Top toric contact lens fitting tips from the experts

Ever get stuck when fitting a patient with toric contact lenses?

Sometimes you want to know what the experts recommend.

Related: Experts offer top blepharitis tips

To help you, we asked contact lens fitting experts for their top tips for ODs fitting toric lenses.

Click here for our expert top toric contact lens fitting tips

David I. Geffen, OD, FAAO

San Diego

Optometry Times Editorial Advisory Board member

1. Don't be afraid to go to a toric lens first.
2. Don't forget about those patients who have 0.50 D of cylinder. Show them a trial lens with -0.75 D to see if they like it. If so, put on a toric lens.
3. Upgrade your patient to newer technology and designs. We have seen rapid change in lens materials and designs. Offer new technology to keep your patients coming back.

Up next: Joe Shovlin, OD, FAAO

Joe Shovlin, OD, FAAO

Scranton, PA

Optometry Times Editorial Advisory Board member

1. Allow ample time for stabilization and equilibration before evaluating rotation.

2. Don’t chase around strange or excessive amounts of rotation (not consistent from lens to lens). Your yield for success will drop off considerably after the first reorder. Try another option or design.

3. A careful sphero-cylindrical over-refraction can be very enlightening. Rotation is often revealed to its fullest extent. Also, when a lens rotates, dial it back to the 6 o’clock position to see what happens. Does it return, or does it now stay at 6 0’clock?

Related: Managing astigmats when they hit presbyopia

Up next: Mile Brujic, OD, FAAO

Mile Brujic, OD, FAAO

Bowling Green, OH

Optometry Times Editorial Advisory Board member

1. Always offer toric lens correction for low astigmats.

2. Don’t forget about gas permeable options or hybrid options to maximize visual acuity.

3. For high cylinder patients intolerant of other options, consider scleral design.

Up next: Crystal Brimer, OD, FAAO

Crystal Brimer, OD, FAAO

Wilmington, NC

Optometry Times Editorial Advisory Board member

1. If a patient has less than 1.00 D cylinder and ocular surface disease, he may actually see better with a more wettable spherical lens.

2. If you don’t have the exact combination needed but are close, send the patient home with what you have, then order the supply plus a box of trials for final approval. This saves the expense and delay of ordering trials and then boxes.

3. Set appropriate expectations ahead of time!

4. Don’t forget to screen for and treat ocular surface concerns for improved wettability, lens stability, and vision

Related: 5 reasons ODs don’t fit contact toric lenses

Up next: Jeffrey Sonsino, OD, FAAO

Jeffrey Sonsino, OD, FAAO

Nashville, TN

1. When taking a history on a previous toric contact lens wearer, ask specifically about how often the lens rotates out of place. A recent study showed that although all toric lenses work relatively well, each lens fails to maintain stability on certain patients.¹ It is not possible to predict which lenses works better with which patient.​

2. Think daily disposables. Daily disposable toric lens materials and designs have advanced ​significantly this year.

3. Hybrid and corneal gas permeable lenses often tackle toric corneas better than soft toric lenses, especially with high cylinder.

Up next: Brian Chou, OD, FAAO

Brian Chou, OD, FAAO

San Diego

1. Besides noting the rotation of the lens based on laser mark position, use a handheld Jackson Cross Cylinder (JCC) to straddle the contact lens axis and assess if rotational compensation is needed.

2. Don’t bother use an aspheric soft lens design to “mask” low astigmatism, even if manufacturer reps and other clinicians suggest this. It doesn’t work.²

3. If the patient has more than 2.50 D of astigmatism due to corneal toricity, start thinking about prescribing rigid optics (such as hybrid lenses, corneal RGPs, and scleral RGPs) rather than soft toric lenses. 

Related: Using toricity with scleral lenses

Up next: Kristopher A. May, OD, FAAO

Kristopher A. May, OD, FAAO

Memphis, TN

1. It’s time to stop masking.

We would never leave 0.75 D of cylinder off a spectacle prescription; why do it with contact lenses? Our power ranges and lens stability are so good now, it’s easy to put a patient in a diagnostic lens at the exam without waiting on an order or even waiting long for the lens to settle. When the patient looks out the front window at his distance vision, you can get some “Wow!” moments.

2. Don’t be afraid to try higher powers. 

It’s amazing how many patients will still say they were told that cannot wear contact lenses because of astigmatism. While the extended range (XR) lenses do have to be special ordered and take some extra time, high cylinder and high power soft lenses can be surprisingly rotationally stable and make for very happy patients. The best part about these patients is they tend to tell the whole world how their new eye doctor did what they thought was impossible.

3. Remember the basics: Vertex and left add, right subtract (LARS).

It’s boring, but they are the difference between success and failure. Vertexing high cylinder powers with rules of thumb can be notoriously inaccurate. There are apps for that now...use them. Sometimes vertexing is the difference between a patient who you thought needed an XR but can be fit in a stock power. Rotationally adjusting power with LARS is not just for the initial dispense, it optimizes lens performance once the patient has worn the lens longer and sets them up for long-term success in her final Rx.

Up next: John Mark Jackson, OD, MS, FAAO

John Mark Jackson, OD, MS, FAAO

Memphis, TN

1. Rotation is not the same as axis misalignment. If possible, adjust the axis to remove misalignment, even with small amounts of rotation.

2. Modern toric lenses don't take very long to settle, no more than five to 10 minutes.

3. Higher astigmats you previously may have not attempted to fit are now very fittable with newer designs with better rotation control.

Related: 10 tips to enhance scleral contact lens success

Up next: S. Barry Eiden, OD, FAAO

S. Barry Eiden, OD, FAAO

Deerfield, IL

1. Toric contact lenses allow careful optimization of vision, what I would call “precision management of astigmatism.” We must have clear and stable vision. Vision fluctuation is not acceptable. Variations in lens designs, materials, etc. can be explored to optimize vision quality outcomes.

2. Proper frequency of replacement selection for the patient (daily disposables vs. frequent replacement vs. other) based upon the patient’s ocular surface/tear film status, lifestyle, and specifics of the Rx required. Some patients may require “extended range” parameters in frequent replacement lenses, taking daily disposables out of the equation, or the use of custom designed lathe cut soft torics. Emphasize compliance with the prescribed frequency of replacement.

3. Material selection considerations can optimize physiological response as well as influence comfort and vision. If reusable lenses are prescribed, then of course careful selection of care systems to keep the lens surface as pristine as possible is key.

Up next: Melissa Barnett, OD, FAAO, FSLS, FBCLA

Melissa Barnett, OD, FAAO, FSLS, FBCLA

Sacramento, CA

1. Offer daily replacement toric lenses. 

2. Allow lenses to settle. 

3. Do not touch the lens to rotate and obtain better vision. If better vision is needed, consider a different lens option.

Related: Surviving allergy season as a contact lens wearer

Up next: Shelley Cutler, OD, FAAO

Shelley Cutler, OD, FAAO

Philadelphia

1. Start with good data (garbage in…garbage out).

An accurate refraction is key. (Don’t just rely on an automatic machine.) If fitting a young patient, make sure a cycloplegic refraction was performed so she won’t accommodate on you.

2. When performing a diagnostic fitting, remember you don’t need as much astigmatic correction at the corneal plane compared to refractive plane. (Note: It’s not always a one-for-one vertex for effectivity).

Always start with less than you need in the diagnostic lens and add to it, especially if you are between choices. If you start with the higher amount, the patient may accommodate through it. Although visual acuity may be acceptable at this visit, asthenopic complaints may crop up later on. Let the patient prove to you that he truly needs the higher amount.

3. Evaluate rotation (via LARS) and movement.

Let the lens settle for five to 10 minutes. Look not only in primary gaze, but ask the patient to look up, down, left, and right to see how quickly the lens returns to where you started.

It should return almost immediately or within one blink. If the lens is bouncing around, you will most likely need a snugger fitting lens. Go with a tighter base curve in the same design; otherwise opt for a new design with a greater sagittal depth.

If the lens is stable, make sure there is adequate lens movement.

Note: For patients with dry eyes, the lens will tighten somewhat over time. This can easily affect rotation, and it might be different from the diagnostic fitting. If the patient is complaining of blur, it may not be dehydration but unaccounted rotation.

Up next: Charissa Young, OD

Charissa Young, OD

Kirkland, WA

1. For higher astigmats with rotated lenses, don’t forget cross-cylinder calculators. They offer better visual outcomes than using LARS.

2. When in between axis options, choose the option closer to the 90° or 180° axis.

3. For presbyopic astigmats, skip monovision and head straight for translating GPs or custom soft options.

References

1. Lee RH, Noorany H, Sonsino J. The toric soft lens experience: Facts revealed. Poster presented at Global Specialty Lens Symposium annual meeting: January 21-24, 2016; Las Vegas.

2. Morgan PB, Efron SE, Efron N, Hill EA. Inefficacy of aspheric soft contact lenses for the correction of low levels of astigmatism. Optom Vis Sci. 2005; 82: 823–8.

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