Toric in one eye, multifocal in the other?

Discussion in 'Eye-Care' started by MS, Nov 10, 2007.

  1. MS

    MS Guest

    Does anyone ever prescribe that combination? Does it make any sense?
    Or--does it only make sense to use multifocal lenses if in both eyes?

    I'll explain why I'm asking this, and hope that the helpful eye
    professionals here will give their opinion.

    I have always been very nearsighted. I wore RGP lenses for many years. In
    the last few years though, I've come to like the comfort and convenience of
    silicon hydrogel soft lenses, wearing them overnight. Even if the vision is
    not quite as clear, to me the comfort and convenience is a good trade-off. I
    have been wearing Focus Night&Day for about five years now, monovision.
    (Currently 55, becoming increasingly presbyopic.)

    My prescription has remained stable for those years-Right -5.25 (distance),
    Left -4.5 (near). (BC 8.4 both eyes) I can get by with that Rx, passed the
    driving test last time, drive in them, etc., but I have noticed that my
    distance vision leaves a lot to be desired, although I can get by. (And I
    realize that presbyopic solutions such as monovision and multifocals always
    involves compromise, lessening of distance vision in order to have near
    vision without reading glasses.) (My left eye is actually more nearsighted
    than my right--so that 4.5 rx left is undercorrected a lot for near vision.)

    At my recent eye exam the O.D. recommended a toric lens for my right eye.
    (I'm actually surprised that that hadn't been recommended to me earlier,
    since I had started with soft lenses, since I do have some astigmatism.) He
    said there wasn't enough astigmatism in my left eye to warrant a toric lens,
    but there was in my right eye. He gave me an Acuvue Advance Toric to try out
    in the right eye, also -5.25, with a cylinder of .75, bc 8.6. I kept the
    N&D -4.5 in my left eye.

    I immediately noticed a significant improvement in my distance version, and
    did wonder why the toric lens hadn't been suggested to me in other years.

    After reading here that the Advance is not rated for overnight wear, and has
    a lower dK than the Purevision Toric (see recent thread about silicon
    hydrogel torics), I asked my doc to try a Purevision Toric. As I was also
    curious about the new Biofinity lens, having read about it here, I requested
    a Biofinity lens to try for my left eye. I picked up these lenses yesterday,
    and first put them on today. The Purevision Toric is the same RX as the
    Acuvue, with the bc being 8.7, and the biofinity is the same RX as the N&D
    (-4.5), with a bc of 8.6.

    Comments on these--comfort--both lenses are comfortable, but so far I
    haven't noticed a difference from the lenses I was wearing before. (I
    haven't yet slept in them though.) Vision--I notice still clearer distance
    vision with the Purevision than with the Advance. Yet, I notice a decrease
    in near vision. Even the letters on the computer screen are not as clear as
    usual. I don't know if that difference could be attributed to the PV Toric
    in my right eye, or the Biofinity rather than N&D in my left.

    The myopia correction in the right eye is the same as before (-5.25). Does
    the addition of the toric astigmatism correction negatively affect near
    vision? Is there any reason why a Biofinity lens in the left (close vision)
    eye could create worse near vision than a N&D lens with the same
    prescription?

    So--although I like the improvement in distance vision, I don't like the
    decrease in near vision. I realize that presbyopic prescribing is a
    compromise, and it's impossible to get perfect vision far and near with the
    same lenses. But--of course I'd like to get it as good as possible. I'm
    wondering whether to suggest any other lens combinations to the OD, for me
    to try out?

    One possibility occurred to me--which I don't know if it is a good idea--but
    I'll ask about it here first. That is, to keep the Purevision toric in the
    right eye, and try a Purevision multifocal in the left eye. Does that make
    any sense--to have a toric single-vision lens in the dominant eye for
    distance, and a multifocal lens in the weaker eye? Is there any advantage to
    having the same brand in both eyes, even if one is toric and the other
    multifocal? (I think it could be advantageous economically, as there are
    often rebates for buying multiple boxes of the same brand.)

    I should mention that I tried the Purevision Multifocal in both eyes last
    year, and decided not to stick with them, and I kept with the N&D
    monovision. Theoretically I like the idea of multifocals much better than
    the idea of monovision. The vision wasn't bad with them, but I didn't see
    much benefit over the monovision n&ds I was used to, thought they (pv)were
    slightly less comfortable, so stuck with N&D. The first trial pair of the
    multifocals that the doc gave me, although high add, gave improved distance
    vision, but much worse near vision. So, he kept trying a lower distance
    power in the left eye (modified monovision), to improve the near vision.
    When it went down to -4.75 left, almost as low a distance power in that eye
    as I have with straight monovision, and my near vision was still not as
    good, I decided to stick with N&Ds.

    This year though, in switching to the Purevision Toric in my right eye, I'm
    wondering whether it might be good idea to try the PV multifocal in my left,
    and see how the two work together. (Again, the left would still need to be
    undercorrected for distance, as the "add" created by the multifocal aspect
    is apparently not enough to give me usable near vision. But I'm wondering if
    it still might be worth trying a multifocal in that eye.)

    Before I ask my OD about this, I am curious to hear the opinions of the
    helpful eye docs who write here. Is that a feasible idea--a toric in the
    dominant, but more astigmatic eye, and a multifocal in the weaker, more
    nearsighted eye, for a myopic presbyopic astigmatic patient, 55 years old?
    :)
     
    MS, Nov 10, 2007
    #1
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  2. MS

    p.clarkii Guest

    0.75D of astigmatism is marginal. Personally, I do like to use it in
    patients who are fit for monovision because every little bit of acuity
    I can squeak out of their distance eye is worth it (to me) since that
    eye is working all by itself in the distance. So docs would simply
    ignor it, which would leave you "slightly" blurry by comparison. Some
    patients would notice it and like it, some patients wouldn't.
    I don't know either. Your doc could probably figure it out. Your PV
    Toric lens might be slightly rotated while the AV Adv. Atig. wasn't so
    that might explain it. It takes an office visit to know for sure.
    Quite possibly. Uncorrected astigmatism can help a little bit seeing
    near things. Correcting it would improve distance but hurt near.
    Unfortunately I have no experience fitting Biofinity yet. It has only
    been released on a very limited basis in the US so far.
    You understand the most important point-- you can't get perfect, only
    "good enough".

    Yes, you should try a lower lens power in your near eye to improve
    near VA, or as you suggest, try a multifocal lens in your near eye to
    boost your near power.
    Sure it does. Its quite logical. There is no "rule" that says both
    eyes must have the same brand.
    The only advantage would be the economic one you indicate. Otherwise,
    just wear what works the best.
    I too find the HIGH add powers in the B&L lenses (Purevision and
    Soflens Multifocals) to be distorting and not very useful but some of
    my patients like them. Everyone is different.
    It will just give you a little extra "boost" at near. Otherwise,
    there is no reason to wear the same brand in each eye (except for the
    rebate issue you mentioned earlier).
     
    p.clarkii, Nov 10, 2007
    #2
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  3. MS

    MS Guest

    Thanks for all the info, P. Clark. I'd be interested in hearing other's
    input as well. I have one question regarding your statement below, and a
    couple other questions:


    The Advance was inserted while I was in the doctor's office, and he looked
    at it in my eye, and said it sat very well. I picked up the PV in his office
    and put it on at home the next day. So true, the doctor hasn't yet seen how
    the PV toric sits on that eye, and I'm sure he will want to see it before
    prescribing that lens. (Do different brands of torics sit on the eye
    differently?) As I said though, the distance vision is very good with the PV
    lens so far, I think even better than with the Advance lens. And it is
    comfortable. If the lens wasn't sitting correctly on the eye, would I have
    good distance vision, and a comfortable fit?

    Is the Biofinity spheric? Could that explain the difference in near vision,
    switching from an aspheric N&D on the near vision eye, to a spheric lens? (I
    may try switching the left eye back to N&D, while keeping the PV toric in
    the right, and see if that improves near vision.) (I don't think I will keep
    Biofinity in the left in any case. It is advertised as being much more
    comfortable, but so far (including overnight now) I don't notice any comfort
    improvement over the other si-hy lenses I have worn. And as you write, it is
    not very available now. Online distributors don't even carry them. They are
    probably extremely expensive, even compared to N&D. It took almost two weeks
    for the trial lens to come to the O.D.'s office, which usually takes one
    day. Strangely enough, on the case the trial lens came in, the word
    "Biofinity" doesn't appear on the label at all. It says SiH 48 (comfilcon
    A).)

    I don't know about reducing the power on the left eye to even less
    than -4.5. At that power, there is already a great difference between the
    eyes. (Why I like the idea of multifocals better. If only they worked as
    advertised!) The left eye's distance vision is already very weak at that
    power. Perhaps just a change to -4.5 multifocal on that eye, instead of
    single vision, would make enough difference in improving near vision,
    without significantly impairing distance vision. Or--do you think it also
    might be worthwhile to try scaling back the right eye to -5 toric, instead
    of -5.25?

    Of course I will have to discuss these options with my eye doc. Just curious
    to hear other's opinions here. (I can see that prescribing for presbyopic
    patients is a complicated art.) (Wouldn't it be nice if some day they
    invented multifocal lenses that really gave all presbyopic patients good
    near, far, and intermediate vision, with no need for monovision? I wonder if
    that will come to pass, in my lifetime?)
     
    MS, Nov 10, 2007
    #3
  4. MS

    MS Guest

    I already switched the left lens back to the N&D, from the Biofinity. Both
    the same RX, -4.5. It's amazing what a difference that makes. The distance
    vision in the left eye is noticeably worse with the N&D, while the near
    vision is better. A significant difference, really.

    Could that difference just be caused by aspheric/spheric? Or, does -4.5 mean
    something different to Ciba than to Coopervision? Do they sometimes put the
    wrong strength in the container? This N&D lens seems definitely weaker (in
    minus strength) than the Biofinity lens with the same number (good for near
    vision, bad for distance).

    I'd still like to improve the near vision a bit more though, depending on
    how much that compromises distance vision. I might see about changing the
    right eye to -5.00 toric, instead of -5.25, and/or changing the left lens to
    a PV multifocal.

    Still curious to hear more opinions on these options......
     
    MS, Nov 10, 2007
    #4
  5. MS

    Dr Judy Guest

    Bioinfinity is aspheric as well. The long wait to get the trial lens
    is likely because the lens has just been launched with limited
    distribution. I'm getting my trial set next week, for 350 offices my
    rep is only getting 20 fitting sets. No two lenses will fit the
    same. Also the aspheric design will be different in the two lenses
    and may be allowing better near with the N&D. B&L has the
    "Occasions" multifocal a number of years ago which wasn't really a
    multifocal at all. It was an aspheric with the aspheric design such
    that the edge of the lens had a touch more plus power.

    Using a distance lens in one eye and a multifocal in the other is not
    a new idea. Works for some, not for others. I have found that some
    monovision patients do not like the loss of contrast inherent to any
    soft multifocal. If you didn't like your near vision with PVMF last
    year, I wouldn't expect you to like it this year.

    Dr Judy
     
    Dr Judy, Nov 11, 2007
    #5
  6. MS

    MS Guest

    Thanks for the info, Dr. Judy! :)

    What about the idea of trying a slightly lesser power in the distance eye
    (-5.00 instead of -5.25, yet still toric), to see if that makes a little
    improvement in near vision? Is that sometimes done? (That would mean less
    disparity between the two eyes.)
     
    MS, Nov 11, 2007
    #6
  7. MS

    Dr Judy Guest

    You really need to work this out with your doctor. Anything can be
    done and over the years I have provided patients with most of the
    options you have discussed. Whether it works for you depends on you,
    just because someone else tolerated it doesn't mean you will.

    The best distance and near vision is delivered with distance contacts
    on both eyes (toric if needed) and reading glasses over. If you want
    to eliminate the readers, then a compromise must be made -- distance
    clarity, near clarity, a litte of both, loss of contrast, reduced
    depth perception. It all depends on which compromise you, personally,
    with your lifestyle and visual demands, can tolerate.

    Dr Judy
     
    Dr Judy, Nov 11, 2007
    #7
  8. MS

    MS Guest

    Just spoke to the O.D. on the phone. I told him I would like to try the
    Purevision Multifocal in the left, to see if that improves my near vision,
    without sacrificing too much from distance.

    He didn't like the idea at all, said my distance vision would be too much
    worse with a multifocal lens in the left eye.

    I brought up my other idea, of scaling back the -5.25 prescription in the
    right (distance) eye to -5.0, to improve my near vision. He thought that was
    feasible, that it would make the distance vision slightly less clear, and
    improve near vision slightly, that it might be a good compromise.

    I asked to get a trial lens of the Purevision toric in -5.0. He didn't want
    to order a trial for me, said he was sure it would work, just wanted to
    order me a box of them. I said I would prefer to try it first, he wouldn't
    order a trial lens first for me. So, I said I would think about it and call
    him back.

    One thing for sure--next year, I think I'll go to a different eye doctor.
    (This is the same doc who told me that Advance had a much higher dK than
    Purevision, which is backwards.)
     
    MS, Nov 12, 2007
    #8
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