Fitting toric soft contact lenses should be something that every eye care professional embraces for the benefit of their patients. If you are fitting the “spherical equivalent” or spherical contact lenses when a patient needs a toric lens due to a higher astigmatic correction, then the patient is not receiving 100% of your experience or knowledge. Sometimes, fitting the spherical equivalent in higher astigmatic patients will result in less than 20/20 visual acuities and a less than optimum fit on the cornea. Occasionally, a patient is limited as to their options simply due to cost or insurance issues. It is our job to educate our patients and have them “see” the benefits if the overall astigmatism warrants a toric soft contact lens. Sometimes the spherical equivalent or a spherical contact lens may work very well – even be the optimum fit. But, there may also be times when that is just the easy way out and the patient should have received a soft toric lens for optimal visual acuity. It is our job to be certain that every contact lens placed on an eye fits properly beyond the limbus, moves adequately on the cornea, provides enough oxygen to prevent corneal complications, and provides superb vision at all viewing distances. In times where managed care companies, insurance companies, and patients are trying to control and regulate costs, it is our job to advise our patients what their best options are for their circumstances. Sometimes this option may require out-of-pocket expenses for patients. This is especially true because toric soft contact lenses are often not covered through insurance.

Toric Lens Options

There are many contact lens modalities available that can benefit our patients today. There are many options available and in large ranges of sphere and cylinder powers, various base curves, various diameters, and various Dk values. Many soft contact lenses have UV-absorbing properties, but are not necessarily a substitute for UV-absorbing eyewear such as sunglasses.

Almost anyone who wants contact lenses should be able to be fit properly. I have found too often that new patients coming to my office have been told that they are not candidates for contact lenses due to their astigmatism. This myth must be removed from public perception. Tyler’s Quarterly provides eye care professionals with a database containing the knowledge and information that can help you fit virtually any patient. If you do not receive this quarterly journal, you can access their website at www.tylersq.com. This journal is updated every 3 months and is a must for any office. Every contact lens company lists their current products including their specific toric lens inventory in the quarterly.

Most contact lens companies provide trial lenses to the ECP in order to try toric lenses on this population that so often seeks viable answers from us. With the diversity and abundance of contact lenses on the market, contact lens wear options are quite numerous. Whether your patient has 0.75D of astigmatism or 5.75D of astigmatism there is at least one option available if not more. Furthermore, with the quality of lenses on the market today, there is no reason why we should not aim for 20/15 vision, as we often do with our spherical patients - assuming they are capable of such superb vision. Even presbyopic patients may find happiness with distance-only toric contact lenses.

Wearing a pair of glasses for reading over the distance contact lenses can be another option for patients who do not want bifocal toric soft contact lenses or if the cost is a significant deterrent. Bifocal toric soft contact lenses are available from Bausch + Lomb, CIBA Vision, Vistakon, CooperVision, PolyVue, Unilens, Blanchard Contact Lens Co., Gelflex, Metro Optics, Special Eyes, Unilens, and X-Cel Contacts. CIBA Vision and CooperVision are now offering daily toric lenses as a new contact lens modality. Of course, several companies are now providing silicone hydrogel lenses with high oxygen permeability and high Dk values.

Monovision can be provided as another option for the presbyopic population with the understanding that binocular vision and depth perception will be affected. These monovision patients should always be provided with the option of having a third contact lens for distance or near. Providing a pair of distance, reading, or preferably, bifocal spectacles should always be offered as a back-up to the contact lenses or for use if an emergency occurs.

Toric Fitting Pearls

Every eye care professional that fits any type of contact lens has a standard examination that provides diagnostic information. This data includes the refractive status of the eyes, and both current health information as well as health history. Sometimes these standard examinations may vary depending upon the problems that are encountered and the specific visual needs of a patient. It should be stressed that any contact lens examination, fitting process, follow-up care, lessons, and educational processes should not be time-dependent. Patients expect the best that we can offer and we should spend the maximum time necessary with each and every patient. It will pay off in the long run. Trial frame refractions will provide the most accurate representation of a patient’s refractive error and in the most realistic setting. This is especially true when the astigmatism axis should be as accurate as possible or when there is a significant change to their prescription.

Biomicroscopy must be detailed and exact in order to properly evaluate the quantity and quality of the tear film, cornea health, eyelids, eyelashes, and conjunctiva for a proper contact lens fit. Any abnormalities may affect a positive visual and fitting outcome. Pupil size should be evaluated in bright, dim, and normal lighting. Pupil size can affect a good visual outcome especially when fitting bifocal contact lenses.

Keratometry readings will provide more information in addition to the refraction, auto-refractor, and retinoscopy tests. If your office is equipped with a corneal topographer the data derived from this instrument will be even more detailed. Some topographer’s come with software that will simulate the fit of a lens on the patent’s eye without ever placing a lens on their cornea – at least for the initial lens selection. This software can greatly speed up the fitting process by possibly eliminating false starts. All fittings must be thorough with the correct base curve, diameter, thickness, and prescription findings used to order trial lenses.

Patient Education and Minimizing Liability

A thorough educational process with lessons involving insertion, removal, use of contact lens solutions, time-use of the lenses, wearing schedule, do’s and don’ts, as well as a question and answer session should be included as a part of the fitting process. Patients must sign a disclosure form or informed consent form being made fully aware of the risks of contact lens wear. Parents or guardians of children must be involved with these instructional sessions. Many companies have CD-ROMs available for patient education presentations that simplify this procedure. The Internet is filled with great educational information. If you view the popular site “You Tube” and search for “Contact Lens Instructions”, 159 videos appear for your educational information. But, be sure to review these videos in advance to verify accuracy.

Written instructions should be provided once the patient receives their trial lenses. These instructions should include the wearing schedule as well as a telephone number to contact in case of any emergency. The patient’s chart should indicate their receipt of these written instructions. A follow-up, final check-up should be scheduled before the patient receives their trial lenses. By federal law, the contact lens prescription must be provided to the patient when the fitting is completed.