5 reasons ODs don’t fit toric contact lenses

It’s time to dispel these preconceptions of fitting contact lenses for astigmatism and use new toric lens options as an opportunity to improve patient care.

I see patients at a private practice that pushes the envelope daily to offer patients innovative eye care, which means annual eye exams don’t play like a broken record.

I’m frequently refitting patients’ contact lenses not because they’re unhappy but because I practice by my Golden Rule: Treat patients how you would like to be treated. This means I’m always moving patients into the latest, best, and healthiest lenses possible.

Related: ODs start fitting toric lenses at 0.75 D of cylinder

Over the last 12 months, I’ve been able to give a big sigh of relief with the launch of new toric soft contact lens options, to name a few:

• Bausch + Lomb’s Biotrue ONEday for Astigmatism

• Johnson & Johnson Vision Care’s Acuvue 1-Day Oasys for Astigmatism

• CooperVision’s Biofinity XR Toric

These new launches have given my astigmatic patients a sharper and more comfortable contact lens experience than lenses past. Had I not lived by my personal practice motto, I may not have refit most of these patients who were not complaining about their current modality. Contact lens dropouts persist as a concern in our profession and with our own patients.

Twenty-three percent of patients are still permanently discontinuing contact lens wear, with discomfort and dryness as the prevailing reasons.¹ Those fit in silicone hydrogel rather than hydrogel for their lens material were less likely to drop out as well as those re-fit into another contact lens. Most importantly, treating the source of the discomfort and treating the patient’s dry eye disease will also reduce your dropouts.

Related: Using toricity with scleral lenses

In 2016, practices reported that contact lens revenue accounted for 32 percent of gross practice sales and that 27 percent of their contact lens fittings were for toric contact lenses.² We traditionally expect patients with astigmatism to present more challenges than their spherical counterparts and to take a bit more time to fit.

Let’s examine the five reasons ODs don’t fit toric contact lenses-and why those reasons are no longer valid.

1. Cost to patient

Yes, contact lenses that correct for astigmatism cost more than spherical contact lenses. Comparing costs with our own distributor revealed that some toric lenses cost up to 35 percent more than their spherical counterparts.

While low, borderline astigmats (usually those with -0.75 D to -1.00 D of cylinder) may prefer their spherical equivalent due to the reduced cost, research shows that patients achieve improved visual acuity in both dim and light environments when their astigmatism is corrected.³ Preliminary research published by the University of Virginia also suggests that correcting astigmatism with toric contact lenses improves driving performance through improved overall tactical driving skills and visual abilities.⁴

Whenever I see a new patient, most of the time I’m refitting them from their habitual monthly contact lenses into daily disposable lenses, and astigmats are no different. In fact, 90 percent of soft contact lenses wearers in the practice are in daily disposables because daily disposable contact lens wearers are more compliant and less likely to overwear lenses.⁵

Related: Study: Most astigmatic patients would choose to trial daily disposable contacts

When refitting patients into daily disposables, I explain the ocular health benefits. I believe that because of the ocular health conversation, I discuss cost less than expected. If cost still becomes a sticking point, pull up your clinical bootstraps. Is this patient cost conscious because he is a contact lens abuser?

Reluctant patients may be more inclined to try toric lenses with a “free” pair (i.e., a trial set). Patients may also need to appreciate the difference in visual clarity themselves in order to understand the benefits of toric lenses.

2. Too much chair time

Regardless of lens type or modality-monthly, daily, toric, spherical-contact lens fitting will require added time to allow the lens to settle and stabilize on the eye.

In a comparison of five major toric contact lenses, 100 percent of the lenses achieved rotational recovery under 100 seconds, even when the lenses were rotated 45 degrees out of alignment.⁶ Boychev and others found that soft contact lenses typically settle within 10 minutes;⁷ thus toric or not, the lens will have most likely achieved rotational stability in this time.

3. Variability in fit (includes rotation)

When fitting contact lenses, learn to discern who are the best candidates.

Beyond patient personal hygiene and visual demands, there are considerations specific to astigmats. Young and colleagues discovered that lens orientation and stability was most dependent on the degree of myopia (the lower the myopia, the more stable the lens), palpebral aperture (the smaller, the more stable), and lens tightness (the looser, the less stable).⁸

While a high myope with large palpebral apertures and steep K values may not be the ideal toric contact lens candidate, knowing this will help you set patient expectations and your expectations for chair time.

Improvements in toric lens designs have also come a long way in providing improved visual stability. In a February 2017 study, there was no significant difference of retention rate of low vs. high cylindrical prescriptions, possibly indicating new toric lens designs are able to provide more visual stability for patients.⁹

Related: Educate your patients about astigmatism

4. Lens comfort

Discomfort is the prevailing reason for contact lens dropout and should be addressed in toric contact lens wearers like it would be in all lens modalities.

While clinically I have had patients report differences in comfort of lenses when one eye wears a spherical lens and the other a toric (typically when a toric is a prism-ballast design and the patient feels the increased lens thickness), research has shown there is no significant difference in the rate of discomfort between spherical and toric wearers in neophyte contact lens dropouts.⁸

When a patient reports comfort in her prescribed lenses one year but not the next, the contact lenses didn’t change, but most likely her ocular surface health did.

You will be a more successful contact lens clinician the more proactively you treat deficiencies in the ocular surface. The 2012 Tear Film and Ocular Surface Society (TFOS) International Workshop on Contact Lens Discomfort report found tear film stability to be a key factor in lens comfort.¹⁰ With 86 percent of dry eye involving meibomian gland dysfunction (MGD),¹¹ a regular assessment of a patient’s meibomian gland expression is critical in any contact lens evaluation. If MGD is not the culprit, a thorough case history involving current or new medication, changes in health history, or changes in environment may reveal other extrinsic factors.

Related: Using tinted contact lenses in practice

5. Power limitations

I’ve been able to move many patients out of custom soft contact lens designs to more affordable, higher Dk options for the first time in years. This is due in part to the rollout of CooperVision’s Biofinity Toric XR, the only silicone hydrogel contact lens available from a major manufacturer beyond the traditional stock range.

Lenses are available from ±10.00 D (in 0.50 D steps after ± 6.00 D) with cylinder powers from -2.75 D to -5.75 D (in 0.50 D steps) and an axis of 5 degrees to 180 degrees in 5-degree steps.

I’m also excited about this year’s rollout of the highest Dk daily disposable toric lens with Johnson & Johnson Vision Care’s Acuvue Oasys 1-Day for Astigmatism, which includes 2260 parameters for coverage of 87 percent of eyes.¹² Coverage ranges from +4.00 D to -9.00 D with up to -1.75 D astigmatism for both with- and against-the-rule prescriptions.

Looking ahead

While recent launches with expanded parameters and improved materials and lens wettability may help reduce industry-wide contact lens dropout, there are still unmet needs in the toric space, namely the multifocal market. A daily disposable toric multifocal design is much needed.

It’s never been easier to fit astigmats with reduced chair time, improved vision with expanded parameters, and better comfort. Fitting with the Golden Rule will likely help you build patient loyalty and referrals. Provide the highest standard of care and potentially prevent dropouts by not missing opportunities to treat the ocular surface and refit patients into toric lenses to ensure happy patient and practice outcomes.

Related: Embracing new contact lens technology

References

1. Dumbleton K, Woods CA, Jones LW, Fonn D. The impact of contemporary contact lenses on contact lens discontinuation. Eye Contact Lens. 2013 Jan;39(1):93-9.

2. Nichols, JJ. Contact Lenses 2016. CL Spectrum. Available at: http://www.clspectrum.com/issues/2017/january/contact-lenses-2016. Accessed 5/17/17.

3. Richdale K, Berntsen DA, Mack CJ, Merchea MM, Barr JT. Visual acuity with spherical and toric soft contact lenses in low- to moderate-astigmatic eyes. Optom Vis Sci. 2007 Oct;84(10):969-75.

4. Cox DJ, Banton T, Record S, Grabman JH, Hawkins RJ. Does Correcting Astigmatism with Toric Lenses Improve Driving Performance? Optom Vis Sci. 2015 Apr;92(4):404-11.

5. Morgan PB, Efron N, Toshida H, Nichols JJ. An international analysis of contact lens compliance. Cont Lens Anterior Eye. 2011 Oct;34(5):223-8.

6. Momeni-Moghaddam H, Naroo SA, Askarizadeh F, Tahmasebi F. Comparison of fitting stability of the different soft toric contact lenses. Cont Lens Anterior Eye. 2014 Oct;37(5):346-50.

7. Boychev N, Laughton DS, Bharwani G, Ghuman H, Wolffsohn JS. How should initial fit inform soft contact lens prescribing. Cont Lens Anterior Eye. 2016 Jun;39(3):227-33. 

8. Young G, Hunt C, Covey M. Clinical evaluation of factors influencing toric soft contact lens fit. Optom Vis Sci. 2002 Jan;79(1):11-9.

9. Sulley A, Young G, Hunt C. Factors in the success of new contact lens wearers. Cont Lens Anterior Eye. 2017 Feb;40(1):15-24.

10. Nichols JJ, Willcox MD, Bron AJ, Belmonte C, Ciolino JB, Craig JP, Dogru M, Foulks GN, Jones L, Nelson JD, Nichols KK, Purslow C, Schaumberg DA, Stapleton F, Sullivan DA; members of the TFOS International Workshop on Contact Lens Discomfort. The TFOS International Workshop on Contact Lens Discomfort: executive summary. Invest Ophthalmol Vis Sci. 2013 Oct 18;54(11):TFOS7-TFOS13.

11. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012 May;31(5):472-8.

12. Johnson & Johnson Vision Care. Acuvue Oasys 1-Day for Astigmatism. Available at: https://www.acuvueprofessional.com/product/acuvue-oasys-1-day-for-astigmatism. Accessed 5/17/17.

Read more in our Toric Contact Lens Resource Center