ACHIEVING SATISFACTORY VISION and comfort is a clinician’s primary goal for each contact lens patient. However, achieving both simultaneously can be one of the greatest clinical challenges, especially for patients who have irregular corneas and/or unusual prescriptions.

Each lens modality has its own unique advantages and disadvantages. Soft lenses tend to offer instant comfort and adequate fitting but may offer less-than-perfect vision due to prescription limitations. Corneal GP and scleral lenses are well known for providing superior, crisp optics but less than optimal comfort, especially for first-time wearers.

Piggybacking, which is a combination of a GP and a soft contact lens, has been used for decades as a reasonable way to obtain the best of both worlds. Many patients are successful with the piggyback system, but it certainly has its limitations: increased cost, differentiating lens care, and reduced oxygen transmission.

The potential for success with this system is essentially what resulted in what we now know as a hybrid lens. Although hybrid lenses have been available for several decades, new iterations have emerged on the contact lens market over the last several years.

The first modern hybrid lens received U.S. Food and Drug Administration (FDA) clearance in 2005.¹ The most significant improvement over earlier designs was a patented junction securing the GP center to the soft skirt. Further updates include a higher-Dk silicone hydrogel skirt, a hyper-Dk GP lens material, and irregular cornea and presbyopia corrections, so there is now a hybrid lens option for essentially every patient type within common practice.

The original lenses, including several iterations, are still available and replaced biannually, but the most recent additions to the hybrid family include several options that allow for correction of corneal astigmatism, presbyopia, ocular surface irregularity, and otherwise regular refractive error.

Some of these newer-generation hybrid lenses can be empirically designed with a sophisticated online calculator that streamlines the fitting process and increases first lens success. The calculator requires keratometry values, horizontal visible iris diameter (HVID), and the manifest sphere and cylinder. HVID can be measured using an HVID ruler, the slit lamp, or a topographer. Other newer-generation hybrid contact lenses can be fitted using traditional diagnostic approaches.

CASE NO. 1: THE PERSISTENT PRESBYOPE

A 51-year-old Hispanic male presented with an interest in wearing contact lenses. He was an information technology professional working 12-plus hours a day on his computer. With a previous practitioner, the patient had tried several contact lens options with minimal success, including soft multifocal torics, monovision with soft torics, and single-vision contact lenses with the addition of over-the-counter readers as needed. He commented that his most recent contact lenses, soft multifocal torics, were comfortable but his vision was compromised while working on his computer. Thus, his primary goal was to wear contact lenses for work with clear intermediate vision representing an important priority.

Objective Findings

Manifest Refraction:

OD: –0.75 –3.00 x 037

OS: –3.00 –1.00 x 092

Add: +2.00 (OD dominant)

Keratometry Values:

OD: 43.25 @ 027 / 46.75 @ 117

OS: 45.50 @ 131 / 46.50 @ 041

HVID (obtained from the topographer):

OD: 11.04mm

OS: 11.21mm

Due to the patient’s visual goals, his past lens failures, and his high amount of irregular astigmatism OD, he had limited options for soft contact lenses, which was further confirmation that a hybrid lens would be the best option. The online calculator provided the following parameters:OD: SynergEyes iD MF EDOF

BC = 7.42mm SK= 42 Power = –3.00D Add = High

OS: SynergEyes iD MF EDOF

BC = 7.26mm SK= 42 Power = –3.75D Add = High

A crucial factor when deciding upon a hybrid option for a patient is to ensure minimal residual astigmatism (0.75D or less). Hybrid lenses neutralize corneal astigmatism due to the underlying tear lens created by the GP lens. Currently, there is no front-surface toric option available; thus, the patient’s corneal cylinder must closely match the refractive cylinder in order to provide the best visual outcome. Patients fit empirically with the online calculator will be flagged if they are not a good candidate for their lenses. For this patient, there was –0.50D residual astigmatism OD and no residual astigmatism OS, which should provide him with optimal vision (Figure 1).

At the dispense visit, the patient read 20/20 at all distances binocularly with no significant over-refraction. The lenses were well centered and had adequate movement and appropriate apical clearance. He was overjoyed with the quality of his vision and the comfort of the lenses.

At the one-week follow-up visit, the patient reported being able to work comfortably at his computer throughout his entire work day with no clinically relevant over-refraction.

CASE NO. 2: PROGRESSIVE MYOPIA

A 13-year-old Caucasian female presented along with her family for a myopia management consultation. She was first diagnosed with myopia at the age of 8 and had been wearing single-vision spectacles or single-vision soft contact lenses since her initial diagnosis. She reported rarely wearing soft lenses due to fluctuating vision. She had been attending virtual school for the previous six months leading up to the appointment, was an avid reader (three to four hours per day), and had limited outdoor time (less than 30 minutes per day). Both parents and her younger brother were all moderate myopes.

As her vision appeared to be declining at a rapid rate, the patient and family became interested in options to slow her myopia progression. After a thorough discussion, they were most interested in a contact lens option and not a pharmaceutical option.

Objective Findings

Manifest Refraction (current):

OD: –7.25 –2.50 x 177

OS: –8.50 –1.25 x 180

Manifest Refraction (eight months prior):

OD: –6.50 –2.00 x 175

OS: –7.50 –1.25 x 180

Keratometry Values:

OD: 44.25 @ 174 / 46.25 @ 084

OS: 44.50 @ 177 / 46.00 @ 087

HVID (Slit Lamp Reticle):

OD: 11.2mm

OS: 11.2mm

Due to her high level of myopia and moderate astigmatism, neither soft contact lenses nor orthokeratology was ideal for this patient for myopia management. In addition, she had a negative experience with soft torics in the past. In patient cases like this, the practitioner is tasked with creating a solution that will provide clear vision along with myopia control.

Although currently off-label, several different extended depth of focus (EDOF) lens designs have been shown to slow myopia progression.^2-4 The theory behind this lens design is that it manipulates spherical and higher-order aberrations to provide competing signals to the retina, creating relative myopic defocus, which slows axial elongation. Considering all of these factors, a hybrid lens appeared to be the ideal option for this patient. The family was informed of the off-label use of this lens design for myopia control and the lens was ordered with the following parameters:

OD: SynergEyes iD EDOF EP

BC = 7.46mm SK= 42Power = –7.25DAdd High

OS: SynergEyes iD EDOF

BC = 7.46mm SK= 42Power = –8.00DAdd High

The right contact lens was ordered with an enhanced profile (EP). This thicker lens design serves two purposes: It reduces lens flexure from high amounts of corneal astigmatism and can improve visual acuity when there is a small amount of residual astigmatism. In addition, adding an EP should be considered when the patient has more than 2.00D of corneal astigmatism, over-refraction with the lens on reveals a sphero-cylindrical prescription, or keratometry or topography produces a toric reading.

At the initial dispense visit, the patient reported clear but “wavy” vision. Her visual acuity measured 20/20^- OD and 20/20^- OS at both distance and near. Both lenses were slightly decentered temporally but showed appropriate apical clearance with a small over-refraction. A topography was also performed over the lens to determine whether lens flexure was distorting vision, but no significant toricity was uncovered.

A second pair of lenses was ordered to address the patient’s issues, with the rationale that improved centration, along with a more accurate prescription, would improve her visual experience. The base curve was steepened with an accompanying power change and the over-refraction was incorporated to create the following parameters:

OD: SynergEyes iD EDOF EP
BC = 7.38mm SK= 42 Power = –8.00D

OS: SynergEyes iD EDOF
BC = 7.38mm SK= 42Power = –9.00D

At the second dispense, the patient reported much improved vision. Due to her high rate of progression, she was followed every six months for the next several years. Her rate of progression decreased to an average of –0.25D change each year and her axial elongation normalized for her age (Figure 2).

CASE NO. 3: IRREGULAR CORNEA

A 30-year-old African American male reported with an extensive, unsuccessful contact lens history. His ocular history was remarkable with moderate to severe keratoconus diagnosed at the age of 21. He underwent bilateral penetrating keratoplasty (PKP) two years prior (Figure 3).

He had worn soft toric contact lenses, GPs, and scleral contact lenses, and each had its own shortcomings. The soft toric lenses provided inadequate vision. The GP lenses provided clear vision but randomly ejected from his eyes throughout the day. The scleral contact lenses provided the best overall vision and comfort, but the patient could not tolerate them long term as they would fog after a few hours of wear and caused corneal hypoxia with neovascularization approaching the graft OD and OS. This latter clinical finding was presumably due to the scleral lenses impinging on the limbus. As a result of the high Dk of hybrid lenses and the linear alignment of the soft skirt on the scleral-conjunctival junction, the UltraHealth lens provided a reasonable solution compared with the other contact lens options.

Objective Findings

Manifest Refraction:

OD: –6.00 –5.50 x 037 20/70

OS: –4.75 –4.50 x 122 20/40

Keratometry Values:

OD: 41.80 @ 25.5 / 46.90 @ 115.5

OS: 43.20 @ 146.9 / 47.10 @ 56.9

HVID:

OD: 12.45mm

OS: 12.52mm

As a result of the irregularity of this patient’s cornea, the consultation team assisted with the design of his lenses. The topographical maps and manifest refraction yielded the following parameters:

OD: SynergEyes UltraHealth 290 Vault / 8.1 MED skirt / 14.5mm DIA / –15.50DS

OS: SynergEyes UltraHealth250 Vault/ 8.1 MED skirt / 14.5mm DIA / –10.00D

At the initial dispense, the lenses were well centered with the appropriate amount of central clearance (Figure 4). However, the visual acuity was poorer than desired—OD 20/80, OS 20/50. Spherical over-refraction significantly improved the vision in each eye—OD SOR +2.00 20/30, OS SOR –1.75 20/25.

At the follow-up visit, the patient reported seeing deposits on the lenses that couldn’t be removed with digital rubbing. Slit examination revealed lipid deposits on the centers of the GP lenses. To help mitigate this problem, one additional pair of lenses was ordered with a surface coating. This is a one-time coating that is added to the lens to help improve contact lens problems related to discomfort, dryness, fogging, or deposits. The coating lasts six months or the lifetime of the hybrid lens. The patient was instructed to continue use of his hydrogen peroxide-based cleaner with the new lenses.

After wearing the lenses for several months, the patient was able to enjoy clear, comfortable vision with his current lenses and minimal deposit formation. Additionally, his corneal neovascularization began to show signs of regression.

CASE NO. 4: THE ASTIGMATIC ATHLETE

An 8-year-old African American female presented with her parents in need of a second opinion. Her previous physician informed her that there were limited contact lenses available in her prescription and that she was too young to wear them. The patient was involved in several sports, including volleyball, softball, and basketball. She had been wearing spectacles and sports glasses since she was 4 years old but felt that her athleticism was limited by her need to wear glasses. She had also been diagnosed with mild refractive amblyopia. Both parents were in full support of their child wearing contact lenses, and she was extremely motivated to succeed.

Objective Findings

Manifest Refraction:

OD: +0.50 –3.25 x 005

OS: +1.00 –3.25 x 175

Keratometry Values:

OD: 41.75 @ 179 / 44.50 @ 089

OS: 41.75 @ 175 / 44.50 @ 085

HVID:

OD: 10.5mm

OS: 10.5mm

All contact lens options (soft toric, corneal GP, hybrid, and scleral) were discussed, including the advantages and disadvantages of each. Her predominantly astigmatic prescription created concern for inconsistent vision with a soft lens. A corneal GP, although it would provide excellent vision, may dislodge during sports and could present difficulties with adaptation. The nuances of scleral lens wear and care seemed to overwhelm both the patient and the parents. Lastly, the hybrid option piqued the patient’s interest with the allure of superior vision and comfort combined in one lens.

Because she was a contact lens neophyte, application and removal were a point of concern, but her parents vowed to help her succeed. Surface coatings can make the lenses slippery and more difficult to handle and was not included in the initial order. The following parameters were ordered for her:

OD: SynergEyes iD SV EP
BC = 7.89mm SK= 40Power = –0.50D

OS: SynergEyes iD SV EP
BC = 7.89mm SK= 40Power = Plano

At the dispense visit, the patient reported good comfort and excellent vision in the lenses with 20/25⁺ OD and20/25 OS. There was no over-refraction and the lenses fit appropriately. However, during the application and removal training, the patient really struggled. She was unable to put either lens on herself, which was her primary goal. She returned for three additional training sessions with each visit demonstrating improved technique.

The two most common methods of applying a hybrid lens are the tripod method and the plunger method (Figure 5). The tripod method uses three fingers to mount the lens. The plunger method mounts the lens using a plunger similar to the technique for scleral lens application. Like this patient, many patients prefer the tripod method because it provides proprioceptive feedback.

Removing hybrid lenses is similar to removing soft contact lenses. The key is to make sure that the patient’s fingers are completely dry and place the fingers at 5 and 7 o’clock on the lens before pinching it off. If this is unsuccessful, consider the “tissue” technique, where the patient places a tissue between the forefinger and thumb and uses the same technique as above. This creates a dry surface to facilitate easier removal. There are also rubber finger protectors and finger cots commercially available that serve the same purpose.

Initially, the patient depended on the tissue method but was able to remove the lens without the tissue after a few weeks. She wears and cares for the lenses successfully on her own and reported that the contact lenses improved her game!

Hybrid lenses have traditionally been considered a specialty design reserved for patients who are seeking a last resort. With this mindset, a plethora of patients are missing out on the many benefits of these lenses. Consider this lens design for any patient seeking clear, comfortable, and consistent vision in contact lenses.

References

1. Potter R. The History of Hybrid Contact Lenses. Contact Lens Spectrum. 2015 Nov;30:30,32-35. Available at clspectrum.com/issues/2015/november/the-history-of-hybrid-contact-lenses. Accessed 2024 Sep 6.

2. Díaz-Gómez S, Burgos-Martínez M, Sankaridurg P, Urkia-Solorzano A, Carballo-Álvarez J. Two-Year Myopia Management Efficacy of Extended Depth of Focus Soft Contact Lenses (MYLO) in Caucasian Children. Am J Ophthalmol. 2024 Apr;260:122-131.

3. Shen EP, Chu HS, Cheng HC, Tsai TH. Center-for-Near Extended-Depth-of-Focus Soft Contact Lens for Myopia Control in Children: 1-Year Results of a Randomized Controlled Trial. Ophthalmol Ther. 2022 Aug;11:1577-1588.

4. Sankaridurg P, Bakaraju RC, Naduvilath T, et al. Myopia control with novel central and peripheral plus contact lenses and extended depth of focus contact lenses: 2 year results from a randomised clinical trial. Ophthalmic Physiol Opt. 2019 Jul;39:294-307.

ASHLEY WALLACE-TUCKER, OD, is a partner at Bellaire Family Eye Care and The Contact Lens Institute of Houston. She has received remuneration from CooperVision, Bausch + Lomb, and Topcon.