By Jeffrey Sonsino, O.D., F.A.A.O.

Many articles have been written about proper patient selection being critical for success with multifocal lenses. We're told to choose patients who have realistic (i.e., low) expectations, non-critical vision needs, and a history of diminishing success with monovision. While this may be the prevailing way to think about patient care, it's not the way I think about it.

One of my goals as an eye care professional is to always offer the newest and best options for my patients. We try new contact lens strategies, and if they do not deliver better results, we return to the original modality or some variant of it. We may have lost a visit, but in the patient's eyes, I just went out of my way to try to give them something more. In the end, I allow them to make decisions about their care and don't try to guess at what will and will not work. The truth is, a lens strategy will work if the patient has some understanding of the technology and believes that it is the best option for them.

With that being said, which patients do I select for multifocals? Anyone presbyopic! Here's the qualifier: To be successful, you must explain the technology in simple terms and set expectations in black and white.

I call this "The Talk" and it includes several key elements:

1. Questions on the current lens strategy: While the answers to these questions may be difficult to hear, this information is critical to getting the conversation started.

• Are you seeing everything you want to see clearly?
• Is your vision comfortable for reading?
• Can you sustain near vision for as long as you'd like or do your eyes tire?
• Do your lenses dry out toward the end of the day?

2. A description of the technology: Keep it simple but give the patient enough information to understand what you're offering to them. For example, when I fit Duette Progressive, I start by telling the patient that looking through this lens is similar to looking through a screen door. When you look through a screen door, both the screen itself and the object beyond the screen are always there. Your brain makes a conscious decision to view one image or the other. Likewise, in the first few days of wearing the Duette Progressive lens, you will notice both of these images. Give your brain some time to adapt, and you will be able to tune out the unwanted image.

3. Well-defined expectations:

• There are no contact lenses which can give you the vision of bifocal or progressive glasses. If that's the kind of vision you need, then we'll keep you in glasses.
• Multifocal contact lenses will not provide the same quality of vision as your natural focusing did 5 years ago.
• You will need over the counter readers for some tasks. My job is to minimize the time that you need the readers.
• We will work together to maximize the distance and near vision. The first set of lenses I order may not be the final lenses. We may need to squeeze better vision, optics, and fit with the first trial.

Once "The Talk" has been delivered, the rest is up to the fitter. New technology will certainly seem to be unknown, scary, and more time consuming in the beginning. But after fitting a few patients, the fear factor subsides and you will have much more success than you may have anticipated.