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Presbyopia…The Short Journey to Contact Lens Success

Published on Feb 10, 2021
15 Minutes Read

Cristina Schnider, OD, MBA, FAAO,
David Ruston, BSc FCOptom DipCL, FIACLE, FAAO


In today’s world, presbyopia doesn’t have to be a major speed bump on the road of life. Today’s presbyopes, Generation X (Gen Xers), born between 1965 and 1980 (currently 40- 55) and Baby Boomers (born 1946-1964) enjoy more affluent and active lifestyles than ever before. Gen Xers are in their prime earning years, and Baby Boomers are just beginning to retire and enjoy life outside of work. Both groups are regular users of digital devices1 (Figure 1), which add to their visual demands, have significant disposable income2, over two-thirds value looking younger3 and they are willing to spend money on products and procedures to maintain a youthful appearance ranging from hair coloring and teeth whitening to cosmetic surgery4.

Of importance to vision care professionals, IPSOS, an independent marketing research agency with experience in healthcare and contact lenses, conducted a survey with 1000 representative consumers between the ages of 12 and 64 in both the United States (US) and United Kingdom (UK). In this survey they identified presbyopes as aged 40+ who either identified themselves as being presbyopic or who suffered from two or more symptoms of presbyopia (JJV data on file, 2020). Using this definition, 352 US contact lens wearers from 40-64 years of age in their Insight Global Incidence Tracker in December, 2018 and found that 94% of them said they expect to continue wearing contact lenses. The same agency surveyed 246 presbyopic contact lens wearers (same definition as above) and 548 non-presbyopic wearers for whom data on place of exam and lens purchase was available and found that the presbyopic group were less likely to purchase contact lenses online than non-presbyopes, and more likely to purchase lenses where they received their eye exams.

Yet despite the introduction of new multifocal contact lens designs by virtually every major manufacturer in recent years, the percentage of multifocal lenses fit in practices globally remains low5. As shown in Figure 2, the use of contact lenses drops sharply at the same time vision correction needs increase in the presbyopic population.  Interestingly, as many as 4 in 10 contact lens wearers are 40+ years old yet according to a poll conducted by Gallup in 2015 only 9% of adults requiring multifocal correction in that age group received a recommendation for contact lenses as a means of correction7. This is a massive untapped opportunity for contact lens practitioners not currently engaged in multifocal fitting.

Figure 1 Smartphone Ownership by Age

Figure 1: Smartphone Ownership by Age*
Adult consumers in the presbyopic age groups are adopting digital technology at high rates, with Gen X’ers and Boomers leading the way in smartphone usage among older adults. In addition, the Pew Research Center also reported that over 50% of Americans also own a tablet computer

Figure 2 The Presbyopic Opportunity Illustrated Vision Correction by Age (US)

Figure 2: The Presbyopic Opportunity Illustrated: Vision Correction by Age (US)**
The teal line represents all users of vision correction, and the red line contact lens wearers. The gap begins to widen between ages 35 and 44, the time when symptoms of presbyopia become evident. The shaded areas represent opportunities to introduce multifocal contact lenses

Navigating a successful journey

A journey analogy is useful in thinking about capitalizing on this opportunity – you have lots of different starting points (patients), destinations (goals) and routes and modes of conveyance to get them there (Figure 3). And while the presbyopia journey is generally but not always easy, it is usually worth it – 67% of multifocal wearers in MSI’s 2015 Gallup study of the US multi-focal contact lens market reported being very satisfied with their soft multifocal contact lenses7 and likely to tell their family and friends. So how do you get started? The first step in a successful journey is the to make sure everything is tuned up and ready to go. Then it’s time to open your favorite navigation app and get going!

Figure 3 Presbyopia Road Trips

Figure 3: Presbyopia Road Trips
The presbyopic road map. A successful journey requires a destination – a mutual definition of success for contact lenses activities, selection of a vehicle (lens design, material and modality) and route (lenses plus spectacles to get them through presbyopia), as well as accommodations for potential roadblocks or need for rerouting. And of course, each patient will be unique, but there are many tools to help you get there

The Tune Up

Before diving in, take some time to make sure everything is in working order and you have everything you need to start the journey. Think of this stage as the “Tune Up”. Starting with the wrong patient, or an incomplete set of tools is a sure way to meet with difficulties. Table 1 includes some key considerations for this stage when selecting patients and Table 2 summarizes guidance on tools to assist you. 

Table 1: Key pre-fit considerations for patient preparation


As soon as presbyopia is evident, especially to begin with

Start YOUNG ~ As soon as presbyopia is evident, especially  to begin with

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Start YOUNG ~ As soon as presbyopia is evident, especially  to begin with

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Start YOUNG ~ As soon as presbyopia is evident, especially  to begin with

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Identify and address lid or ocular surface disease

Start HEALTHY ~ Identify and address lid or ocular surface disease

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Start HEALTHY ~ Identify and address lid or ocular surface disease

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​Start HEALTHY ~ Identify and address lid or ocular surface disease​

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Max Plus Distance Rx, Functional Add, Identify Sensory Dominance

Start FRESH ~ Max Plus Distance Rx, Functional Add, Identify Sensory Dominance

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Start FRESH ~ Max Plus Distance Rx, Functional Add, Identify Sensory Dominance

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Start FRESH ~ Max Plus Distance Rx, Functional Add, Identify Sensory Dominance

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Avoid cyls over 0.75DC

-3.00-0.50 x165

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-3.00-1.00 x165

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Table 2: Key pre-fit considerations for tool availability


Select a preferred design and 1 backup design with distinct characteristics

Start BALANCED ~ Select a preferred design and 1 backup design with distinct characteristics

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Start BALANCED ~ Select a preferred design and 1 backup design with distinct characteristics

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Start BALANCED ~ Select a preferred design and 1 backup design with distinct characteristics

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Include glasses in your tool kit to supplement your best CL selection (near, distance, MFs, PALs, sunglasses)

Start EQUIPPED ~ Include glasses in your tool kit to supplement your best CL selection (near, distance, MFs, PALs, sunglasses)

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Start EQUIPPED ~ Include glasses in your tool kit to supplement your best CL selection (near, distance, MFs, PALs, sunglasses)

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Start EQUIPPED ~ Include glasses in your tool kit to supplement your best CL selection (near, distance, MFs, PALs, sunglasses)

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Patient Considerations

Start with the “easy” ones! A younger presbyope who is already successfully wearing contact lenses has already demonstrated “road readiness” to some degree. Studies*** say that nearly 2 in 5 contact lens wearers are 40+ years old and large number wish to stay in lenses (responded “definitely/probably would continue wearing contact lenses in the next 12 months)6. These wearers can be prone to dry eye and lid disease and should have a comprehensive evaluation of the ocular surface and lid status.

Patient Considerations

For any issues identified, institute procedures to address them prior to fitting multifocal contact lenses. Pucker found that the odds of dropping out were significantly increased with each worsening grade of upper or lower eyelid meibomian gland (MG) plugging, upper eyelid meibum quality, and upper eyelid MG tortuosity8. Simple interventions such as thermal pulsation9 or microblepharon exfoliation10 can have significant impact on lens wearing comfort, retinal image quality and thereby success.

Performing a NEW refraction is also essential, even with a seemingly well-corrected patient. There is a documented progression toward more plus in distance refractions with age11, and most multifocals perform best with a maximum plus distance refraction – adding +0.50 should easily blur the best corrected visual acuity line (which monocularly should be a solid 20/20). It is also not advisable to rely on a current or previous contact lens prescription in lieu of a good spectacle refraction.  Avoid patients with astigmatism exceeding 0.75D. While there are new toric multifocals available, it is highly advisable to get very comfortable with spherical multifocals before attempting to add astigmatism to the mix. 

Determine the lowest “functional”, age-appropriate add required to perform day to day activities. A general rule of thumb for maximum add is +1.00 to 1.25 (low) for the 40’s, +1.50 to +1.75 (medium) for the 50’s, and +2.00 to +2.50 (high) for the 60’s – considerably lower than seen with many PAL prescriptions. With a maximum plus distance refraction, this should give them a comfortable range around their preferred working distance for typical activities. DO NOT use visual acuity as a standard for determining near addition power (add)12–14. Instead, use a functional technique with relevant near target materials, font sizes and lighting. Mobile phones, handheld devices or other simulations of near work are recommended for refining reading add.

Use ALL Your Tools

If you cook, you probably have different knives, pans, dishes and spices to help prepare the perfect meal. We wear different shoes for walking, running, playing tennis, special occasions.  Every sport requires different equipment. It seems that presbyopic correction is one of the few areas of life where we expect one tool to do every job!  We have many tools, and on the presbyopia journey, we will have the most success if we employ them all – multifocal contact lenses, Progressive Addition spectacle Lenses (PALs), top up reading glasses. It’s a matter of combining them to meet critical needs for appearance, convenience and functionality.

Use ALL Your Tools

The destination

Once your tune-up is complete, it’s time to pull out the “app” and go through the steps to accomplish the actual journey.  First, set the “Destination” – and more importantly, the contact lens-specific destination. Identify the situations where contact lenses are the BEST solution (and/or or glasses unacceptable) and jointly agree on a measure of performance in the patient’s real world they can use to judge success. This will be your “contract” with the patient in determining any future tweaks or solutions. It’s helpful to also identify areas of flexibility, such as periods of fixed activity where glasses would be acceptable.

Remember – these questions should highlight situations where contact lenses are the best option and will help identify a concrete definition of success for you and your patients. 

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Helpful questions for this step:

  • Complete this sentence: If I could do “X” without wearing glasses, I would consider these contact lenses successful
  • When is wearing glasses (PALs, Bifocals, Readers)really annoying?
  • When would you consider wearing glasses in some form acceptable?

The route

Typically, there are multiple ways to get to your destination, and sometimes it’s just a matter of personal preference.  On the presbyopia journey, it’s important to understand the preferences and pain points for your patient in planning what tools you have to help them get to their destination. Never make assumptions for them, you need to ask. It’s also key to realize and communicate to the patient that you have many tools in your toolbox to help them navigate through various situations and enable them to keep wearing lenses as their presbyopia evolves. Make sure you understand the specific situations/reasons for wanting to avoid use of glasses. The three typical areas are appearance, convenience and functionality, and each may lead to different solutions. 


Sometimes people avoid reading glasses or progressives out of fear of looking old in front of their friends or colleagues but have no absolute objection to wearing them when out of public eye. Others may actually enjoy wearing them in some situations for appearance reason.

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Helpful questions:

  • Is there something specific about how you look in glasses that bothers you?
  • Are there times you prefer not to wear, or wouldn’t mind wearing glasses?


If someone is on the move a lot between meetings, different projects in the home, or many activities with varying distance and near tasks, having to locate their readers may be very frustrating. Solutions could include having multiple pairs staged around the house or workplace, or using PALs, but this is a great opportunity to suggest multifocal contact lenses, which travel with them everywhere.

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Helpful questions:

  • What does a typical day look like for you in terms of near work vs. distance tasks? How does it differ on the weekend or on vacation?
  • Are there periods where you do sustained periods of near or distance work in the same place each day where you could keep a pair of supplemental glasses handy if required?
  • How well can you control your environment (lighting, distance, contrast, image size, etc.) for your desired activities?


Some multifocal glasses have been shown to impair depth perception and edge‐contrast sensitivity at critical distances for detecting obstacles in the environment, and have been associated with trips and falls in the elderly15,16.  And in fact, the effect was demonstrated for bifocals and trifocals in addition to PALs, so appears to be an effect of looking through plus powered additions generally. If a patient has concerns about PALs or multifocals while driving or navigating stairs, etc., contact lenses could help in those situations, and multifocal glasses could still be used for more sedentary situations.

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Helpful questions:

  • Are there things you feel you just can’t do well in glasses?
  • Are there specific situations where using PALs or multifocal glasses concern you?

Multifocal Contact Lens Design Options

In recent years, consensus has become quite clear around the monovision versus multifocal question, and the science is overwhelming in favor of multifocal contact lenses17.

Monovision reduces binocularity, binocular summation and thereby high contrast visual acuity and offers a limited window of success for patients – essentially wasting the period when adapting to multifocal contact lenses is arguably easiest18,19. Further, several studies show that when exposed to both monovision and multifocal lenses, the preference is for multifocals for both early and more mature presbyopes12,19–21, thus helping us keep them satisfactorily corrected through the evolution of their presbyopia.

With rare exceptions, today’s soft multifocal lenses offer you a choice of center near aspheric designs, or a zonal aspheric system consisting of a center near design paired with a center distance design – an evolved version of modified monovision. Among the center near designs, only one also offers pupil size optimization to account for changes with age and refractive error, and a hybrid aspheric center/spherical periphery design for improved centration. These are important considerations as pupil size is known to decrease with age and refractive error, with myopes and younger ages having larger pupils than hyperopes and older ages22–24. The desired optics will be compromised if any mismatch occurs25. Placing the most critical near optics in the center ensures that those powers will be available across a range of luminance for a patient with a given age and refractive error (Figure 4).

Figure 4 Illustration of how pupil size optimization can improve design match

Note: For illustrative purposes only. Pupil area can vary ~20% at a given luminance–actual measurements were taken across the power range of +4.00D to -6.00D.

Figure 4: Illustration of how pupil size optimization can improve design match across ages and refractive powers. When optics are not designed with the known patterns related to age and refractive power (a), mismatches with pupil size are more likely to occur. If design incorporated these patterns, chances are greater for a more appropriate match across the range of pupils encountered.

The trick is then to ensure that the intermediate and distance optics are also available and optimized within the given range of pupil sizes. It follows, then, that centration of these complicated optics over a generally smaller pupil is also highly relevant as decentered multifocal contact lenses induce significant amounts of third-order aberrations26.

These factors should all be considered when deciding which fitting sets should be incorporated into the practice and when selecting a lens of first choice. It is certainly not necessary to carry all the possible designs but having two that offer unique fitting approaches is probably wise, with an overall preferred design to act as first choice. In addition, with the complexities inherent in multifocal contact lens fitting, having consistency in designs across materials and modalities within a manufacturer has some advantages. 

Lens Material, Modality and other features

Having access to both hydrogel and silicone hydrogel materials, as well as both daily disposable and reusable lenses in the practice enables you to meet a wider range of patient needs. Hydrogels are known for their demonstrated ability to maintain a low inflammatory response, and they provide acceptable levels of corneal oxygenation with a low infection risk profile when worn for daily wear27,28. Silicone hydrogels provide improved corneal physiology from decreased hypoxia across a wide range of powers and thicknesses and may offer some long-term wearers a comfort benefit, though this is very difficult to predict8,29.

Daily disposability offers extreme flexibility and convenience and reusable lenses offer a cost-effective option for many wearers.

The Reroute

As 2020 more than adequately demonstrated, life doesn’t always go as planned, and sometimes we will need to make course adjustments. Keep in mind that with multifocal contact lenses, very small tweaks can make large differences. There are a couple hints that will help you determine when to make a small adjustment, and when to make a radical course change, or postpone the trip altogether! Always follow the fitting guide and avoid making changes until after the patient has “lived” in their world with lenses for several days. General guidance is as follows:

  • To improve distance performance, lower the add in the most affected eye.
  • Always use REAL WORLD near situations and materials to evaluation range and near functionality – NOT visual acuity charts or cards
  • To improve near performance, increase plus in +0.25D steps in the distance power (if tolerated); test by adding lenses with BOTH eyes open and viewing the target.
  • Limit lens changes to 1 or 2 maximum; if not successful, change designs or try again another year! Motivations can change when people experience the ongoing challenges of presbyopia.
  • Alter the environment (improve lighting, change text size or working distance) to enhance near performance.
  • Use distance or reading glasses to “fill in” for occasional use in irregular or unique situations such as theater, movies, and night driving.

Lens Material, Modality and other features

Post-Journey Wrap-up

Fitting multifocal contact lenses provides a great opportunity to gain personal and professional satisfaction. Once you experience the “wow” moment when a presbyopic patient realizes they can actually do the things that matter to them without glasses, you’ll want to do it again and again. 

It’s a bit like fitting glasses or contact lenses to a young myope who didn’t realize what they were missing in the world – the reactions of successful patients are immensely satisfying! Dedicating yourself to a positive and flexible approach to fitting presbyopic patients with multifocal contact lenses provides a great opportunity to gain not only this satisfaction but to differentiate yourself and your practice. 

The benefits of multifocal contact lens fitting to your practice can be summed up in “Three R’s”:

  • Retention – Chances are that you have a wealth of potential patients already in your practice.  By tapping into the current contact lens wearers who are beginning to experience early signs of presbyopia, you have an excellent chance to help them continue to appreciate the benefits of contact lenses throughout presbyopia and keep them in your practice.  Chair time will be reduced compared to a non-contact lens wearing patient and these patients can be highly motivated to stay in contact lenses.  And if you occasionally need to add a form of spectacle vision correction to supplement in cases of unusual or more extreme need, don’t present it as a failure, but as just another tool in your tool box to help them on their journey.  Just having the conversation about options and exploring options can create tremendous loyalty to your practice.
  • Referrals – Never underestimate the power and pervasiveness of the “40-something grapevine”. Presbyopic patients have loads of presbyopic friends and being the only one not borrowing readers or using their phone flashlight to see the menu at a restaurant is sure to attract attention and generate questions. And presbyopes have families as well, so you may gain younger patients as an added benefit.
  • Revenue – Confidently fitting multifocal lenses is still a rare skill, and a specialty, so do charge appropriately for your services.  It is well established that when looking at all income to the practice, a contact lens patient is significantly more profitable over the long term than a spectacle-only patient30. Successful multifocal contact lens patients will virtually always be dual wearers of contact lenses and glasses – often high margin glasses such as progressives.  So consider a fee structure which covers a “suite” of solutions that also includes pricing and policies for sunglasses and spectacles, or that offers some form of credit toward spectacle options if the contact lens option ends up not working out.  Promotions can encourage patients to check out more products in your practice, and that perfect pair of non-prescription sunglasses may help tip the scales in favor of the contact lenses31!

And finally… have fun… and use ALL your tools, and always follow the manufacturer’s fit guide.  Be proactive about offering the option to both current contact lens patients as well as new presbyopes and persist even when you hear a series of “No’s”. A seed planted this year could bear fruit in the future.

*PEW Technology Device Ownership Research 2019.

** IPSOS Global Incidence Tracker, retail outlet consumption data and national census population data in US.

***JJV Data on File 2018. Growth Levers analysis based on IPSOS Global Incidence Tracker, retail outlet consumption data and national census population data covering the United States, United Kingdom, Russia, Japan, South Korea, and China.

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9.     Jackson MA. A Systematic Approach to Dry Eye using LipiFlow Treatment. US Ophthalmic Review 2014;07:104.

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16.   Johnson L, Buckley JG, Scally AJ, Elliott DB. Multifocal Spectacles Increase Variability in Toe Clearance and Risk of Tripping in the Elderly. Invest Ophthalmol Vis Sci 2007;48:1466–71.

17.   Evans BJW. Monovision: a review. Ophthalmic and Physiological Optics 2007;27:417–39.

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IMPORTANT SAFETY INFORMATION ACUVUE® Brand Contact Lenses are indicated for vision correction. As with any contact lens, eye problems, including corneal ulcers, can develop. Some wearers may experience mild irritation, itching or discomfort. Lenses should not be prescribed if patients have any eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye problems. Consult the package insert for complete information. Complete information is also available from Johnson & Johnson Vision Care, Inc., by calling 1-800-843-2020, or by visiting

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