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C L I N I C A L A N D E X P E R I M E N T A L

OPTOMETRY
cxo_530 76..81

RESEARCH PAPER

Stereoacuity with balanced presbyopic contact lenses

Clin Exp Optom 2011; 94: 1: 76–81 DOI:10.1111/j.1444-0938.2010.00530.x

Teresa Ferrer-Blasco* OD PhD Background: To evaluate near stereoacuity with the balanced Proclear Multifocal simul-
David Madrid-Costa† OD PhD FAAO taneous vision contact lens.
* Optometry Research Group (GIO), Methods: Twenty-five presbyopic subjects were fitted binocularly with the Proclear Mul-
Optics Department, University of tifocal contact lens and with distance contact lenses combined with reading spectacles,
Valencia, Spain which served as controls. After one month, stereoacuity was measured using the vecto-

European University of Madrid, Spain graphic Titmus and Random dot stereotests and the Howard-Dolman (HD) apparatus
E-mail: teresa.ferrer@uv.es under photopic conditions (85 cd/m2) at 40 cm. Binocular high-contrast visual acuities
(BHCVA) at distance and near were examined.
Results: For the multifocal group, mean stereoacuity with the Howard-Dolman method
was 22.40 ⫾ 8.23 seconds of arc. Using the Titmus and the Random dot sterereotests, the
values were 56.40 ⫾ 18.00 and 54.80 ⫾ 20.23 seconds of arc, respectively. For the SCL
group, mean stereoacuities were 19.9 ⫾ 4.6, 51.2 ⫾ 16.4 and 51.2 ⫾ 20.88 seconds of arc,
with the Howard-Dolman, Titmus and the Random dot, respectively. There were no
statistically significant differences among groups for Howard-Dolman (p = 0.07), Titmus
(p = 0.10) and Random dot (p = 0.17) stereotests. No statistically significant differences
were found between the Titmus and the Random dot stereotest values (multifocal group:
p = 0.30 and SCL group: p = 0.50), however, these values differ significantly from those
found using the Howard-Dolman method for both groups (p < 0.001). For the multifocal
group, BHCVA was -0.007 ⫾ 0.060 and 0.012 ⫾ 0.063 logMAR for distance and near
vision, respectively. For the SCL group, these values were -0.02 ⫾ 0.05 and -0.01 ⫾ 0.06
logMAR, for distance and near vision, respectively. Comparing both groups there were
no statistically significant differences between groups for either distance (p = 0.08) or
near (p = 0.09).
Submitted: 14 February 2010 Conclusions: The Proclear Multifocal contact lens provided good distance and near
Revised: 3 June 2010 visual acuity preserving stereopsis. Multifocal optics with one lens biased to distance
Accepted for publication: 29 June 2010 viewing and the other lens biased toward near viewing minimally affects stereoacuity.

Key words: multifocal contact lens, presbyopia, simultaneous vision, stereoacuity, vision evaluation

Presbyopic correction with contact lenses contact lenses are based on one of three one eye for near vision. In alternating
is one of the most important areas of principles: monovision, alternating vision vision, the line of sight alternates between
contact lens practice. Current techniques or simultaneous vision. In monovision, two optical zones, one for distance and
for the correction of presbyopia with one eye is corrected for distant vision and one for near, and in simultaneous vision,

Clinical and Experimental Optometry 94.1 January 2011 © 2010 The Authors
76 Clinical and Experimental Optometry © 2010 Optometrists Association Australia
Stereoacuity with balanced presbyopic contact lenses Ferrer-Blasco and Madrid-Costa

the contact lens has multiple powers posi- (addition and zones), and the different for initial lens selection.24 This design
tioned within the pupil at the same time. vectographic stereotests used (fixed dis- combines spherical and aspheric optics
Although previous reports have shown parity steps) may play a role in the out- and unique zone sizes to produce a ‘D’
that the success rate for monovision is comes reported. The use of tests where lens for the dominant eye (centre-distance
between 70 and 76 per cent,1,2 it has been disparity is constructed vectographically design), which emphasises distance vision
reported to decrease in stereopsis.2–4 The may not be sensitive enough to detect and an ‘N’ lens for the non-dominant eye
amount of decrease becomes more signifi- subtle changes in stereoacuity produced (centre-near design), which optimises
cant with increased addition power in the by defocused images in eyes with multi- near vision. The balanced presbyopic
non-dominant eye. In a crossover study of focal contact lenses. The Howard-Dolman lens combines multifocal optics with one
38 presbyopic patients, Richdale, Mitchell method is more accurate than vecto- lens biased to distance viewing and the
and Zadnik4 showed that 76 per cent of graphic discrete tests to determine other lens biased toward near viewing
the patients preferred multifocal soft stereoacuity as it allows continuous (Figure 1). The ‘D’ lens has a spherical
contact lenses to monovision. Recently, measurement of stereoacuity.22,23 central zone 2.3 mm in diameter dedi-
Gupta, Naroo and Wolffsohn5 have con- To date, no study has been conducted cated to distance vision, surrounded by an
cluded that a centre-near aspheric simul- to evaluate threshold stereoacuity at near annular aspheric zone of 5.0 mm and a
taneous vision multifocal contact lens in patients wearing simultaneous vision spherical annular zone of 8.5 mm both
provides better stereoacuity than monovi- contact lenses for presbyopia. The objec- increasing in addition power. In contrast,
sion. New simultaneous vision lenses have tive of this study was to assess the stereoa- the ‘N’ lens has a spherical central zone of
been developed that are intended to cuity outcomes of patients fitted bilaterally 1.7 mm dedicated to near vision followed
address many of the limitations that have with the Proclear Multifocal simultaneous by an aspheric annular zone of 5.0 mm
been identified in earlier generations of vision contact lenses and to compare the and a spherical annular zone of 8.5 mm
this type of contact lenses. results to those with distance contact both reducing addition power. Each ‘D’
Stereoscopic acuity or stereoacuity is the lenses combined with reading spectacles and ‘N’ design is available from +4.00 to
ability to discriminate very fine differences using the Howard-Dolman method, the -6.00 in 0.25 D steps and in four different
of depth from geometric disparity. It is Titmus and the Random dot stereotests. addition powers (+1.00, +1.50, +2.00,
quantified by the minimum geometric dis- +2.50). Patients wore the contact lenses
parity that elicits a sensation of depth. during one month. The lens is manufac-
METHODS
There are several factors that affect stere- tured from Omafilcon A that has a water
opsis including reduced contrast, refrac- content of 62 per cent. The lens has a total
tive error, heterophoria, aniseikonia and Patients and lenses diameter of 14.4 mm and a base curve of
age.6–14 Simultaneous vision contact lenses A study was conducted of 25 presbyopic 8.70 mm.
enable projection onto the retinal plane patients, 18 females and seven males, with The patients were also fitted with spheri-
of images set at distance and near. When no prior experience with presbyopic cal single vision distance soft contact
the eye is viewing a distant object, there is contact lenses. Inclusion criteria were age lenses combined with reading spectacles.
a focused image of the distant object and between 50 and 60 years, spherical equiva- These contact lenses maximised distance
an out-focus image of the same distant lent error between +3.00 and -3.00 D and visual acuity and the near spectacle pre-
object formed on the retina and when the the desire to no longer wear any form of scription was selected to provide best
eye is viewing a near object, there is a spectacle correction for distance and acuity at 40 cm.
focused image of the near object and near vision. Exclusion criteria included
an out-focus image of the same object ocular disease, history of ocular surgery or
formed on retina. In both situations, the inflammation, astigmatism greater than Procedures
unwanted effect of the light on the out-of- 0.75 D and the presence of any binocular Each patient was given a comprehensive
focus image of multifocal systems is to vision abnormalities (for example, am- eye examination, including medical and
reduce the contrast of the in-focus blyopia and/or strabismus). The study ocular history, visual acuity, stereoacuity,
image.15,16 Clear bifoveal images are followed the tenets of the Declaration of binocular testing, refraction and slitlamp
needed for high-resolution stereopsis and Helsinki and was approved by the Institu- biomicroscopy. Binocular distance visual
reduction in retinal image contrast pro- tional Review Board. Informed consent acuity was determined using the ETDRS
vided by simultaneous vision contact was obtained from all patients after the high-contrast logMAR chart with the Func-
lenses may result in worsening of stereop- nature and possible consequences of the tional Vision System (Stereo Optical
sis. Previous studies analysing stereopsis study had been explained. Company) and near visual acuity was mea-
with multifocal contact lenses have shown Patients were fitted with the Cooper- sured by means of the Precision Vision
a high variability among results.3–5,17–21 The Vision (Fairport, NY) Proclear Multifocal Logarithmic Visual Acuity Chart 2000
use of different optical principles (refrac- contact lens. We followed the fitting New ETDRS at 40 cm. Stereoacuity was
tion or diffraction), the design of the lens nomogram suggested by the manufacturer measured using three methods: the

© 2010 The Authors Clinical and Experimental Optometry 94.1 January 2011
Clinical and Experimental Optometry © 2010 Optometrists Association Australia 77
Stereoacuity with balanced presbyopic contact lenses Ferrer-Blasco and Madrid-Costa

Howard-Dolman, the Titmus and the tronic caliper to get the distance in common tests for stereopsis measurement
Random dot tests. microns between the left and the right and are valued clinically because they are
The Howard-Dolman apparatus, consid- rods. We did five sets of 10 measurements compact, easy to store and carry, and
ered the gold standard to measure stere- for each patient. Stereoacuity (SA) is quick to administer and score. These tests
oacuity, is a box with two vertical black defined as: provide a measure of local stereoacuity
rods (Figure 2A). The patient uses the psy- over a broad range of horizontal dispari-
SA = ( Δd d2 ) × IPD
chophysical method of adjustment to ties via the vectographic technique using
make the two rods parallel to one another. where d is the distance from the left rod to Wirt rings in an easily portable form. All
The patient sits so that the opening in the eye, Dd is the distance between the left rings involve monocularly visible contours
the box is at eye level. Usually, the patient and the right rods and IPD is the interpu- and the patient is required to wear pola-
uses a pair of strings that are on a pulley pillary distance (Figure 2B). In our experi- rising filters. The Wirt circle targets allow a
arrangement to make the adjustment. ment, the fixed rod was located at 40 cm near threshold measurement of stereoacu-
One rod is moved by pulling on the string. from the eye and interpupillary distance ity, with each set providing a different level
In our case, we modified the apparatus was measured for each patient. of disparity. The tests were performed at
including a small wheel to move slowly The Titmus and Random dot tests 40 cm through polarising spectacles. The
and accurately the right rod and an elec- (Figures 2C and 2D) are the most test plates were held at a 45 degree angle
to the facial plane. The patient was asked
to say which of the rings ‘popped out’ or
stood in front of the other. This was
a four (Titmus)/three (Random dot)-
alternative, forced-choice test and there-
fore, it is best to continue to the ninth
(Titmus)/10th (Random dot) group of
rings, forcing the patient to guess, if nec-
essary, after 15 seconds of inspection of a
single group. The criterion for scoring was
the last group correct before two consecu-
tive misses. The Titmus test has disparities
ranging from 800 to 40 seconds of arc and
the Random dot from 400 to 20 seconds
of arc.
Both the order of testing and the
contact lens conditions were randomised
Figure 1. Optical design of the Proclear Mutifocal contact lens for the dominant eye ‘D between patients after contact lens
lens’ with centre-distance power and for the non-dominant eye ‘N lens’ with centre-near wearing of one month in each condition
power (multifocal and SCL) at two measurement

Figure 2. Howard-Dolman apparatus (A), schematic drawing for computation (B. IPD = interpupillary distance, d = distance from the
left rod to the eye, Dd = distance between the left and the right rods), Titmus test (C) and Random dot test (D)

Clinical and Experimental Optometry 94.1 January 2011 © 2010 The Authors
78 Clinical and Experimental Optometry © 2010 Optometrists Association Australia
Stereoacuity with balanced presbyopic contact lenses Ferrer-Blasco and Madrid-Costa

clear Multifocal lens provides good


Multifocal SCL p value outcomes for distance and near vision
HCDVA (logMAR) -0.007 ⫾ 0.006 -0.02 ⫾ 0.05 0.08 (approximately 6/6). Unfortunately,
(0.1 to -0.1) (0.1 to -0.1) there were no previous studies published
HCNVA (logMAR) 0.012 ⫾ 0.063 -0.01 ⫾ 0.06 0.09 about the visual performance of this lens
(0.1 to -0.1) (0.1 to -0.1) on presbyopic patients to compare with
Stereoacuity H-D (sec arc) 22.4 ⫾ 8.23 19.9 ⫾ 4.6 0.07 our results. Despite this, we can compare
(16 to 50) (15 to 38) with other simultaneous vision multifocal
Stereoacuity Titmus (sec arc) 56.4 ⫾ 18 51.2 ⫾ 16.4 0.10 lenses (with other surface designs). Previ-
(15 to 38) (40 to 100) ous studies on the Focus Progressive17,25
Stereoacuity Random dot (sec arc) 54.8 ⫾ 20.23 51.2 ⫾ 20.88 0.17 contact lens agree with our results
(20 to 100) (20 to 100) (approximately 0.0 and 0.05 logMAR for
distance and near vision, respectively).
HCDVA: binocular mean high contrast distance visual acuity; HCNVA: binocular mean high contrast
near visual acuity; H-D: Howard-Dolman Worse results were found by Gupta, Naroo
and Wolffsohn5 with the high addition
PureVision contact lens (0.08 ⫾ 0.10 and
Table 1. Outcomes of visual acuity for distance and near and stereoacuity for the 0.27 ⫾ 0.09 logMAR for distance and near
patients examined wearing both multifocal contact lenses and spherical single vision vision, respectively). In relation to the
distance contact lenses with reading spectacle (SCL) control group, there were no differences
both for distance (p = 0.08) and near (p =
0.09) visual acuity.
Stereoacuity may be measured using dif-
ferent tests. Titmus and Random dot ste-
sessions. Thirteen patients wore the mul- error was +0.15 ⫾ 1.93 D (range +3 to -3D)
reotests provide fixed disparities and so
tifocal contact lenses during one month and the mean near spectacle addition was
accuracy of the outcomes depends on the
and after this period were examined. +2.11 ⫾ 0.34 D (range 1.5 to 2.5 D). Mean
number of steps and its disparity level. In
Then, they were fitted with the SCL astigmatism was 0.26 ⫾ 0.31 D (range zero
contrast, the Howard-Dolman method
and the procedure was repeated. Twelve to 0.5 D). Interpupillary distance was also
gives a continuous measure of stereoacuity
patients wore SCL for one month and measured showing a mean value of 61.16
with high accuracy. We should consider
after the examinations were completed, ⫾ 1.99 mm ranging from 58 to 64 mm.
that the Titmus and Random dot ste-
they were fitted with multifocal contact Table 1 shows the visual acuity out-
reotests do not establish a stereoscopic
lenses and the procedure was repeated. comes for distance and near vision for the
threshold. For most patients, both are
All examinations were performed under multifocal and SCL groups. Comparing
suprathreshold tests and therefore are
photopic conditions at 85 lux and by both groups there were no statistically sig-
much easier for the patient on that point
the same experienced contact lens nificant differences for distance and near
alone than the Howard-Dolman. This last
practitioner. vision (p < 0.05). This table also shows the
one is time-consuming and requires math-
mean values of stereoacuity obtained in
ematical computation. Disparity values of
Data analysis both groups using the different tests.
the Titmus and Random dot stereotests
Data analysis was performed using SPSS for There were no statistically significant
are computed for fixed distance of obser-
Windows version 12.0 (SPSS Inc, Chicago, differences among groups for Howard-
vation (40 cm) and interpupillary distance
IL). Normality was checked by the Shapiro- Dolman, Titmus and Random dot
of the patient (6.0 cm). Elkington and
Wilk test and a paired-sample t-test and stereotests (p > 0.05). No statistically sig-
Frank26 reported that 40 to 50 seconds of
ANOVA test were performed to compare nificant differences were found between
arc is considered normal stereoacuity mea-
outcomes between tests and groups. Differ- the Titmus and the Random dot stereotest
sured at 40 cm. The results found in our
ences were considered to be statistically values (multifocal group: p = 0.30 and SCL
study both wearing multifocal or SCL were
significant when the p value was less than group: p = 0.50), however, these values
similar to the mean reported by these
0.01 (that is, at the one per cent level). differ significantly from that found using
authors (Table 1). Both tests, Titmus and
the Howard-Dolman method for both
Random, provide a measure of stereoacu-
groups (p < 0.001).
ity by asking the patient to identify the
RESULTS
correct target that has stereoscopic depth
No subjects withdrew from this study at (target with disparity). The working dis-
DISCUSSION
any point. Mean age of the patients was tance and interpupillary distance will need
55.1 ⫾ 3.1 years (range 50 to 60 years). Our results in terms of binocular high- to be taken into consideration when calcu-
The mean spherical equivalent refractive contrast visual acuity show that the Pro- lating stereoacuity. Both tests are strictly

© 2010 The Authors Clinical and Experimental Optometry 94.1 January 2011
Clinical and Experimental Optometry © 2010 Optometrists Association Australia 79
Stereoacuity with balanced presbyopic contact lenses Ferrer-Blasco and Madrid-Costa

First author Patients Mean age ⫾SD Contact lens Test Stereoacuity Binocular distance Binocular near
(years) (sec arc) visual acuity visual acuity
(logMAR) (logMAR)

Sheedy et al18 40 N/A CIBA Spectrum Random dot About 60 About 0.0 N/A
Back et al 19
15 57 ⫾ 5 Concentric Center-Near Random dot 92 ⫾ 51 -0.03 ⫾ 0.06 -0.09 ⫾ 0.11
CooperVision Echelon 95 ⫾ 63 -0.05 ⫾ 0.08 -0.1 ⫾ 0.13
Kirschen et al3 19 52.5 Acuvue Random dot 50.8 ⫾ 25.4 +0.01 ⫾ 0.05 +0.05 ⫾ 0.08
Fisher et al 17
42 52.3 ⫾ 1.2 Focus Progressive Random dot About 75 -0.01 About +0.05
Acuvue About 95 +0.03 About +0.05
Richdale et al4 38 50.1 ⫾ 4.7 B&L Soflens Random dot 126 ⫾ 137 -0.12 ⫾ 0.09 +0.01 ⫾ 0.12
Freeman et al 20
8 63 ⫾ 4 Diffrax Titmus 100 About -0.02 About 5.5†
Woods et al 21
25 45.4 ⫾ 2.8 Air Optix Aqua Low add Random dot 54 ⫾ 35 -0.03 ⫾ 0.07 -0.01 ⫾ 0.08
Gupta et al5 20 55.0 ⫾ 5.1 PureVision‡ TNO random dot 174.0 ⫾ 95.2 +0.05 ⫾ 0.08 +0.21 ⫾ 0.13
Low add 152.7 ⫾ 101.7 +0.02 ⫾ 0.06 +0.16 ⫾ 0.14
High add 200.0 ⫾ 84.9 +0.08 ⫾ 0.10 +0.27 ⫾ 0.09

SD: standard deviation; N/A: not available; † N Type reading acuity; ‡ mean values for low and high addition

Table 2. Outcomes of several studies evaluating near stereopsis after simultaneous vision multifocal contact lenses

accurate for a working distance of 40 cm aspheric refractive and diffractive multifo- obvious that there is variability among
and 6.0 cm interpupillary distance, cal contact lenses. Table 2 shows the main results (from 50 to 174 seconds of arc).
changes from both values produce differ- outcomes of previous literature evaluating The use of different optical principles
ent outcomes, which may be incorrect. near stereopsis in patients fitted with simul- (refraction or diffraction) and the design
The results measured using the Howard- taneous vision multifocal lenses. The first of the lens (concentric or aspheric and
Dolman apparatus were better, namely, study was done by Sheedy and colleagues18 addition power) and hence the image
about 22 seconds of arc. Using this showing a stereoacuity of about 60 seconds created on the retina makes these differ-
method, we can establish the stereoscopic of arc. Back, Grant and Hine19 fitted 15 ences plausible.
threshold for each patient and the patients with the concentric centre-near Comparing our results with those found
measure is more accurate compared to bifocal lens of CooperVision and the in previous studies using the same ste-
standard clinical stereotests. Values for a Echelon lens and found 92 ⫾ 51 and 95 ⫾ reotest, we may observe similar values
normal population using this method vary 63 seconds of arc, respectively. Krischen, reported with the Acuvue3 and Air Optix
with age and a result of 14 seconds of arc Hung and Nakano3 with the Acuvue lens Aqua21 lenses (about 50 to 55 seconds of
or better is expected for an adult with a found a mean value of 50.8 ⫾ 25.4 seconds arc). At this point, we should consider that
normal binocular system.8,27 Our results in of arc. Worse values were found by Fisher, differences in interpupillary distance of
the multifocal group were slightly worse Baumann and Schwallie17 on 42 patients the patients and the working distance of
than those reported in the literature and with the same lens and the Focus Progres- the test as variable factors to be considered
those found in the SCL group (despite not sives. Richdale, Mitchell and Zadnik4 with when comparing different studies. Other
being statistically significant) the differ- the Bausch & Lomb Soflens also found ways to restore near vision with contact
ences may come from the different retinal worse results with 126 ⫾ 137 seconds of arc lenses such as monovision show worse
imagery created on the retina by the mul- on 38 patients. Freeman and Charman20 values for stereoacuity (using vectographic
tifocal contact lens (near blur of 0.01 using a diffractive lens reported a mean tests) with means of 287.8 ⫾ 184.3 seconds
logMAR visual acuity). value of 100 seconds of arc. of arc,3 205 ⫾ 2144,4 273 ⫾ 102,5 113 ⫾
No previous studies have analysed stere- Recently, Woods, Woods and Fonn21 12519 and 384 seconds of arc.28 Undoubt-
oacuity in patients fitted with the Proclear with the Air Optix Aqua low addition edly, simultaneous vision lenses give
Multifocal contact lens, either using vecto- contact lens found better values (54 ⫾ 35 improved stereoacuity over monovision
graphic or the Howard-Dolman method. seconds of arc) and in contrast, Gupta, correction. The design of the Proclear
The published research studies were done Naroo and Wolffsohn5 found worse values Multifocal lens combining multifocality
using the Titmus and Randot tests with with the Pure vision (174.0 ⫾ 95.2 seconds with monovision does not affect stereoacu-
other models of concentric refractive, of arc). Considering all these studies, it is ity as traditional monovision techniques.

Clinical and Experimental Optometry 94.1 January 2011 © 2010 The Authors
80 Clinical and Experimental Optometry © 2010 Optometrists Association Australia
Stereoacuity with balanced presbyopic contact lenses Ferrer-Blasco and Madrid-Costa

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GRANTS AND FINANCIAL SUPPORT
Refract Surg 2003; 29: 703–711.
We thank CooperVision for providing all 16. Montés-Micó R, España E, Bueno I,
Dr Teresa Ferrer-Blasco
contact lenses for this study. This research Charman WN, Menezo JL. Visual perfor- Optometry Research Group (GIO)
was supported in part by Ministerio de mance with multifocal intraocular lenses: Optics Department, Faculty of Physics
Ciencia e Innovación Research Grants mesopic contrast sensitivity under distance University of Valencia
(#SAF2008-01114# and #SAF2009- and near conditions. Ophthalmology 2004; C/o Dr Moliner
111: 85–96.
13342#). The authors have no proprietary 17. Fisher K, Bauman E, Schwallie J. Evaluation
50. 46100 Burjassot (Valencia)
interest in any of the products mentioned of two new soft contact lenses for correction SPAIN
in this article. of presbyopia: the Focus Progressives mul- E-mail: teresa.ferrer@uv.es

© 2010 The Authors Clinical and Experimental Optometry 94.1 January 2011
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