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C. Initial Lens Visual Evaluation

While lenses are settling, it is helpful to take the patient from the exam

room to a “real-world” setting such as a room with an outside view.

Once an acceptable t has been achieved, the visual performance of

the lenses may be evaluated. Visual acuity is tested at distance. If

necessary, a spherical over-refraction should be performed using a trial

frame or hand-held lenses rather than a phoropter. This technique is

essential when tting multifocal lenses because it allows the patient to

maintain the head posture and direction of gaze (relationship between

eye and head) that he or she would naturally use during everyday tasks.

This ensures that the visual performance of the lens is being assessed

under conditions where the on-eye positioning matches that which will

occur when the lens is being used, for example, for near work activities.

In addition, pupil size will not be articially decreased by the reduction

in light associated with looking through the apertures of the phoropter,

or by proximal cues associated with the nearness of the instrument.

D. Fitting Procedure

Step 1:Afterthetriallenseshavesettledfor5to10minutes,measure

distanceacuitywhilethepatientisviewingthechartbinocularly

(i.e.,simultaneouslywithbotheyes).Usinghand-heldtrial

lenses,add+0.25Dsimultaneouslytoeacheyeoralternatively

oneatatimetoachievebestdistancevision.Notewhetheror

notthisreducesthemeasuredbinoculardistanceacuity.Ifit

doesnot,thentherewillbesomeextratoleranceforincreasing

theamountofplusforoneorbotheyesintheeventthatnear

visionislessthanoptimal.

Step 2:Evaluatethepatient’ssubjectiveimpressionofthenear

visionwhentryingtoreadtypicaleverydaymaterial(e.g.,a

newspaper,magazine,numbersonawatch).Lightingand

readingdistanceshouldbewhatisnormalforthepatient.

Step 3:Allowingthepatienttoassumeanaturalreadingposition,

measurebinocularactivityat40cm(16in.)undergoodlighting

conditions.

Step 4:Theresultsofsteps2and3willdeterminewhetherthepatient

requiresanincrementinpluspowerfornearworkactivities.If

thesubjectivequalityofnearvisionislessthanoptimal,then

usehand-heldtriallensestodeterminewhetheradditionalplus

powerwillimproveperformanceatnear.Binocularviewing

mustbemaintainedthroughoutthisassessment.

     Improvedvisionatnearmaybeachievedbyaddingplustoone

orbotheyes.IfthetestingperformedinStep1indicatedsome

toleranceforplus,determinewhethertheadditionalpluspower

foreacheyewillproducethenecessaryimprovementinnear

vision.

If the patient cannot tolerate an additional plus power for each

eyewhenviewingatdistanceorifthisdoesnotproducethe

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