Here’s a toric math problem. Check out Figure 1. Do you remember this from optics class?

Now, let’s see whether we can make the math add up (Figure 2).

Most patients do not understand what “astigmatism” is. They may have heard the word and may think it is some sort of disease state, but many really have no idea.

Have your astigmatism speech organized and easy to understand: The eyes of an astigmat focus light into two unique images, and it requires a uniquely designed contact lens to correct their vision and meet their daily visual demands.

Many practitioners look to minimize issues related to contact lens wear. A history of product availability, comfort, and on-eye stability issues were some of the reasons why many of our astigmatic patients were fit with a spherical equivalent lens that “masked” their cylinder.

The problem is that uncorrected astigmatism can cause other issues. A loss of sharpness may produce eye fatigue and/or headaches. This is further complicated for patients who have presbyopia and astigmatism. Fortunately, we live in a new era and, because of that, we need to change our mindset. There are many new, innovative technologies in this space that we can provide to our patients.

Instead of prescribing the same old contact lenses that your patients have always been given, look for ways to upgrade their vision and contact lens-wearing experience. Increasing the numbers of contact lens wearers can result in positive practice growth.

According to one survey, eyecare practices can receive between $177 and $326 in annual revenue for each contact lens patient.¹ This does not even include the future value of that patient and other contact lens referrals from that patient, which can have a lifetime total of close to $25,000.¹

Here are some steps to making the toric math add up.

BEGINNING TORIC MATH 101

Stop the practice of masking the cylinder. Patients judge our ability to improve their vision the minute they walk out the door. Whether they are wearing their new glasses or contact lenses, they are expecting good eyesight instantaneously (Figures 3 and 4).

If they are not perfectly happy with what they are seeing, some patients will complain. Other patients just won’t come back to you. Remember the lifetime value that a contact lens wearer brings to your eyecare practice. That math is easy to consider.

Additionally, if patients find out that there is technology out there that provides better vision, they will be upset if they did not hear about it from you. In some cases, patients will just seek the services of another eyecare provider; one study reported that one-third of respondents said they would likely seek out the services of another practitioner if their existing one didn’t inform them about their options.²

Many of today’s toric lenses orient themselves properly within 60 seconds and the on-eye stability is much improved. With today’s technology, there is no reason to mask a patient’s cylinder at all. If there is any doubt as to whether or not to fit those patients with lower cylinder amounts, demonstrate the difference in the phoropter and ask which they would prefer (Figure 5). This is often helpful if someone is going back and forth between 0.50DC and 0.75DC.

This is also an opportunity to demonstrate the cylinder axis. Explain that this will be closely monitored during the fitting process to ensure that their contact lenses perfectly line up in order to provide the best vision possible, and that some minor fine-tuning adjustments may be necessary.

INTERMEDIATE TORIC MATH 102

Every patient who has astigmatism is a candidate. Maybe this started long before the contact lens technology with which I have been blessed to work, but there are still patients who remember being told that they were not candidates for contact lenses.

Toric contact lens technology has grown exponentially for the standard parameters, but also in the specialty lens and multifocal toric areas. For those reasons, proactive eyecare practitioners have an opportunity to grow this population.

1) Innovation There are many new materials and modalities that may provide improved ocular health and convenience. Your patients need to be aware of this. Talk to them about innovation and new technology. Newer silicone hydrogel toric lenses offer improved oxygen permeability, and daily disposable toric lenses offer a great option for part-time and full-time wearers looking for the highest convenience. By offering patients an option that they may not have heard about in the past, forward-thinking practitioners will tap into this growing market of contact lens wearers.

2) Stability There is a group of patients who have astigmatism who have failed with contact lenses in the past because they were not seeing consistently well throughout the day. They felt they did not see as well as they did in their glasses and may not have thought about trying contact lenses again. This visual fluctuation could have been due to an unstable lens, too much rotation, and/or the specific contact lens parameters not being available. Eyecare providers need to be proactive and inform their patients that there are many new contact lens options that could satisfy their visual requirements and make them happy.

It is important to set patient expectations with everything we are prescribing, and this is no different. Discuss how astigmatism-correcting contact lenses only come in specific prescription power ranges and how the contact lens fit is a process that helps ensure their astigmatism power and the orientation of those different powers (already demonstrated behind the phoropter) are lined up perfectly for them to achieve their best vision. This further demonstrates how a contact lens prescription is often different from their spectacle prescription, but that both are customized for their eyes and their vision.

3) Comfort The environment in which our contact lens wearers live and work often does not help. Not only are many of our patients indoors with forced air most of the day, but many spend their workdays in front of computers. This often results in end-of-the-day dryness, digital fatigue, and fluctuating vision. Ask how many hours they spend in front of a computer. In general, however, expect this to be an issue with all patients. Additionally, ask patients at what time their contact lenses begin to dry out and if/when their vision begins to fluctuate.

Discussions about digital technology can open the door for eyecare professionals to recommend daily disposable and high-quality silicone hydrogel contact lenses. Consider something like this: “There are new and improved contact lens options that have moisturizing agents added into the newer materials, which allow them to maintain hydration longer and transmit more oxygen. This can often improve the stability of your vision and your end-of-day comfort.”

ADVANCED TORIC MATH 103

Advanced toric lens designs offer improved comfort and vision for those difficult-to-fit patients. Specialty contact lenses encompass a large variety of needs, such as those who have high levels of astigmatism, keratoconus, and post-traumatic corneas, but also those who have irregular astigmatism, multifocal–astigmatic contact lens wearers, and post-refractive surgery patients. Due to the custom needs of these patients, they often require more training and more chair time. This is the reason many eyecare professionals don’t take the time to do the math. Let’s look at a few subsets of patients.

Highly Astigmatic Patients A significant number of patients have been underserved in the past with this visual issue. This is due to the limited number of options along with the advanced difficulty of stabilizing the contact lens on the eye. This can lead to poor visual clarity and a potential dropout.

There are many soft lens manufacturers that have expanded available parameters for the higher astigmatic patient in a variety of contact lens brands. This helps greatly, but don’t forget about other options. Rigid GP lenses can be invaluable for some of these patients. GPs may be the best option to maximize visual clarity. Back-toric or bitoric GPs may be necessary for those patients who have higher levels of astigmatism that matches their corneal curvature. Scleral or large diameter GPs may also provide a unique opportunity in some instances.

Hybrid technology may provide yet another option for patients who have higher levels of astigmatism. The hybrid technology platform utilizes a GP center with a soft skirt surrounding it. This may provide improved comfort with the visual clarity of GPs in one lens.

Astigmatic Presbyopes When any astigmatic contact lens wearer crosses into presbyopia, things become more challenging. Again, this has been due to limited options in the soft contact lens market. Soft toric multifocal lenses combine the stabilizing and optical design of toric technology with multifocal technology. Remember to fit the toric technology first. Initially adjust for any rotation or instability and then satisfy the multifocal aspect. Utilize the manufacturer’s fitting guides to streamline this process and customize these designs for your patients’ specific visual demands.

GP materials and hybrid technology offer designs in the presbyopia arena as well. They may be first-line treatments for some patients but secondary options for others, depending on their visual needs and their history of contact lens wear. Make sure to ask as many questions as possible up front to determine which option would be the best to start with.

Keratoconus and Other Specialty Situations, Like Trauma and Surgery (Penetrating Keratoplasty and/or Refractive Surgery) We are blessed to practice in an era in which manufacturers have developed multiple options, like mini-scleral and scleral contact lenses. These contact lens options are in the form of larger diameters (> 13mm), which can aid in vaulting the irregular cornea. Additionally, there are hybrid and even custom soft lenses with a thicker modulus that can prevent flexure in order to correct the vision of these patients.

Specialty lenses are being used more often due to their ability to provide better vision by masking irregularities with vaulting technology for those unique corneas. This occurs because of their large diameter and ability to be better tolerated compared with traditional, small diameter GPs. Scleral lenses are custom fit to vault the cornea and thus much of the lens lands on the sclera as opposed to the cornea. In order to be successful with these options, fitting sets and advanced technology are a must.

FORWARD-THINKING TORIC MATH 104

When fitting specialty lenses, analyze where you are now and where you would like to go. Start with developing your protocol and being deliberate with your goals. Recruit key people and offices in your area, including other optometrists not performing this specialty, primary care physicians, ophthalmologists, and school nurses.

Consider external and internal advertising, which can result in positive feedback and reviews. This may include school newsletters, fundraisers, websites, and social media outlets. Consider finding ways to capture your patients’ reactions to your successful fit and posting them on social media outlets. This moment can turn patients into your biggest advocates.

Customize the Process This starts with understanding the patients’ occupations and hobbies, as this information will aid in identifying their daily visual needs. Discuss proper expectations before you start. Taking a little more time up front to determine their starting lens and initial reaction with a fitting lens may save some time down the road. Often, fitting guides have been developed to help streamline the process.

Utilize Technology Topography is critical to understanding the corneal mapping. Anterior segment optical coherence tomography (OCT) can aid in the process of fitting vaulted contact lens products.

Develop Your Market This starts with being prepared and developing your protocol. Staff and practitioners need to understand how to best take care of these patients. Training patients how to apply, remove, and care for their specialty contact lenses is a skill that needs to be understood. Marketing programs around this goal of increasing the number of custom contact lens wearers can help recruit and prepare everyone involved.

Utilize Available Tools We all remember LARS (left add, right subtract) when making toric lens adjustments, but there are a variety of online tools as well. There are toric lens calculators for more advanced alterations as well as manufacturers’ fitting tools to help enable success with each unique design. Make sure to ask about these tools at your next association meeting or when you meet with that unique vendor.

UTILIZING A CASE TO DEVELOP YOUR OPTIONS

A 49-year-old male engineer presented for a contact lens examination and reported blurred vision at distance and at near (“loss of crispness”) with his current spherical daily disposable lenses. This was a new patient who had recently considered switching to full-time spectacle wear due to his dissatisfaction with the vision provided by his contact lenses. The patient’s refraction was OD: –1.00 –1.00 x 175 20/20, OS: –0.75 –1.00 x 020 20/20, with a +1.50D near add 20/20 OU.

Fitting the astigmatic patient who develops presbyopia can be a contact lens challenge. His astigmatism needs to be addressed here, as this uncorrected astigmatism has resulted in an overall loss of sharpness everywhere and created a potential contact lens dropout.

Additionally, his background as an engineer helps the practitioner understand that he is a critically observant patient, and spherical contact lenses of any modality are really not an option. Here’s how to decide which is the best option for this patient:

• Identify your patient’s priorities. This will often guide your next steps. This patient was using daily disposable lenses and that was a priority of his. He liked the convenience that daily disposables provided and wanted to continue with that modality if possible. Based on that, the options were: 1) refit with daily disposable soft toric lenses with a monovision enhancement; or 2) refit with daily disposable soft toric lenses with the addition of presbyopia-correcting drops (instilled 10 minutes prior to contact lens use).
• If he would consider reusable contact lenses, there are more multifocal toric lens options available now. If the patient wants to consider a reusable contact lens, a multifocal toric lens would be a good starting point because no options exist in the daily disposable modality. By combining the toric technology with the multifocal technology, the practitioner can treat both conditions most accurately. Other options to consider are multifocal GP offerings, hybrid technology, and even multifocal scleral lenses. These contact lens options offer unique platforms and designs, which allows the contact lens practitioner to provide a customized product to patients.

IN SUMMARY

Astigmatic patients are an exciting category of contact lens wearers. There is significant value to the patient and to the practice in taking care of these unique patients. Many of them have had challenges in the past and are looking for someone to take a little more time with them. Some of them may have considered giving up on contact lenses due to their dissatisfaction with the experience. If you can convert those patients, they will become the best advocates for your skills and the practice. CLS

REFERENCES

1. Rumpakis J. New Data on Contact Lens Dropouts: An International Perspective. Rev Optom. 2010 Jan;147:37-42. Available at reviewofoptometry.com/article/new-data-on-contact-lens-dropouts-an-international-perspective . Accessed Apr. 19, 2022.
2. Studebaker J. Soft Multifocals: Practice Growth Opportunity. Contact Lens Spectrum. 2009 Jun;24:40-43. Available at clspectrum.com/issues/2009/june-2009/soft-multifocals-practice-growth-opportunity . Accessed Apr. 19, 2022.