Technological advances in soft toric lens manufacturing over the last two decades have facilitated vastly improved yield, better lens designs, and a wider parameter range, all of which provide broad coverage to the astigmatic population. Toric lenses now offer predictable and high-quality vision and comfort, and they are available in custom designs and frequent replacement modalities—even daily disposable, despite the thousands of stock keeping units (SKUs) involved.

Has this investment in technology paid off with an increased market share? The global contact lens market pie contains a fairly generous slice dedicated to serving the astigmats of the world, but the increase in market share has perhaps not fulfilled its potential.

Where We Are

From the first International Contact Lens Prescribing survey (Morgan et al, 2002), we can see that in 2001, toric lens fits represented an average of 21% of all soft lens fits across the six early participating countries. Despite all of the technological advances of the previous two decades, the average toric use in 2017 reported by Morgan et al (2018) is only 5% higher at 26%.

It should be noted, however, that the latest report considers many more countries, and the diversity across these 30 countries may be suppressing the average. The 2017 average of the original six countries is 31%, a much more significant increase from the 2001 value of 21%.

The responses to this annual international survey provide interesting information about different views and practices around the globe as well as changes over time. Table 1 shows the percentage of soft lens fits that were reported as being toric in Morgan et al’s surveys covering 2001, 2007, and 2017 (Morgan et al 2002, 2008, 2018). It illustrates how the initial six countries have altered in their toric lens prescribing since 2001.

Also in the table are data from the two largest contact lens markets—Japan and the United States—plus the average across the variable number of reporting countries for each year. Those countries in the table that showed rapid adoption of torics between 2001 and 2007 seem to have hit a plateau in the past decade. The U.S. data stands out from the others, with a large increase since 2007. It is interesting that despite Japan being the second largest world market for contact lenses, the toric penetration remains low at just 15% of all soft lens fits.

Looking at the entire 2017 survey data for new soft lenses fit, the majority of countries fit approximately 30% of patients with toric lenses; the highest numbers are reported by Portugal (41%), Israel (37%), the Czech Republic (36%), Switzerland (35%), and the United Kingdom (35%) (Morgan et al, 2018).

However, there are still countries that have not adopted toric lenses to the extent that prescription demographics would suggest; the lowest are Lithuania (17%), Bulgaria (16%), Japan (15%), the Philippines (14%), and Moldova (8%).

Where We Should Be

Given the variation in toric lens use around the world, it is worth considering what the expected market share should be. It is now widely accepted that astigmatism of 0.75D or higher warrants correction to improve acuity and reduce symptoms of asthenopia. Luensmann et al (2018) reviewed almost 102,000 multi-practice records and established that 41% of all eyes had a cylindrical refraction component of 0.75D or higher. Young et al (2011) reviewed the prescriptions of more than 11,500 contact lens fittings and found that more than 47% of people had more than 0.75DC in at least one eye, and 24% had that amount of astigmatism in both eyes. This means that 47% of soft lens wearers should be fit with at least one toric lens, and approximately 35% of soft lenses sold should be toric. This high level of potential market continually drives the industry to offer custom torics in virtually any prescription configuration and to expand the offerings in the frequent replacement and daily disposable segments.

Why the Difference?

Are rigid lenses replacing soft torics? This is unlikely because very few countries report a significant percentage of rigid fits, let alone toric rigid fits. A notable exception may be Germany, reporting in 2017 that 77% of new fits were rigid lens fits and that 30% of those were toric.

Does cost play a part? Perhaps patients are willing to accept the visual compromise of spherical lenses rather than pay extra for torics? Or are practitioners choosing not to offer toric options to everyone on the misguided belief that cost is a prohibitive factor?

Do some practitioners believe that 0.75DC doesn’t need to be corrected? Most manufacturers provide most countries with minimum toric lens cylinder powers of –0.75DC. In these lower-astigmatism cases, the challenge can be to educate the lens fitters as well as the patients about the benefits of toric lenses.

Perhaps the shortfall comes from underserving those who have uncommon lens parameter needs. Not all markets can offer the high-cylinder ranges available in some countries. Even in those countries with the broadest range, practitioners still call for higher cylinder powers and more axis options in frequent replacement lenses.

However, the issue is one of financial viability. The current common range of four cylinder powers in 18+ axis options covers almost 3,000 prescriptions, which in turn covers the needs of approximately 95% of astigmats (Luensmann et al, 2018). Expanding the range by one more power or axis option requires significant manufacturing investment to cover all SKUs, and yet this may only increase the prescription coverage by < 1%. Such a low return may not justify such investment. The same investment-return barrier prevents soft torics from being offered in multiple base curves. In cases in which high powers, oblique axes, or uncommon fit parameters are needed, custom toric lenses are the only option.

Is More Growth in the Future?

Many countries already use toric lenses in three out of 10 new fits/refits. However, there are many countries demonstrating less penetration, and it is reasonable to assume that there is significant growth ahead for those. Perhaps the next two decades will see more even toric lens adoption around the world.

We may also see growth as practitioners explore the benefits of fitting asthenopic 0.50DC astigmats with a 0.75DC toric lens. In these days of more visually demanding work and hobbies, particularly based around digital devices, better correction of low levels of astigmatism is becoming more important to avoid the perils of asthenopia, which could ultimately lead to drop out. As early presbyopes can attest, an extra 0.25DS correction can be game changing; in the future, we may see the same attention paid to the often overlooked 0.50D cylinder. CLS

For references, please visit www.clspectrum.com/references and click on document #274.