HYBRID MULTIFOCAL TROUBLESHOOTING

Have you ever had a contact lens patient who has astigmatism and presbyopia? Of course! We see these patients every day. Standard soft contact lenses are extremely limited when it comes to presbyopic lenses that also assist with astigmatism. Soft toric multifocal lenses don’t have a large parameter range, and our options are fairly limited. What if you could offer your patient a lens that could work better than a soft toric multifocal?

Hybrid multifocals represent a great option for your presbyopic patients. The gas permeable (GP) lens in the center of the hybrid lens can help correct corneal astigmatism, while the soft skirt can provide more comfort and stability. The GP lens can be made with single vision optics or multifocal optics, which can give patients more options when it comes to multifocal designs. Hybrid lenses can correct astigmatism without a toric ballast system, providing stable vision no matter where the lens is rotated. Hybrid progressive lenses offer dual aspheric optics, which can yield great vision at all distances.

Good Candidates for Hybrid Multifocal Lenses

• Presbyopes with astigmatism

• Soft contact lens wearers, desiring better vision at near

• Patients desiring freedom from glasses

• Patients who have tried monovision but could not adapt

• Current GP lens wearers looking to try a multifocal option

• Patients wanting to try the latest technology

Poor Candidates for Hybrid Multifocal Lenses

• Patients with lenticular cylinder (hybrids currently only correct for corneal cylinder)

• Patients experiencing extreme dry eye with any soft or GP lens

• Patients with unrealistic expectations

• Patients with irregular astigmatism (hybrid multifocals work best on normal corneas)

• Patients with extreme ocular surface disease

• Patients unmotivated to try a different lens modality

Other Reasons Hybrid Lenses are a Viable Option

• Elimination of rotation issues: Since hybrid lenses don’t require a toric ballast system, the patient doesn’t need to insert the lens in a certain direction. No matter the orientation of the lens, the vision will be stable and consistent.

• Ultraviolet (UV) protection: Hybrid lenses contain built-in UV protection, and with all of the science behind the damaging effects of UV light, this is a great feature and selling point.

• Cannot order online or through big box companies: Patients can only order hybrid lenses through a certified practitioner, which can help keep patients ordering in office. This is a great benefit for private practitioners.

• Patient loyalty: When you fit a patient with a type of contact lens they can’t obtain from any practitioner down the block, this can build good faith and patient loyalty. Because you’re fitting the patient with a truly custom product, they’re much more likely to stay with you over time.

Once you’ve determined good candidacy for a hybrid multifocal, present the option to the patient. Say something such as, “Mrs. Jones, I see you’ve been wearing soft toric lenses for many years, and you’re looking to reduce your dependency on reading glasses. There is a contact lens option that might work well for your special type of prescription. It is called a hybrid lens. A hybrid lens is unique because it has a gas permeable contact lens in the center, which yields crisp vision, and a soft contact lens skirt, which assists with lens comfort and stability. It can also help you see at all distances — distance, intermediate, and near. Is this something you would like to try?”

Common Patient Questions

• How are these different from my current contact lenses (if wearing lenses)?

• How will I be able to see at all distances?

• How much are the contact lenses compared to the ones I am wearing now?

• What happens if the lenses don’t work for me?

It is important to have answers to all of your patient questions, before they are asked. Be sure to inform patients about the different lens modality, along with insertion and removal techniques. Also inform patients about the cost difference, and let them know if the replacement schedule differs from their current lenses. Hybrid lenses are typically replaced every 6 months, so even if the cost is higher initially, many times, it ends up costing about the same as their current lenses on an annual basis.

Figure 1. Hybrid lens

Develop a protocol for your office if the lenses don’t work for the patient. In my office, we refund the patient the entire cost of the lenses, minus shipping and restocking fees (this is true for all specialty lens types). Having a refund policy of this nature may help ease patient concerns. I like to tell patients, “If these lenses don’t work for you, we can refund your money for the lenses and apply it toward other lenses. We can always go back to your current lenses if you’re not happy with the new lenses.” I find this helps patients take the plunge and try a new lens modality.

Ordering Hybrid Multifocal Lenses

Figure 2. Hybrid lens on eye

Ordering hybrid multifocal lenses is easy. They are empirically ordered, so there’s no need for a diagnostic fitting set. Information required includes: manifest refraction, keratometry values, add power, and dominant eye. The lens will then be calculated, fabricated, and sent to your office.

Hybrid Lens Dispensing

Apply the lenses and allow them to settle about 10 to 15 minutes before assessing vision. Be sure to tell patients their vision won’t be ideal as the multifocal is trying to accomplish many different ranges of vision. “Don’t worry if your vision is a little off when I apply the lenses. These lenses are new to you, but the more you wear the lenses, the better your vision will get. Your eyes will slowly get used to the lenses, and each day, you will notice your vision improves at each distance.” After allowing the lenses to settle, check the distance and near vision. I like to use vision charts to obtain a baseline of what the patient is seeing right off the bat. If the vision is acceptable, then proceed to insertion, removal, and lens care training.

Hybrid lenses can be inserted just like a soft contact lens. Patients can place the lens directly on the center of the cornea if they wish. Alternatively, they can put a drop or two of saline or multipurpose solution in the center of the GP portion, tuck their chin to their check and place the lens to their eye. In the second scenario, the small amount of fluid behind the lens can provide extra comfort and cushioning. Each patient will prefer a different insertion method.

Hybrid lens removal can be more challenging than traditional soft lenses or traditional GP lenses. There are some great videos online that I like to show patients before attempting removal. It is important that their fingers are dry and that the thumb and forefinger are close together (not spaced far apart) to gently pinch the lens. Using the thumb and forefinger, gently pinch the soft portion of the lens at 6:00 and push up slightly to remove the lens. The technique for removing hybrid lenses can take time to perfect, so warn patients before they begin so they don’t become anxious. If a patient has an extremely difficult time, the use of silicone-tipped plastic tweezers can assist with removal.

Hybrid lenses can utilize soft multipurpose solutions and hydrogen peroxide systems. Lens care is quite easy and will be familiar to existing contact lens wearers.

Hybrid Lens Follow-up Care

Allow patients wearing hybrid lenses at least 2 to 3 weeks to adapt to their lenses before seeing them again. Patients wearing any type of multifocal will need more time to neuro-adapt, so seeing them too soon after the lenses are dispensed is usually counter-productive. During the follow-up visit, ask questions about quality of vision and how often they’re reaching for their reading glasses. Often, patients will achieve 20/30 vision all around and are extremely happy with their vision. In these cases, leave the contact lens prescription alone and keep the patient happy.

Troubleshooting

Decreased wear time: Hybrids should exhibit movement similar to a soft lens. Upon blink, the lens should move about 0.5 mm to 1 mm. If the lens doesn’t exhibit any movement, flatten the skirt. If the skirt is already flat, then flatten the base curve of the GP lens.

Lens dryness: If patients complain that their lenses dry out quickly after insertion, try changing their solution. If they’re using a multipurpose solution, try switching them to a hydrogen peroxide system or vice versa. Another option is adding a surface coating, which will coat the surface of the entire front and back of the hybrid lens, making it more lubricous. Surface coatings also can greatly improve wettability problems and reduce lens deposits. Surface coatings are inexpensive to add to hybrid lenses, and should be considered in many patients.

Real life patient example: Let’s say a 50-year-old presbyope comes into your office wearing progressive addition lenses, and desires more freedom from spectacles. Upon asking more questions, you find the patient thinks he’s not a good candidate for contact lenses due to astigmatism. Hybrid lenses are a great option for astigmatic presbyopes because the gas permeable center of the lens can mask corneal astigmatism. The soft skirt of the lens can provide patients with good comfort, too. Hybrid lenses can be empirically ordered with keratometry values, refraction, add power, and eye dominance. This can greatly reduce chair time, especially if the first set of lenses ends up being the pair that is finalized. Also, the warranty on hybrid lenses is excellent in the case of any exchanges or returns.

Summary

Hybrid contact lenses offer an exciting new technology to patients who have higher vision demands and are willing to try a different, unique modality. Since the lenses are very customizable, patients are likely to achieve better vision than they would with traditional, standard contact lenses. Hybrid multifocals are a great tool to have in your toolbox when fitting multifocal patients with contact lenses.