by sex according to Morgan and colleagues7 Organization for Standardization), publica-
tion of the International Standard Oph-
thalmic Optics-Contact Lenses,27 the term
70
simultaneous vision contact lens was
Si-Hy
60 deprecated and ISO dened the term
16% Hy simultaneous image multifocal contact
50
lens for bifocal and multifocal contact
Percentage

40
30 33%
20
10
14%
0 1%
Non-presbyopic
Figure 2. Types of presbyopic contact lens tting according to Gispets and colleagues9
contact lenses, whereas in monovision, one
eye is corrected for distance while the fel-
low eye is optimised for near vision.15
Monovision is independent of the pupil
size and thus, there is no compromised
vision in dim lighting or low contrast condi-
tions; however, there is a reduction of
stereoacuity,1619 especially when high
addition powers are needed.20,21 Also, if a
patient has difculty in suppressing one
eye, he/she will be unable to adapt to
monovision correction.18
Within the multifocal lens category, a sub-
division can be done to include all types of
multifocal lenses which are currently availa-
ble: translating multifocal lenses with clearly
differentiated near and distance vision
zones22 and simultaneous image lenses,
which might use concentric, aspheric or dif-
fractive designs. When presbyopia is cor-
rected with contact lenses, multifocal lenses
are tted 3.6 times more than monovision
Rigid
8%
3%
16%
4%
5%
Monovision Multifocal
Fit type
lenses.7 It has been reported that the suc-
cess rate of prescribing multifocal contact
lenses is 67 to 83 per cent after three
months.13 It has also been reported that the
actual success rate for long-term wearers is
lower, being around 30 to 40 per cent in
most of cases.13
SIMULTANEOUS VISION VERSUS
SIMULTANEOUS IMAGE CONTACT
LENSES
Simultaneous vision is achieved when dis-
tance and near powers are positioned
within the pupillary area at the same time.
The patient suppresses the blurred image
and chooses the clearest one for that task.
This concept is based on blur interpreta-
tion and/or blur tolerance of superim-
posed multiple images on the retina
formed by various powers of the lens. This
method of correction involves a counteracting of the effects of the reduction
lenses, as their performance does not pri-
marily depend on the lens movement and
two or more zones continually cover the
pupillary area. Similarly, the terms alter-
nating vision bifocal contact lens and
translating vision bifocal contact lens were
deprecated and ISO dened the term
alternating image bifocal contact lens for
bifocal contact lenses, the performance of
which depends primarily on the movement
of the contact lens allowing seeing through
the portion for distance or near vision.
To achieve pure simultaneous images,
both contact lens areas, near and distance,
must rest within the pupillary area for all
gaze positions. If that is not achieved, we
have no pure simultaneous image, but a
simultaneous image combined with alter-
nating images depending on the area of
the lens where the pupil is located
(Figure 3). Monovision and simultaneous
image are similar because two images are
processed at the same time, distance and
near. Monovision uses one eye for distance
and another for near with binocular image
degradation in most cases. With simultane-
ous images, the image degradation occurs
monocularly.
The aim of the simultaneous image lenses
used to compensate presbyopia is to enlarge
the depth of focus, the range of distance
over which visual performance measure-
ments exceed a given threshold. Thus, the

Clinical and Experimental Optometry 100.2 March 2017 2016 Optometry Australia
108

Figure 3. Pupil coverture in a concentric bifocal contact lens with a large (A and B)
and small (C and D) pupil. A centred contact lens is represented in (A) and (C) and an
inferior decentred contact lens is shown in (B) and (D).
of the amplitude of accommodation in the
aging eye is possible. This gain in depth of
focus involves some compromise in visual
performance, which is measurable in terms
of contrast sensitivity or visual acuity.28,29
The compromise between depth of focus
and image quality depends on various fac-
tors related to the patient, such as the pupil
diameter2831 and age,32 contact lens design
and to the interaction between the patients
eye and the contact lens, such as lens
centration.28,31
In simultaneous image correction, light
rays passing through the pupil to form the
retinal image encounter either both distance
and near corrections (bifocal, two-foci) or a
smooth transition in power between distance
and near corrections (multifocal, multiple-
foci). Thus, any region of the retina receives
both in-focus and out-of-focus images.
Ideally, the brain selects the in-focus stimu-
lus, while suppressing out-of-focus stimuli.33
In practice, the contrast of the desired in-
focus image is reduced by the superimposed
out-of-focus image.30,34 Multifocal designs
involve a progressive, rotationally symmetric
gradation of power from the centre to the
edge of the contact lens optical zone. This is
achieved by the use of one or more aspheric
surfaces, which produce greater power
either in the lens centre (centre-near) or in
the periphery (centre-distance).3440
2016 Optometry Australia
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa
VISUAL OUTCOMES WITH CONTACT
LENSES FOR THE COMPENSATION OF
PRESBYOPIA
Fisher, Bauman and Schwallie41 found that
distance and near acuity as well as stereoa-
cuity and visuomotor task performance were
better with the best spectacle correction
than with either an annular soft bifocal
design or an aspheric soft multifocal design.
Jimenez, Durban and Anera42 found similar
visual performance between progressive
addition lenses and annular soft bifocal
lenses under varying conditions of illumina-
tion. One study has concluded that spectacle
lens acuity does not differ signicantly from
bifocal and multifocal contact lens acuities.14
Table 1 shows different studies about visual
performance with soft simultaneous image
multifocal contact lenses.
MULTIFOCAL AND BIFOCAL SOFT
CONTACT LENS DESIGNS
The following contact lens designs have
been developed and clinically tested
(Figure 4).
Concentric or annular designs
These are designed with a small (typically
two-thirds to three-fourths the size of the
Clinical and Experimental Optometry 100.2 March 2017
pupil in normal room illumination) central
annular zone, which provides either dis-
tance or near power, surrounded by a
peripheral annulus granting either near or
distance vision, respectively9 (Figure 4A).
Aspheric lens designs
These have a gradual change of curvature
along one of their surfaces (anterior or
posterior) based on the geometry of
conic sections. The rate of attening
(or eccentricity) is greater (and sometimes
much greater) than single-vision lens
designs, thereby creating an increase in
plus power toward the periphery of the
lens. Aspheric designs are truly multifocal
to the extent that they display a gradual
transition in lens power between distance
and near powers by manufacturing the lens
with front, back or front and back aspheric
surfaces.9 The following models can be
dened according to how the change of
curvature is performed.
1. For the centre-near design (Figure 4B),
the highest plus power is in the geomet-
rical centre and decreases in power
toward the periphery.14 It incorporates
controlled amounts of negative spheri-
cal aberration.
2. In the centre-distance design, the low-
est plus power is in the geometrical
centre and increases in power toward
the periphery.14 It incorporates con-
trolled amounts of positive spherical
aberration.
Although the best image on the retina
with these contact lenses is degraded by
the induced spherical aberration, this is
outweighed by increase in the vergence
range, over which there is no apparent
deterioration in retinal image quality. In
other words, depth of focus is increased
(Figure 5).14,18,35,4345
Diffractive designs
These are the only simultaneous image
lenses that exhibit true equality of near
and distance powers. A central zone
focuses images at distance by refraction
of light and near through diffraction prin-
ciples created by the zone echelettes
(Figure 4C). According to some authors,14
as equal amounts of light pass through
both the distance and near elements of the
lens, diffractive designs may be considered
truly pupil-independent. A total of 40 per
cent of light is distributed to each of the
109
110
Author Ages
(year) Subjects (years) Refraction Pupil diameter Inclusion criteria Lens type Follow-up Results Summary

Llorente- 20 presbyopes 4160 Sphere Photopic, 2 to Distance and near PureVision High One Average binocular spectacle PureVision multifocal
Guillemot 2.00 to 4 mm visual acuity Addition month corrected and contact lens preserves good VA
and +3.25 D Mesopic, 5 to (VA) 0.00 logMAR (compared to (wash-out VA were 0.05  0.07 and and visual
colleagues Cylinder up 6 mm Normal binocularity PALs, one week) 0.01  0.03 logMAR for performance under
(2012)12 to 0.75 D progressive distance photopic, real life conditions
No ocular disease addition 0.10  0.06 and
Addition No eye surgery spectacles) 0.18  0.05 logMAR for
1.00 to distance mesopic and
2.75 D No previous use of 0.08  0.06 and
presbyopic contact 0.02  0.05 logMAR for near
lens (CL) photopic, respectively.
Statistically signicant
differences were found in

Clinical and Experimental Optometry 100.2 March 2017

contrast sensitivity with the
two types of correction, with
spectacle correction being
better in all cases

Madrid- 20 presbyopes 4248 Sphere Photopic, Monocular corrected PureVision One Contrast sensitivity may Both simultaneous
Costa and 2.50 to 3.46  0.13 mm VA 0.00 logMAR or Multifocal Low month improve with time due to vision multifocal CLs
colleagues +2.25 D Mesopic, better Add adaptation to multifocality provided adequate
(2013)48 Cylinder up 4.44  0.09 mm Pupil >3mm Acuvue Oasys scatter distance visual quality
to 0.50 D for presbyopia Both designs provide good under photopic and
Normal binocularity mesopic conditions
Addition VA under photopic conditions
No ocular disease and better VA was
1.25 to PureVision performed better provided under
1.75 D No eye surgery than Acuvue Oasys under mesopic conditions
No amblyopia or mesopic conditions for the PureVision
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa

strabismus Distance contrast sensitivity lens. Both lenses

No ocular was within normal limits with provided adequate
inammation both designs visual performance at
intermediate distance
but the near VA
appears to be
insufcient for early
presbyopes, who
require a moderately
demanding near
visual quality.

Madrid- 20 presbyopes 4563 Sphere Photopic, Monocular VA 0.00 Proclear One Proclear Multifocal Toric The multifocal toric
Costa and 3.00 to 3.46  0.23 mm logMAR Multifocal Toric month contact lens provides good CL studied is a good
colleagues +3.00 D Mesopic, Photopic D and N binocular distance and near option to compensate
(2012)143 Cylinder 5.32  0.36 mm pupil 3mm Proclear VA both presbyopia and
0.75 to Toric + reading Statistically signicant astigmatism,
Normal binocularity providing an optimal
2.75 D spectacles differences with Proclear

2016 Optometry Australia

Table 1. Summary of the outcomes obtained in different studies about visual performance with soft simultaneous image multifocal contact lenses
Table 1. Continued
 Author Ages
(year) Subjects (years) Refraction Pupil diameter Inclusion criteria Lens type Follow-up Results Summary

Addition No ocular disease monofocal toric in distance distance,

1.00 to No eye surgery and near that were not intermediate, and
3.00 D clinically relevant near visual quality
No amblyopia or without
strabismus There was a reduction in

2016 Optometry Australia

contrast sensitivity for the compromising the
No ocular Proclear Multifocal Toric stereopsis
inammation compared to monofocal
contact lens in all
frequencies, especially for
high spatial frequencies
(12 and 18 cycles per
degree) associated to VA
Near contrast sensitivity was
better with the N design
than the D design
Vasudevan, 10 presbyopes 4045 Sphere 4 mm Monocular VA of 6/6 Acuvue Oasys 1015 No signicant difference There is no
Flores and 6.00 to (controlled by multifocal minutes between the three lens signicant difference
Gaib +6.00 D room AirOptix designs and subjective in objective or
(2013)61 Cylinder up illumination) multifocal refraction in phoropter for subjective visual
to 0.75 D high and low contrast performance in early
Bionity distance and near VA presbyopes t with
Addition multifocal MFCL following a
1.00 to No signicant difference in
Randomised t contrast sensitivity, optical limited adaptation
3.00 D of all lenses in period
aberrations, accommodative
the same visit response, range of clear vision
and stereoacuity (SA) between
the three lens designs

Ferrer- 25 presbyopes 5060 Sphere Normal binocularity Proclear One Proclear Multifocal CL SA is minimally
Blasco and 3.00 to Desire to no longer multifocal month provided good outcomes for affected by
Madrid- +3.00 D wear spectacles Spherical CL+ distance and near vision multifocal-induced
Costa Cylinder up reading retinal blur
(2011)144 to 0.75 D spectacles Proclear Multifocal
Addition CL provided good VA
1.50 to preserving good
2.50 D stereopsis,
comparable to the
ndings when using
distance CL
combined with
reading spectacles

20 presbyopes 5060 Normal binocularity

Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa

Clinical and Experimental Optometry 100.2 March 2017

111
Table 1. Continued
112
Author Ages
(year) Subjects (years) Refraction Pupil diameter Inclusion criteria Lens type Follow-up Results Summary

Ferrer- Sphere Desire to no longer Focus One No statistically signicant Both simultaneous
Blasco and 3.00 to wear spectacles Progressives month differences were found aspheric multifocal
Madrid- +3.00 D No ocular disease PureVision (no wash- between the two types of CL (Focus
Costa Cylinder up multifocal out) lenses at distance Progressives and
(2010)145 No ocular surgery or PureVision MF)
to 0.75 D inammation SA was better with Focus
Progressives compared with provided good
Addition outcomes for
2.00 to PureVision: Howard Dollman
(4 sec of arc of difference) distance and near VA
3.00 D preserving stereopsis
Titmus (20 sec of arc of
difference), and Random dot Focus Progressives
(31 sec of arc of difference) had slightly better
near VA and SA than
PureVision, may be

Clinical and Experimental Optometry 100.2 March 2017

related to the
asphericity and the
near addition
SA measurements
with Howard Dollman
is more accurate than
using vectographic
test

Monts- Six 4860 Sphere 3 mm No ocular disease, PureVision Fitted and For non-presbyopic group, Simultaneous image
Mic and presbyopes 2534 3.00 to amblyopia or Multifocal Low evaluated distance VA was always MFCL provide good
colleagues Eight non- +3.00 D strabismus Add on the worse with the multifocal CL visual performance at
(2011)44 presbyopes Cylinder up No history of ocular PureVision same day (MFCL) rather than the distance and
monofocal CL (MCL) reasonable but
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa

to 0.75 D surgery or Multifocal High

inammation Add For non-presbyopic group, in
near VA there were no
Normal clinical Monofocal CL
amplitudes of (baseline) statistically signicant
accommodation differences between MFCL
For a 2.5 and and MCL
Monocular VA of 6/6 4 D stimulus
For presbyopic group, in
distance VA and near VA
there were no statistically
signicant differences
between MFCL and MCL
For both groups there were
no statistically signicant
differences in CS distance
and near for MFCL and MCL
Both groups accommodate in
much the same way whether
slightly impaired
performance at near
PureVision Multifocal
High Add slightly
enhances near vision
for advanced
presbyopes
compared with
PureVision MF Low
Add and Focus
Progressives,
reducing distance
vision quality
MFCL do not relieve
accommodation in
any way

2016 Optometry Australia

Table 1. Continued
 Author Ages
(year) Subjects (years) Refraction Pupil diameter Inclusion criteria Lens type Follow-up Results Summary

they are wearing a MFCL or MFCL had little

not impact on
For presbyopic group there accommodative
were signicant differences errors in younger
subjects

2016 Optometry Australia

between PureVision High Add
and MCL Used centre-near
For presbyopic group, designs compared
monocular distance and near with Tarrant and
accommodative facility in all colleagues studies
conditions was zero that used centre
distance designs to
For non-presbyopic group relieve
there were no statistically accommodation
signicant differences
between MFCL and MCL MFCL studied do not
create images from
near objects clear
enough to provide
changes in
accommodative
system
It would be better to
wear these lenses for
about one to six
months because of a
possible
neuroadaptation of
the subjects to
multifocality
Madrid- 10 non- 2535 Sphere 3 mm No ocular disease, Focus Fitted and There were no statistically There were no
Costa and presbyopes 3.00 to amblyopia or Progressives evaluated signicant differences in the signicant differences
colleagues +3.00 D strabismus PureVision on the accommodative response for in accommodation
(2011)146 Cylinder up No history of ocular Multifocal Low same day the 2.5 D and 4.0 D stimulus response for both
to 0.75 D surgery or Add between MCL and MFCL stimuli (2.5 and 4.0
inammation For the 4.0 D stimulus D) for MCL and MFCL
PureVision
Normal clinical Multifocal High PureVision Low Add obtained Only PureVision High
amplitudes of Add a peak velocity value higher Add provides a
accommodation than MCL decrease in effort to
Monofocal CL accommodate with a
Monocular VA of 6/6 (baseline) For the 4.00 D stimulus,
statistically signicant 2.5 D stimulus
For a 2.5 and decrease in time constant MFCL studied do not
4.0 D stimulus with MCL compared to provide important
PureVision Low Add changes in
accommodative
system in young
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Clinical and Experimental Optometry 100.2 March 2017

113
Table 1. Continued
114
Author Ages
(year) Subjects (years) Refraction Pupil diameter Inclusion criteria Lens type Follow-up Results Summary

Time constant higher with subjects, because

the 4.0 D stimulus than with
the 2.5 D stimulus for all CL
For the latency in the
moment of accommodation,
no statistically signicant
differences between 2.5 D
and 4.0 D stimulus for all CL
For the amplitude of pupil
constriction, was lower with
PureVision High Add than
MCL at 2.5 D stimulus. No
differences for the 4.0 D
MFCL do not create
images from near
objects clear enough
(except PureVision
HA for the 2.5 D
stimulus)
It would be better to
wear these lenses for
about one to six
months because of a
possible neuro-
adaptation of the

Clinical and Experimental Optometry 100.2 March 2017

stimulus for all CL subjects to
multifocality
For the pupillary constriction
per dioptre of Accommodative
accommodation, PureVision parameters could
MF High Add and Low Add change over time
values were lower than MCL. with a learning
No differences for 4.0 D process with this
stimulus MFCL

No signicant differences for

the pupil transience for 2.5 D
and 4.0 D stimulus for all CL
Ruiz- 18 non- 2535 Sphere 3 mm No ocular disease, Focus Fitted and No signicant differences in There were no
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa

Alcocer and presbyopes 3.00 to amblyopia or Progressives evaluated accommodative response for signicant differences
colleagues +3.00 D strabismus PureVision on the the 2.5 and 4.0 D stimulus in accommodation
(2012)147 Cylinder up No history of ocular Multifocal Low same day with all CL response for both
to 0.75 D surgery or Add At 0.0 D stimulus SA become stimuli (2.5 and 4.0 D)
inammation more negative with for MCL and MFCL
PureVision
Normal clinical Multifocal High PureVision Low and High Vertical coma does
amplitudes of Add Add than with MCL not change with
accommodation At 2.5 D stimulus there was a accommodation for
Monofocal CL any stimulus
Monocular VA of 6/6 (baseline) signicant increase in
negative values of SA for all Horizontal coma
For a 2.5 and CL changed with
4 D stimulus accommodation
At 4.0 D stimulus SA always
became more negative becoming more
compared with the 0.0 D negative with single
stimulus for all CL. Changes vision (MCL) for both
only signicant for the MCL stimuli

Table 1. Continued

2016 Optometry Australia

 Author Ages
(year) Subjects (years) Refraction Pupil diameter Inclusion criteria Lens type Follow-up Results Summary

For vertical coma, no The changes in coma

statistically signicant could be because of
differences were found for all small decentrations
stimuli with all CL. In of the lenses

2016 Optometry Australia

contrast, signicant Accurate t
differences were found for assessment is
horizontal coma essential when tting
MFCL as an increase
in ocular aberrations
because of poor t
could lead to negative
results in visual
quality
Slight decrease in
root mean square
with accommodation,
signicantly with
MCL for both stimuli
Near vision was
reached either by
accommodation or
adaptation to these
aberrations
Plainis and 12 non- 2229 Sphere Spectacle corrected Air Optix Aqua 30 min Optimal VA was achieved Performance with
colleagues presbyopic 5.25 to VA worse than 6/6 multifocal close to 0.0 D spectacle lens aspheric MFCL
(2013)37 patients under +0.75 D Hyperopia >0.75 power for all lenses and for centre-near design,
cycloplegia Cylinder up both pupil diameters enhanced for small
Myopia >6.00 pupils and with
to 0.50 D VA simulating distance
Anisometropia >0.50 defocus was always better binocular compared
with the naked eye than with to monocular vision.
No abnormal
phorias or refractive MFCL although VA with Coupling of the
surgery MFCL was always better than wearers ocular
0.0 logMar spherical aberration
VA for intermediate and near with MFCL aberration
defocus was better the higher proles contributes to
the near correction their functionality
(High > Med > Low > Naked) MFCL should have
VA was better with 3 mm customised proles
pupil than 6 mm pupil to full the vision
demands of each CL
user

Table 1. Continued
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Clinical and Experimental Optometry 100.2 March 2017

115
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa

two foci, distance and near, with the rest

lost to dispersion, neutralisation and scat-
ter.43 This design involves a loss in image
contrast caused by the fraction of light that
goes into higher diffraction orders.9 It may
Summary

provide unacceptable patient comfort and

tting difculties as well as a signicant vis-
ual compromise in low levels of illumina-
tion44 and glare was often a problem.13
Average DOF (depth of focus)

correction increased for both

VA was better with binocular

Diffractive contact lens designs are not cur-

aberration) near VA reduced

The higher ocular spherical

aberration, the lower VA at
with positive than negative

(3 mm) than for the larger

VA declined more rapidly

With centre-near designs

rently commercially available for presby-

aberration became more

was larger with smaller

as the ocular spherical

rather than monocular

opic correction.9

3.0 D defocus (near)

DOF increased as the
addition of the MFCL
defocus with MFCL

(negative spherical
(6 mm) pupil

FITTING PROCESS
Results

positive
viewing

criteria

Patient selection and tting

considerations
Follow-up

Some considerations must be taken into

account for patient selection to ensure the
multifocal contact lens tting success. All
these considerations are summarised in
Table 2.9 Bennet14 also listed some multifo-
cal contact lens tting considerations that
Lens type

should be considered by any practitioner

for presbyopia-correcting contact lens
tting.
1. The patient should be informed about
the multifocal/bifocal contact lens
Inclusion criteria

option prior to entering presbyopia.

2. The benets of visual independence
from spectacles should be presented to
patients as a factor for improving their
quality of life.
3. Patients must be informed that some
visual compromise may result depend-
ing on the contact lens option selected
Pupil diameter

for presbyopia correction.

4. Patients should be informed that they
must have a spectacle correction to be
used as a back-up for contact lenses.
Additional plus power would be of help
Refraction

when reading ne print, especially in

dim illumination and additional minus
power would be helpful when driving
at night.
5. The clinician must have multiple diag-
(years)
Ages

nostic sets/inventories and be willing

to try different types of lenses.
6. Unequal additions can be prescribed
sometimes to obtain satisfactory vision
at all distances.
Subjects

7. A modied monovision approach, in

Table 1. Continued

which one eye is slightly over-plussed at

distance may allow the patient to
obtain all of their visual goals.
8. A period of time between 15 and
Author
(year)

20 minutes is needed in the tting

Clinical and Experimental Optometry 100.2 March 2017 2016 Optometry Australia
116

Figure 4. Different multifocal contact lens designs. A. Concentric design. B. Aspheric
design. C. Diffractive design.
process to allow the lenses to settle
prior to the evaluation of the lens-to-
cornea tting relationship.
9. Loose trial lenses or ipper bars should
be used for over-refracting the patient
to provide a more natural environment
and to check vision binocularly to sim-
ulate a real-world environment.
10. The clinician must be aware of the bin-
ocular summation of visual acuity.
11. When the lenses are dispensed (and/or
with the diagnostic lenses in combina-
tion with the over-refraction), patients
should walk around the ofce and per-
form common visual tasks (look at a
computer, read a magazine, look at dis-
tance et cetera) and indicate the visual
tasks that they are pleased with and
those that they feel could be improved.
2016 Optometry Australia
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa
Task-oriented evaluation
Each patient requires a customised
approach for multifocal contact lens tting.
Task-oriented visual satisfaction may prove
helpful in lens design selection,9,48 as well
as in predicting wearing success.9 Patients
should be asked about how they spend
their time during the day and also about
the visual tasks that are specially important
and time-consuming for the patient (that
is, computer use, driving, reading et
cetera).14 The visual demands which are
required to perform habitual tasks have
been described and should be considered
before the selection of the multifocal con-
tact lens design to t (Table 3).9 Plainis
and colleagues37 suggested that further
research using advanced behavioural meth-
ods should be undertaken to simulate
Clinical and Experimental Optometry 100.2 March 2017
performance of individuals during their
daily living tasks and activities, such as
reading, driving and using hand-held
devices. Gispets and colleagues9 evaluated
task-oriented visual satisfaction and wear-
ing success with two types of simultaneous
image multifocal soft contact lenses and
observed that visual satisfaction decreased
for tasks involving higher visual demands
and for near and far viewing distances
rather than for intermediate vision.
Adaptation time
Adaptation to multifocal contact lenses is
not an immediate process because the
brain needs time to integrate effectively
those images presented for each of the dis-
tances. Visual performance may improve
with time.37 Functionality of any of the
simultaneous image designs should also be
governed by blur adaptation, which is
believed to occur at the cortical level.49
Several authors have shown an improve-
ment in acuity/sensitivity after limited peri-
ods of spherical defocus blur.4951 Wang
and Ciuffreda52 suggested that depth of
focus may signicantly improve after peri-
ods of blur adaptation. Jung and Kline53
postulated that the ability to identify a
blurred text by elderly people involves not
only age-related optical changes but also
experience-mediated neural compensation.
There is evidence that the neural responses
that underlie adaptation to transient blur
are intact in the ageing visual system.54
In addition, older people may be more tol-
erant to blur than younger people.55
Presbyopes wearing progressive-addition
lenses report limits of clear and comforta-
ble vision beyond those expected from
blur-detection thresholds,56 suggesting that
there is a tolerance to the induced blur.
Woods and colleagues57 found that toler-
ance to defocus blur was related to mea-
sures of personality and they concluded
that blur tolerance may provide a new
measure of the impact of degraded images
on quality of life. If blur tolerance can be
predicted with a questionnaire that evalu-
ates personality, such a questionnaire
would be useful in a clinical setting to indi-
cate how likely an individual would tolerate
interventions that may induce blur.57
Woods and colleagues57 also found that
blur tolerance decreased with the increase
in pupil size, which suggests that there may
be an interaction between defocus and
117
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa
Figure 5. Distribution of focus and image quality in multifocal contact lens compared
to monofocal contact lens
ocular aberrations that are usually of
higher magnitude with larger pupils.
Multifocal contact lens vision generally
deteriorates during the early days of con-
tact lens wearing but it is not clear how this
trend changes after the fourth day of wear-
ing. Wan58 suggested that patients should
be advised about possible shadowing and
ghost images in the initial four to seven
days of multifocal contact lens wearing. It
should be considered that all scientic evi-
dence leads to the conclusion that early vis-
ual assessments with a multifocal contact
lens provides little information about the
visual performance later on during long-
term wearing.6 Gispets and colleagues9 rec-
ommend a multifocal contact lens wearing
of 15 days before a denitive assessment of
the visual performance, with an initial
three-day period for the selection of the
nal distance and addition power modica-
tions. Fernandes and colleagues19 com-
pared the visual performance achieved
with Bionity multifocal contact lenses
(CooperVision) and monovision using
spherical Bionity contact lenses. An
Clinical and Experimental Optometry 100.2 March 2017
118
improvement in vision was observed from
one to 15 days of multifocal contact lens
wearing, suggesting that an adaptation
effect in the multifocal modality is
achieved, while the contrary occurred with
the monovision option.19
SUBJECTIVE VARIABLES
The term 20/happy has been associated
with multifocal contact lenses because the
corrected vision with them may be reduced
compared with their spectacle acuity but
the patient is satised.14 Some individuals
are so motivated to not wear spectacles that
they are satised with a multiple-line Snel-
len acuity reduction.14 The patients subjec-
tive perception of his/her vision combined
with the range of clear vision
(in centimetres) at near appear to be the
most useful indicators of the individual sta-
tus.6 Traditional acuity based on tests and
other objective measures are generally
unhelpful.6 Performance reductions that
are subjectively perceptible to wearers may
not result in reduced visual acuity, when
measured by conventional chart-based
methods.6 Other issues are as important as
visual acuity, such as visual quality, func-
tional reading speed and comfort.68 Sub-
jective visual satisfaction and wearing
success have been studied previously with
different contact lens designs and wearing
modalities.6,9,18,59,60 Papas and colleagues6
considered subjective variables, such as
ghosting (distance and near), perception
of haloes, lens comfort, visual quality (dis-
tance, intermediate and near), facial recog-
nition and overall satisfaction with
multifocal contact lenses. Specically, they
evaluated the subjective visual satisfaction
with a 100-point numerical rating scale,
including variables such as ghosting,
appearance of halos, lens comfort, vision
quality, vision uctuation, facial recogni-
tion and overall satisfaction.6 Signicant
reductions were found for all wearing mod-
alities and for all subjective vision variables
that were evaluated. Interestingly, these
reductions were not associated with similar
reductions in visual acuity, leading the
authors to recommend the use of a subjec-
tive evaluation of vision. Vasudevan, Flores
and Gaib61 rated subjectively multifocal
contact lens ttings using a 1-to-5 scale (1:
not at all, 2: not very, 3: no opinion, 4:
somewhat, 5: extremely) to evaluate dis-
comfort, burning, irritation, distance blur,
near blur and decreased contrast.
Key factors for the tting
The rst step in multifocal contact lens t-
ting is to choose the right design for an
individual patient. We must consider a
group of key factors for the selection of the
contact lens design: age, motivation, pupil
size, tear lm, ocular aberrations and ocu-
lar dominance.
AGE
Age inuences the success of simultaneous
image contact lens ttings, not only due to
the increase in the contact lens addition
required with age (that is, large power gra-
dient across the lens surface)32 but also
due to the associated decrease in pupil
diameter with age (that is, increase in
depth of focus and reduced useful optic
zone of the lens) and the reported major
tolerance to defocus.62 The last two factors
have been found to contribute to an
increase in the subjective depth of focus of
about 0.027 D per year from the age of
21 to 50 years.63 The behaviour of these
multifocal lenses in terms of distance and
near correction will vary among patients of
2016 Optometry Australia
 Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa

PUPIL SIZE
High probability of Moderate probability of Pupil diameter should be evaluated both in
success success Low probability of success normal room illumination and with
dimmed light before multifocal contact
Moderate to high Moderate to high myopia Low ametropia or emmetropia
lens tting. It should be considered that
hyperopia
pupil size is dependent upon retinal lumi-
No astigmatism Astigmatism <1 dp Astigmatism >2 dp
nance and state of adaptation, the state of
Young presbyopes, low Medium presbyopes, medium Old presbyopes, high addition the entire central nervous system (for
addition addition example, fatigue), psychic inuences, such
Normal pupil size Large pupil size (>5 mm) Small pupil size (<3 mm) as fear and pain (for example, contact
(35 mm) lens-induced corneal irritation) and age.40
Successful contact lens New contact lens wearer Unsuccessful contact lens Pupil diameter becomes smaller as presby-
wearer wearer opia advances65 and diminishes during bin-
BUT >10 seconds BUT between six and nine BUT ve seconds ocular observation by around 0.5 mm for
seconds the photopic range of luminance.66 For
Highly motivated Moderately motivated Not motivated the same photopic range, the pupil diame-
Aware of vision Accept not much vision Unrealistic expectations ter increases as the size of the stimulus
compromise compromise eld increases. For eld diameters up to at
least 25 , the pupil diameter depends on
No perfectionist people Not much perfectionist people Anxious or perfectionist people
the corneal ux density rather than simply
No amblyopia Low amblyopia (12 lines) Moderate to high amblyopia
on the luminance.67,68 Therefore, pupil
Good manual dexterity Medium manual dexterity Poor manual dexterity diameter is affected during contact lens
Frequent changes in Long time in near work High visual demands (night wear by a great variety of factors.
focus driving) Previous studies18,69,70 have demon-
Good ocular health Medium dryness, no retinal High dryness, cataracts, retinal strated the dependence of vision with mul-
disease disease tifocal contact lenses on pupil size. Pupil
BUT: tear break-up time dynamics are extremely relevant when con-
sidering presbyopic corrective options with
contact lenses.35 A large pupil (more than
Table 2. Patient selection considerations to ensure the multifocal contact lenses tting 5.0 mm in normal room illumination) is
success according to Gispets and colleagues9 not very common in the presbyopic popu-
lation but if present, aspheric designs
would be contraindicated due to the gener-
Habitual task Visual demand Viewing distance ation of glare and ghost images under low
illumination conditions.14 A pupil diameter
Workplace Teaching Medium Combination far/near greater than 6.0 mm would be expected
Writing High Near only with younger presbyopes and under
Reading High Near very poor lightning conditions.65 Stepped
proles of multizone refractive contact
Computer work High Intermediate
lenses are reasonably robust against pupil
Meetings Low Combination far/near changes. The performance of progressive
Home Cinema/theatre Medium Far aspheric designs is clearly dependent on
Driving High Far pupil diameter, particularly in the case of
House care Low Combination far/near simple parabolic power proles.65 There-
Sports Medium Far fore, there is a marked interaction between
the pupil diameter and the power proles
Reading High Near
of the lenses, with a crucial effect on the
TV Medium Far distance correction and near addition pro-
Computer work High Intermediate vided by the multifocal contact lenses.38,64
The pupil size has a signicant impact
on the ability of a subject to tolerate defo-
Table 3. Habitual tasks and visual demands according to Gispets and colleagues9 cus in optical systems that rely on spherical
aberration or multifocality for their
the same age, as well as in the same patient MOTIVATION effect.71 Eyes with larger pupils tolerate
for different situations.64 Consequently, the Multifocal contact lens wear requires a myopic defocus better (that is, they have
visual quality outcomes obtained with a par- higher level of commitment to the tting better visual acuities in the presence of
ticular multifocal contact lens in a single process by the patient than monofocal refractive errors) than eyes with smaller
patient cannot be extrapolated to the designs, which is often associated with a pupils. Eyes with smaller pupils see better
entire population of a determined age.64 higher patient motivation.14 at distance when they are emmetropic,

2016 Optometry Australia Clinical and Experimental Optometry 100.2 March 2017
119
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa
because the peripheral less-focused light is
excluded.71 Madrid-Costa and colleagues48
pointed out that, attending to the results of
their study, multifocal designs based on
continuous power gradient could provide
better visual quality results than multi-zonal
refractive designs under mesopic condi-
tions, when the pupil diameter becomes
larger. These results under mesopic condi-
tions should be kept in mind when advising
patients who need optimal spatial vision
under low luminance or night illumination,
as might be encountered when driving at
night.48
TEAR FILM
The most important physiological change
that impacts the presbyopic patient is the
decrease in tear production that occurs
with age. This change results from a reduc-
tion in both the Goblet cells of the con-
junctiva and the mass of the lachrymal
glands.14 Also, there is an increase in tear
retention after the fourth decade40 due,
perhaps, to the change of lid shape and
the reduced facility of punctal drainage.
Likewise, some elderly patients may have a
reduced tear ow due to an active disease,
such as rheumatoid arthritis (for example,
keratoconjunctivitis sicca in Sjgrens
syndrome). Furthermore, there are various
systemic and topical drugs that may
decrease signicantly the tear volume,
such as anticholinergics, antihistamines, diu-
retic hydrochlorothiazide, certain hormones
(including those used in post-menopausal
hormone replacement schemes), betablock-
ers, psychotropics, tricyclic antidepressants
or salicylic acid.
Discomfort due to eye dryness has been
found to be the primary reason for the dis-
continuation of contact lens wear by
patients.72 Koetting and Andrews73
reported an eye-related reduction in tear
pH (more acidic) that may affect the tting
characteristics of certain high water-
content soft contact lenses. Soft contact
lens wearers may choose to cease lens wear
altogether as a remedy for symptoms of
dryness.74 More than 40 per cent of former
soft contact lens wearers referred to dry-
ness as their primary reason to discontinue
the use of lenses and this has been con-
rmed in other recent studies.75 Du Toit
and colleagues76 found that, whereas
28 per cent of presbyopic patients reported
dryness prior to contact lens wear, 68 per
cent reported dryness after six months of
lens wear. Consequently, the assessment of
Clinical and Experimental Optometry 100.2 March 2017
120
both tear quality and volume is impor-
tant.14 Andres and colleagues77 reported a
signicant reduction in uorescein tear
break-up time (BUT) with increasing age
and found it predictive of dry eye pro-
blems. A tear BUT of 10 seconds or greater
has been recommended for successful daily
wear,78 whereas a BUT of less than 10 sec-
onds suggests the potential development of
difculties during lens wear with time.75 If
the BUT is between six and nine seconds,
patients should be advised that all-day wear
cannot be guaranteed.79 These individuals
tend to benet most from disposable or gas
permeable lens wear, with regular cleaning
and frequent use of rewetting drops. A
BUT of ve seconds or less typically contra-
indicates contact lens wear, especially if the
BUT measurement is repeatable.80 If the
patient has Meibomian gland dysfunction
or blepharitis, tear quality can be signi-
cantly affected and therefore, these condi-
tions must be treated prior to contact lens
tting in the presbyopic patient.14
Soft contact lens wear is associated with
reversible changes in corneal and conjunc-
tival sensitivity, as well as with inammation
that may lead to dryness symptoms.40,8184
McMonnies and Ho85 reported a signi-
cantly higher frequency of dry eye symp-
toms in contact lens wearers, indicating
that contact lens wear may affect the tear
function. For a non-contact lens wearing
group, Du Toit and colleagues76 found that
bulbar hyperaemia and the type and extent
of corneal and conjunctival staining
increased after six months of contact lens
wear. These authors also found signicant
increases in discomfort, blurry and uctuat-
ing vision, dryness and foreign body sensa-
tion.76 Dry eye symptoms seem to be more
inuenced by contact lens wear than by
age or gender,76 although females have
higher dryness ratings than males,76 espe-
cially after menopause.86
The blink interval should be also consid-
ered when multifocal contact lens tting is
planned. A normal blink occurs after every
four or ve seconds. If a patient blinks less
frequently, contact lens wear can be nega-
tively affected in a borderline dry eye
patient.14 It should be considered that the
primary functions of blinking is to keep the
eyes hydrated and to protect against for-
eign objects.87,88 Average individual blink-
ing rates increase with age89,90 and are
correlated with dopamine levels in humans
and primates.91,92 The inhibition of ocular
blinking might constitute an adaptive
reaction to minimise the loss of visual infor-
mation93 and is related to the level of
engagement of a person with what is being
looked at.93 This fact may affect presbyopes
that work with computers or other elec-
tronic devices.
A valid questionnaire should be able to
identify soft contact lens wearers who are
struggling with clinically signicant soft
contact lens-related dry eye complaints94
and are sensitive enough to feel the
improvement when treated with products
designed to reduce those symptoms.95,96
ABERRATIONS
There is an interaction between the ocular
aberrations and the aberrometric prole of
the correcting lens.97,98 Ocular spherical
aberration is known to play a key role in
the optical performance of the eye.99 Con-
tact lenses may induce a signicant change
in the level of aberrations of the eye, with
induction of primary coma, if the lens is
decentred.100 The astigmatism induced by
multifocal contact lenses may also amplify
the multifocal behaviour of lenses, leading
to an enlarged depth of focus with a worse
peak performance.43 Also, we must con-
sider that wearing a contact lens may
induce additional aberrations due to lens
exure.43
There is still a doubt about whether a
standard commercially available multifocal
contact lens with certain power and aberra-
tion proles would provide similar perfor-
mances on eyes having the same refractive
needs but different levels of inherent
spherical aberration. Bakaraju and collea-
gues35 demonstrated that eyes having the
same refractive prescriptions but diverse
levels of inherent spherical aberration per-
formed differently when tted with identi-
cal multifocal contact lens designs, with a
performance largely dependent on the
exposed pupil and the level of residual
accommodation.35 When deliberately
induced aberrations are considered as a
mode of presbyopic correction to increase
the depth of focus, the coupling effect
between the aberrations of the correcting
lens and those of the uncorrected eye do
play a vital role in the overall performance
outcomes.35 The spherical aberration of
the eye is very variable in the general
population101103 and tends to increase
with age.104106 Because the contribution of
a soft lens and the eye to the overall spheri-
cal aberration are additive107 and in the
case of centre-near lenses, their signs are
2016 Optometry Australia

opposite, the addition effect for lenses
with aspheric proles is likely to be
reduced.65 The wide range of spherical
aberration values for different individuals
helps to explain why some wearers may
nd the lenses helpful, while other do
not.37 When the extended depth of focus
is due to primary spherical aberration,
the introduction of greater amounts of
aberration to increase the effective read-
ing addition are expected to be accompa-
nied by substantial losses in visual
acuity.34 In spite of the benet of spheri-
cal aberration in near vision, it can also
be a crucial factor in the degradation of
the image contrast, which decreases as
spherical aberration increases.7
The radial variation in power across the
lens surface produces an enhanced depth
of focus over which reasonable image qual-
ity and on-eye visual acuity can be
achieved.23,108,109 The through-focus nature
of the image will change with the pupil
diameter and within the depth of focus
and the best focus will vary with the spa-
tial frequency spectrum of the object
viewed;30,110112 however, it is clear that the
add effect is not the same as the depth of
focus because even a single vision lens
yields a non-zero depth of focus. The add
effect is constituted by the increase in
depth of focus over what would be
achieved with a single-vision lens.113 There
is a loss in depth of focus when there is
1.00 D or more of residual astigmatism.
More complex aberrations, such as coma
and spherical aberration combined with
astigmatism can be even more visually dis-
ruptive. Clinicians need to be alert about
how residual astigmatism and corneal aber-
rations can undermine visual quality and
depth of focus.71
Another important aspect to consider
in multifocal contact lens tting is the
coupling of the spherical aberration of
the eye with the power prole of multifo-
cal lenses. Lenses with centre-near design
have a negative spherical aberration,
which is the opposite sign of the ocular
spherical aberration, with a common
value of around 0.10 D/mm2 in the pres-
byopic population.105,106 Therefore, the
eye-lens combination will have a lower
value of negative spherical aberration
than that of the out-of-eye lens. This
could reduce the add effect provided
by the lens.64 In addition, dynamic ele-
ments, such as the tear lm and accom-
modative system, may also contribute to
2016 Optometry Australia
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa
the reduction and variability of the add
effect.61 Previous studies114 have
reported a general tendency of the spher-
ical aberration to change from a positive
value in relaxed eyes toward a more nega-
tive value when accommodation
increases.61
OCULAR DOMINANCE
Traditionally, ocular dominance has been
considered of relevance in presbyopic cor-
rection, both in monovision and multifocal
wearing modalities. It is not uncommon for
different dominance tests to yield different
results. Ooi and He115 in 1999 reported
that ocular dominance changed with differ-
ent test conditions, at different positions in
the visual eld and with different attention
levels. These same authors demonstrated
that interocular imbalance is a sensory eye
dominance that cannot be equated with
motor eye dominance. It manifests largely
as a binocular phenomenon, which bears
little relationship with the monocular neu-
ral mechanisms of contrast detection and
brightness perception.116 Another study117
investigated a battery of motor and sensory
ocular dominance tests and found a level
of uncertainty in more than 11.5 per cent
of cases using the optical blur test (+1.00 D
lens), whereas a clear answer was obtained
in all cases using the hole-in-card
approach. In contrast, Pointer118 used a
+1.50 D lens to test the sensory dominance
in 72 emmetropic healthy subjects and con-
rmed that subjective uncertainty was mini-
mised. This author suggests that a blurring
lens of this power should preferably be
used if the sensory ocular dominance test is
used in different clinical applications,118
such as contact lens tting. It should be
considered that the dominant sensory eye
is commonly distance-corrected in partially
or complete monovision approaches.
Schor, Landsman and Erickson119 demon-
strated that interocular suppression of blur
became enhanced when the non-dominant
motor eye was blurred and it became
reduced when the dominant motor eye
was blurred; however, Robboy, Cox and
Erickson120 demonstrated some years
later that the correction of the dominant
motor eye for a given viewing distance
was an unreliable method of optimising
blur suppression or binocular high/low
contrast visual acuity at that distance.
Recently, Zheleznyak and colleagues121
found that through-focus visual acuity was
unaffected by ocular dominance and
Clinical and Experimental Optometry 100.2 March 2017
hypothesised that the assignment of the
dominant eye to distance or near may be
an important factor to optimise contrast
threshold performance at different object
distances in both modied and traditional
monovision. Robboy, Cox and Erickson120
several years before also concluded in a
study evaluating the relationship between
ocular dominance and monovision visual
performance that the selection of the dis-
tance monovision eye must be realised in
vision performance areas other than vis-
ual acuity.
The motor and sensory dominant eye
must be determined in any multifocal
contact lens tting. Where necessary a
modied monovision or a combination
of centre-near and centre-distance multi-
focal contact lenses in each eye, the
impact on visual acuity and contrast sen-
sitivity of selecting the motor or sensory
dominant eye for distance should be
tested. It is possible that the impact of
correcting the dominant or non-
dominant eye for distance has a minimal
impact on visual performance and there-
fore, the selection of one or the other
may be arbitrary.122
FITTING TOOLS
Power proles
Power proles are useful tools that show us
how the power of each multifocal contact
lens varies from the centre to the periph-
ery. Manufacturers only provide a few para-
meters of their multifocal contact lenses,
such as a basic description of the design
(centre near or centre distance), the
refractive power for distance vision and the
nominal addition power. Commercial
secrecy makes it unusual for the power pro-
le to be described in detail, making it dif-
cult to properly assess the likely merits
and disadvantages of any particular prod-
uct.65 A knowledge of complete power pro-
les would give practitioners a better
understanding of the behaviour of these
lenses and it could improve the nomogram
tting for each individual patient.64
Techniques for measuring the power dis-
tribution are based on HartmannShack or
interference systems and they allow the cli-
nician to discuss how the distance and near
corrections provided by these lenses vary
with the pupil diameter61 and with its cen-
tration.65 Power proles give considerable
121
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa
insight into the performance of simultane-
ous image lenses.123 If combined with
knowledge of the ocular aberrations and
likely normal pupil diameter of the individ-
ual patient, power proles can be valuable
guides to the visual performance that the
patient might achieve with different lens
designs.63 When there is a smooth addition
progression area in intermediate zones,
better results in intermediate vision are
expected when the contact lens is cen-
tered.124 Transition between central and
peripheral zones could be more or less
abrupt depending on lens design and
power prole (Figure 6).
To calculate the near addition, we
should dene two concepts: the effective
near addition, which is the difference
between the maximum positive or least
negative power and the nominal distance
power and the maximum near addition,
which is the difference between the most
positive or least negative and least positive
or more negative powers. The near addi-
tion provided by any of the multifocal
lenses could be modied simply by choos-
ing another value of the nominal distance
power.61 The modication of the nominal
distance power of the lens has two conse-
quences: the change in near addition and
the change of pupil diameter, for which
the lens provides the distance correction. A
lens with an over-positive correction would
provide a higher near-addition value; how-
ever, the distance correction of the patients
would be reached at a higher radial dis-
tance from the centre.64 The patient would
Figure 6. Power prole of four contact lenses: Focus Progressives, Air Optix Aqua
Multifocal High Add, Air Optix Aqua Multifocal Medium Add and Air Optix Aqua Mul-
tifocal Low Add. These lenses are compared to Air Optix Aqua Monofocal (Monts-
Mic and colleagues64).
Clinical and Experimental Optometry 100.2 March 2017
122
need a larger pupil diameter for the lens to
provide the distance correction.64 In
reverse, if we select a lens with an over-
negative correction, it will provide a lower
near-addition but the patient will require a
smaller pupil diameter to obtain distance
correction.38,64
Defocus curve and
accommodation
To determine the range of focus and visual
performance achieved with available multi-
focal contact lenses, there is an objective
clinical measure of how well a lens is cor-
recting presbyopia, called the defocus
curve (Figure 7). Defocus curve evaluations
can provide a useful method to compare
different presbyopia-correcting strategies125
by evaluating visual acuity at different dis-
tances from the patient126129 or through
different levels of defocus induced with
trial lenses.129133 The defocus curve is the
best objective indicator of the extended
range of vision for a patient using any
presbyopia-correcting lens.71 The range-of-
focus metrics represent the dioptric range
of defocus (or object vergence), over which
the patient can maintain a given level of
acuity (Figure 8).134 Defocus curves can
only be interpreted when the pupil size is
provided as the spherical aberration
induced by the contact lens changes with
pupil size.71
Early presbyopes maintain residual
accommodation, allowing them to focus on
an object inside the depth of focus
provided by the lens design, therefore
increasing the range of optimal vision.
Vasudevan, Flores and Gaib61 found that
the accommodative response was different
between the subjective refraction and mul-
tifocal contact lenses; however, there was
no signicant difference between different
contact lens designs. In the presence of an
accommodative stimulus that exceeds the
depth of focus of the eye, blur is created
that stimulates an accommodative
response.58 Likewise, the increased depth
of focus might result in decreased accom-
modative stimulus and thereby, a lower
accommodative response that would be
helpful in presbyopes with insufcient
amplitude of accommodation.61 This
response is not expected to change signi-
cantly after days of adaptation with multifo-
cal contact lenses.61 Bakaraju and
colleagues35 found that for a 55-year-old
subject corrected with high addition
designs, the residual accommodation of
0.50 D was used when the demand reached
3.00 D and for 45-year-old subjects cor-
rected with low additions, the partial
reserve of 1.50 D was used when the
demand exceeded 1.50 D in steps of
0.50 D.35
KEYS FOR A FITTING SUCCESS
Fitting problems
Back and colleagues134 stated that subjects
who did not achieve successful lens wear
were categorised as failing for either vision-
related or non-vision-related reasons.
These authors dened vision-related fail-
ure when the main reason for dissatisfac-
tion with lens wear included symptoms of
unacceptable visual compromise, such as
blur and/or ghosting at distance and/or
near.134 Non-vision-related failure was
dened as the inability to achieve an
acceptable lens t with the limited para-
meters available, difculty in handling con-
tact lenses, problems with ocular health
precluding lens wear, such as dry eye and
irritated pinguecula, discontinuation due
to non-compliance, general health or per-
sonal reasons or early transfer to another
lens option (less than three months suc-
cessful lens wear).134
Problems reported by wearers of presby-
opic contact lens include compromised dis-
tance and/or near visual acuity, decreased
contrast sensitivity, reduced stereoacuity,
2016 Optometry Australia
 Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa

all lenses used were made of the same

material and had similar dehydration
levels, these authors thought that differ-
ences in comfort were related to better
visual adaptation and more effective cor-
rection with multifocal lenses compared
to monovision.19

Wearing success
There is a large disparity of criteria to
dene wearing success and patient satisfac-
tion. The confusion in reported rates arises
because of varying criteria used to dene
success, namely, differences in study dura-
tion, ambiguous denitions of the base
population used to calculate success rates
and no criteria of minimum wearing times
or sufcient intention to continue lens
wear after study completion.135 Wearing
Figure 7. Defocus curve for the PureVision Multifocal Low Add (Madrid-Costa and
success has been dened as wearers still
colleagues143) using their lenses a minimum of eight
hours per day, ve days per week, at three
months after the initial contact lens adapta-
tion135 or the percentage of subjects opting
to continue multifocal lens wear after the
completion of one study and also by the
Visual acuity (logMAR)

+0.10 logMAD + best VA (relative) number of subjects still wearing their

lenses six months later.9

Patient satisfaction
The study of Gispets and colleagues9
NEAR INTERMEDIATE DISTANCE revealed effects of visual demand, observa-
+0.30 logMAR (absolute)
tion distance and contact lens design on
visual satisfaction of multifocal contact lens
wearers. Visual satisfaction was assessed by
means of several task-oriented patient eval-
-4.00 -2.00 -0.50 0 +0.50 uation questionnaires, where subjects had
Defocus (D) to grade satisfaction with the performance
of their multifocal contact lens designs dur-
Figure 8. Absolute and relative range-of-focus and three area-of-focus defocus curve ing diverse visually demanding habitual
metrics for simultaneous multifocal optical devices. The absolute criterion of +0.30 tasks at home or at the workplace, includ-
logMAR is depicted by the lower dashed line. The relative cut-off criterion of +0.10 ing near, distance and intermediate vision
logMAR above the best acuity is depicted in the upper dashed line. The blue arrows activities.9 As expected, visual satisfaction
with multifocal contact lens wear was lowest
depict the range-of-focus metrics for either criterion. The near area is between 25 cm
for those tasks with a higher visual demand
and 50 cm. The intermediate area is between 50 cm and two metres and the distance
(distance and near) and was found to
area metric starts from two metres. increase in those tasks requiring intermedi-
ate vision or a combination of distance and
ghost images, coloured haloes and uctua- has been extensively reported in the litera- near vision.9 Wearing success may depend
tions in vision resulting from changes in ture.6,127,140,141 Particularly demanding vis- on high or low visual demands of multiple
pupil size.14,18,45,80,135139 Some studies ual tasks, such as driving at night, were the occupational groups.9
documented blurred and insufcient qual- most challenging for this modality of con-
ity of vision as the principal reason for con- tact lens wear in agreement with a previ- SUMMARY
tact lens discontinuation.18,56,140142 Some ous study by Chu, Wood and Collins.142
authors also reported that the main reason Fernandes and colleagues19 compared The latest generation of soft simultaneous
for multifocal lens discontinuation was end-of-day comfort with multifocal contact image contact lens designs has proven to
insufcient quality of vision. This nding lenses and monovision. Considering that be very valid for the correction of

2016 Optometry Australia Clinical and Experimental Optometry 100.2 March 2017
123
Soft multifocal contact lenses Prez-Prados, Piero, Prez-Cambrod and Madrid-Costa
presbyopia. The adaptation problems are
based on a lack of knowledge of the needs
and characteristics of the patient, as well as
the performance of these lenses depending
on certain variables of the patient, such as
pupil diameter and dynamics for each
luminance condition, patient and lens
aberrations, the lens design, tear lm,
residual accommodation or centring of
lenses. Likewise, subjective factors are most
useful for assessing the tting success, such
as the appearance of haloes, blur in far
and near, manipulation of the lens and the
feeling of comfort.
According to the peer-reviewed litera-
ture, the following conclusions with direct
clinical applications can be extracted.
1. Complete and appropriate information
about the contact lenses that are
going to be tted, including benets
and inconveniences, should be pro-
vided to the patient prior to the t-
ting. Thus, the patient will accept any
problem or change required during
the tting.
2. Each patient requires a customised
approach for multifocal contact lens t-
ting, considering the visual demands
required to perform habitual tasks.
3. A multifocal contact lens wearing of
15 days before a denitive assess-
ment of the visual performance, with
an initial three-day period for the
selection of the nal distance and
addition power modications, is
recommended.
4. Patients tted with multifocal contact
lenses should be advised about possible
shadowing and ghost images in the ini-
tial four to seven days of multifocal
contact lens wearing.
5. The clinical results of presbyopia-
correcting contact lenses must be eval-
uated, not only considering the visual
acuity but also subjective variables such
as ghosting, perception of haloes, lens
comfort, visual quality, facial recogni-
tion and overall satisfaction.
6. The key factors for the selection of the
contact lens design are age, motivation,
pupil size, tear lm, ocular aberrations
and ocular dominance.
7. Aspheric multifocal contact lens
designs should be avoided in eyes
with large pupils (greater than
5.0 mm in normal room illumination)
due to the generation of glare and
ghost images under low illumination
conditions.
Clinical and Experimental Optometry 100.2 March 2017
124
8. Multizone refractive contact lenses are
reasonably robust against pupil
changes and may be more adequate in
eyes with signicant dynamic changes
in pupil size, although the potential
degradation of the visual quality with
these lenses in mesopic conditions
must be controlled.
9. Progressive aspheric designs, especially
those with simple parabolic power pro-
les, are more dependent on pupil
diameter changes. In such cases, some
changes in distance power and addi-
tion may be required to achieve a suc-
cessful visual outcome, some of them
even contradicting the manufacturer
tting guides.
10. Tear BUT of 10 seconds or greater and
a blink rate of one blink after every
four or ve seconds are recommended
for a successful daily wear of soft
presbyopia-correcting contact lenses.
11. The interaction between the ocular
spherical aberration and the aberro-
metric prole of the correcting lens
may induce the requirement of
changes in the addition of the con-
tact lens to t. Lenses with centre-
near design have a negative spherical
aberration and therefore, the eye-
lens combination may have a lower
value of negative spherical aberration
than that of the out-of-eye lens, redu-
cing the add effect provided by
the lens.
12. Multifocal contact lens decentration
must be avoided and this generates pri-
mary coma, which deteriorates signi-
cantly the visual quality.
13. Ocular dominance must be considered
when different contact lens designs or
additions are combined. The impact
on visual acuity and contrast sensitivity
of selecting the motor or sensory domi-
nant eye for distance correction should
be tested.
14. The defocus curve is the best objective
indicator of the extended range of
vision for a patient using any
presbyopia-correcting lens.
The objective must be to achieve the
highest level of customisation, in such a
way that we can take control of key factors
that determine the tting success. We
believe that future research is needed
about the key factors affecting the tting
success, as well as to dene success. We
encourage laboratories to publish the
power proles of their multifocal contact
lenses to help clinicians so that they can
make customised ttings. Initially, we had
very little information about soft multifo-
cal simultaneous-image contact lenses,
such as nominal distance power, addition,
design (centre-near or centre-distance)
and basic laboratory recommendations
about tting one design or other depend-
ing on visual needs, ocular dominance
and addition.
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