WITH THE INCREASED FREQUENCY of digital device use and active lifestyles, people make high demands on their vision. The onset of presbyopia can be especially frustrating in today’s world, in which practitioners are challenged to satisfy the visual needs of contact lens wearers, particularly those who require astigmatic correction as well. Thankfully, advancements in contact lens technology now allow practitioners to correct vision for patients who have both astigmatism and presbyopia.
According to the 2020 United States Census, 42% of the US population (66.3 million people) is 45 years old or older.1As presbyopia begins, this population starts to experience blur at near and may start to feel as if they need to hold materials further away to see near work clearly.2 Correcting visual blur can be accomplished with the use of spectacles or contact lenses and, according to a survey conducted by the National Institutes of Health, an estimated 16.7% of adults in the United States wear contact lenses to correct their vision.3
The 2024 Contact Lens Spectrum (CLS) overview of market trends predicted that the soft contact lens market would continue to grow approximately 6% to 7% globally over the next year.4 CLS continues to report that silicone hydrogel (SiHy) lenses consume the majority of market share at 64% of all contact lenses fit, with hydrogel lenses at a not-so-close second with 15% of fits, GP lenses (including small- and large-diameter scleral lenses) with 13% of market share, and finally hybrid lenses representing 2% of fits within North America.4
Correcting astigmatism with contact lenses adds complexity when fitting patients of any age. Research has shown that nearly 50% of all contact lens-wearing patients have astigmatism >0.75 D in 1 eye and nearly 25% have that same amount in both eyes.5 It is generally agreed that, for a patient who has ≥0.75 D of astigmatism in their refractive error, toric correction in a contact lens is required to optimize vision. The majority of patients who have astigmatism can be classified as having regular astigmatism, in which the flattest and steepest meridians of the cornea are 90° apart.
Regular astigmatism can be further divided into 3 categories: with-the-rule (WTR), against-the-rule (ATR), or oblique. WTR astigmatism is defined as having the steepest corneal curvature in the vertical meridian, meaning the vertical meridian requires more minus power than the horizontal, resulting in a refractive power with an axis of 180° (± 30°).6Against-the-rule astigmatism is just the opposite, with the steepest corneal curvature occurring horizontally, resulting in a minus cylinder vision correction with an axis of 90° (± 30°).6 Oblique astigmatism occurs when the steep and flat meridians are 90° apart and located between WTR and ATR meridians.6
When determining the best type of lens correction for an astigmatic patient, one must also consider both the magnitude and type of astigmatism present. Refractive astigmatism is the total amount found in the refractive error, as it combines astigmatic power from both the cornea and the crystalline lens.6 If corneal astigmatism is approximately equal to the refractive astigmatism, the patient may be corrected with either soft toric or spherical rigid GP lenses, depending on the amount of astigmatism.6 If the corneal astigmatism is equal to refractive astigmatism and is less than 2.50 D, a spherical GP can be fit, due to added refractive correction secondary to the tear lens power.6
If, however, the refractive astigmatism differs from the corneal astigmatism and there is ≥0.50 D of lenticular cylinder, a patient is best corrected with soft toric lenses or toric GPs, both of which require rotational stability on eye.6
Early presbyopes may initially self-correct their reduced near vision by wearing their current distance-only contact lenses and purchasing a pair of low-powered, over-the-counter reading glasses. While this option does give clear vision at distance and near, there are many other contact lens options that provide more convenient visual clarity without the need for glasses.
Reading glasses can be cumbersome to carry around constantly, and multiple powers may be needed for computer distance compared to other near visual demands. Additionally, reading glasses can be challenging to use when patients require dynamic vision changes from distance to near for tasks like public speaking.
Monovision
Monovision is 1 way to avoid having to use over-the-counter readers over contact lenses. Monovision is the system for visual correction in which 1 eye is corrected for distance, while the other is corrected for near.7 This causes 2 different images to appear on each retina simultaneously; therefore, patients must learn to suppress 1 of the images (ie, suppressing the eye corrected for near while viewing distant objects and vice versa).8
The dominant eye is most often the eye that is corrected for distance while the nondominant eye is corrected for near.9Eye dominance is a binocular test that utilizes a +1.50 DS to +2.00 DS loose lens. With both eyes open and fully corrected for distance, the plus lens is presented over each eye. The eye that experiences greater distance blur with the plus lens is considered the dominant eye.10
Although the dominant eye is usually corrected for distance, patients who perform near activities most of the day may prefer to have their dominant eye be corrected for near rather than distance.11 This is more patient dependent and is usually attempted when patients have involuntarily switched to their dominant eye while performing near work. Monovision may be a valuable option for astigmatic presbyopes as they can usually keep wearing the same brand of contact lenses they wore before presbyopia by simply adjusting the power in one eye to focus for near. This strategy also keeps the cost of the lenses the same for the patient, although it may require more chair time for the practitioner because the final prescription is optimized based on the patient’s needs.
Although it has great value to the patient, monovision is not without some drawbacks. Patients trying monovision for the first time are accustomed to having a clear retinal image in both eyes simultaneously. As vision will now be blurry in 1 eye and clear in the other, the patient might be disoriented and require a longer adaptation time than they needed with their habitual correction.12 Additionally, higher add powers will require a larger difference in image quality between the 2 eyes, making it difficult to suppress.13 This can lead to a more profound loss of stereopsis.14
Another common complaint of patients wearing monovision contact lenses is glare while driving at night, with as many as 80% reporting symptoms.15 Although most room illumination (overhead lights, streetlamps, etc.) is above and outside of the patient’s field of view, vehicle headlights project a very bright light close to one’s line of sight. This, in combination with the pupil’s mydriatic response in dark environments, results in blur of the patient’s near eye, thereby increasing symptomatic glare.16 Prescribing single-vision distance spectacles over monovision contact lenses for driving may mitigate this.
While we think of visual needs at a range of different distances (distance, intermediate, and near), we can only optimally correct for a certain range with monovision. Over-spectacles may be prescribed with the monovision contact lenses, and many combinations are available to address individual needs.11
Multifocal Contact Lenses: Spherical
Soft multifocal contact lenses are a great option for many presbyopic patients. A number of different spherical multifocal contact lenses are available. Soft multifocal lenses provide vision correction at near, intermediate, and distance simultaneously and require adaptation for first-time wearers.
Patients who have low astigmatism (less than 0.75 DC) may achieve clear vision with a soft spherical equivalent multifocal lens.11 For patients who have moderate to high astigmatism (greater than or equal to 0.75 DC), a spherical GP multifocal may be beneficial. GP multifocals offer superior vision compared to soft multifocals due to their optical design and tear lens.17 The tear lens can correct low to moderate amounts of corneal astigmatism, usually less than 2 D. This tear lens also allows the GP lens to rotate slightly without inducing unwanted cylinder power. Higher amounts of corneal astigmatism may cause the lens to decenter along the steep meridian.18
The multifocal optics available in GP lenses can include simultaneous vision correction (Figure 1), as available in soft multifocal designs, and can also be designed with optics more similar to those of a progressive addition lens (PAL) or bifocal spectacle lens. Segmented, translating lenses (Figure 2) are designed to align different parts of the lens with the visual axis. For example, as a patient wearing these GPs looks down to read, the GP lens translates and shifts to the superior cornea, resulting in a single clear image on the retina. This inherent quality of GP lenses results in visual clarity that is far superior to that of soft multifocal lenses.19
Along with superior vision, GP lenses could be more cost effective compared to soft contact lenses. However, patients who worry about losing lenses may have more peace of mind using a soft disposable lens.
Multifocal Contact Lenses: Toric
Another option for astigmatic, presbyopic patients is soft multifocal toric lenses. Soft multifocal torics are fit similarly to single-vision toric lenses and are a great option for those unable to adapt to GP lenses. Planned replacement toric multifocal lenses offer presbyopic correction and astigmatism correction up to –5.75 D cylinder power. With increased brand options and improved optics, this method of correction has gained popularity. However, limited parameter availability and lack of fitting sets from commercial contact lens manufacturers present challenges to practitioners when fitting patients with high toricity. Higher cylinder correction can be custom made by various laboratories.11
As with single-vision soft toric lenses, the lens rotation of toric multifocals may induce uncorrected cylinder power, especially with higher toric powers6 (Figure 3). In these cases, a multifocal GP could offer superior vision. Those patients who have residual astigmatism or high corneal toricity with GP lenses may be fit in a front-surface toric or bitoric multifocal, respectively.11
Specialty Multifocal/Monovision
Some patients may wear specialty contact lenses for various ocular conditions and also require astigmatism and presbyopic correction. These lenses may include scleral and/or hybrid lenses, both of which are available in multifocal options.
With these lenses, astigmatism is corrected with the tear lens, and residual astigmatism may be resolved with front-surface toricity, depending on the manufacturer.20 Otherwise, a monovision approach with specialty lenses may still be viable if the toric multifocal is not available. Additionally, while uncommon, monovision orthokeratology (ortho-k) may be attempted in current ortho-k wearers. The myopia of the nondominant eye is typically undercorrected to provide adequate near vision during the day without the need for daytime contact lens wear.21
Additional Considerations
Although the above techniques might be available and appropriate for patients, there are several factors to consider when determining the best initial method for correcting astigmatism and presbyopia. As practitioners, we must present all options with transparency, educating patients about considerations including cost and potential chair time.
These can be limiting factors for patients and could help determine the best initial lens selection. Other aspects to think about are patient occupation and hobbies that involve specific visual demands and needs.
Knowing this information will guide lens selection, help provide the clearest form of communication between patient and practitioner to ensure transparency from the very beginning, and promote a positive exam environment. Some clinical pearls on fitting contact lenses for presbyopic patients can be found in Table 2.
Conclusion
There are a multitude of options available to correct vision for patients with both presbyopia and astigmatism. Knowledge and mastery of the available options will allow practitioners to help patients meet their visual needs while limiting valuable chair time.
References
1. US Census Bureau. Age and sex composition in the United States: 2023. census.gov/data/tables/2023/demo/age-and-sex/2023-age-sex-composition.html. Published April 24, 2024. Accessed March 27, 2025.
2. American Optometric Association. Adult vision: 41 to 60 years of age. aoa.org/healthy-eyes/eye-health-for-life/adult-vision-41-to-60-years-of-age?sso=y. Accessed February 1, 2025.
3. Cope JR, Collier SA, Rao MM, et al. Contact lens wearer demographics and risk behaviors for contact lens-related eye infections--United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(32):865-870. doi:10.15585/mmwr.mm6432a2
4. Nichols JJ, Fisher D. Contact lenses 2024. Contact Lens Spectrum. 2025;40(1):2-13,15-16,18-19. clspectrum.com/issues/2025/januaryfebruary/contact-lenses-2024
5. Young G, Sulley A, Hunt C. Prevalence of astigmatism in relation to soft contact lens fitting. Eye Contact Lens. 2011;37(1):20-25. doi:10.1097/ICL.0b013e3182048fb9
6. Bennett ES, Henry VA, Kinoshita BT, Lampa M. Correction of astigmatism. In: Bennett ES, Henry VA, eds. Clinical Manual of Contact Lenses, 5th ed. Wolters Kluwer PE. 2020:388-439.
7. Finkelman YM, Ng JQ, Barrett GD. Patient satisfaction and visual function after pseudophakic monovision. J Cataract Refract Surg. 2009;35(6):998-1002. doi:10.1016/j.jcrs.2009.01.035
8. Collins MJ, Goode A. Interocular blur suppression and monovision. Acta Ophthalmol (Copenh). 1994;72(3):376-380. doi:10.1111/j.1755-3768.1994.tb02777.x
9. Jain S, Arora I, Azar DT. Success of monovision in presbyopes: review of the literature and potential applications to refractive surgery. Surv Ophthalmol. 1996;40:491-499. doi:10.1016/s0039-6257(96)82015-7
10. Hom MM. Monovision and bifocals. In: Hom MM, ed. Manual of Contact Lens Fitting and Prescribing with CD-ROM. 2nd ed. Boston: Butterworth-Heinemann. 2000;327-354.
11. Bennett ES, Henry VA, Richdale K, Benoit DP. Multifocal Contact Lenses. In: Bennett ES, Henry VA, eds. Clinical Manual of Contact Lenses, 5th ed. Wolters Kluwer PE. 2020:440-491.
12. Westin E, Wick B, Harrist RB. Factors influencing success of monovision contact lens fitting: survey of contact lens diplomates. Optometry. 2000;71(12):757-763.
13. Hansen DW. It’s time to minimize monovision. Contact Lens Spectrum. 2001;16(1):15. clspectrum.com/issues/2001/january/prescribing-for-presbyopia
14. Woods J, Woods C, Fonn D. Visual performance of a multifocal contact lens versus monovision in established presbyopes. Optom Vis Sci. 2015;92(2):175-82. doi: 10.1097/OPX.0000000000000476
15. Labiris G, Toi A, Peterente A, Ntonti P, Kozobolis VP. A systematic review of pseudophakic monovision for presbyopia correction. Int J Ophthalmol. 2017;10(6);992-1000. doi: 10.18240/ijo.2017.06.24
16. Johannsdottir KR, Stelmach LB. Monovision: a review of the scientific literature. Optom Vis Sci. 2001;78:646-651. doi:10.1097/00006324-200109000-00009
17. Byrnes SP, Cannella A. An in-office evaluation of a multifocal RGP lens design. Contact Lens Spectrum. 1999;14(11):29-33. clspectrum.com/issues/2001/january/prescribing-for-presbyopia
18. Anderson G. A GP bifocal for active presbyopes. Optom Manag. 2003;38(6):74. optometricmanagement.com/issues/2003/june/contact-lens-management-a-gp-bifocal-for-active-presbyopes
19. Bennett ES. Innovations in gas permeable multifocal contact lenses. Clin Optom. 2010(2):85-90. doi:10.2147/OPTO.S7021
20. Collier C. GP, hybrid, and scleral multifocals. Rev Cornea Cont Lenses. 2018:16-19.
21. Gifford P, Swarbrick HA. Refractive changes from hyperopic orthokeratology monovision in presbyopes. Optom Vis Sci. 2013;90(4):306-13. doi:10.1097/OPX.0b013e318287328e