Proactive Contact Lens Fitting for the Presbyopic Astigmat

The combination of presbyopia and astigmatism can present specific challenges to vision correction with contact lenses. One initial barrier may be patients’ preexisting beliefs about their options. Though multifocal toric contact lenses are available in gas permeable, scleral, and soft lens materials, many astigmats believe they are ineligible for contact lenses. In a 2021 US survey, approximately 46 percent of astigmats either believed their vision problem might prevent them from wearing contact lenses or were not sure (1).

Beyond patient awareness, barriers can exist among eye care practitioners, who may have their own reservations about chair time, requirements for patient follow-up, as well as the probability of success and vision quality achievable with multifocal toric contact lenses – based either on their own previous experiences or on what colleagues have told them (2). Consequently, spectacle-wearing presbyopes and/or astigmats who are interested in contact lenses (even part time) may receive fewer recommendations from their eye care provider (3, 4).

Effective conversations

Generally, success in fitting contact lenses is likely to be greater with a proactive approach (5).  Good opportunities for an initial dialogue with astigmatic contact lens wearers may arise before the onset of presbyopia; waiting until presbyopia has set in risks the patient gradually reducing their frequency of lens wear as near vision becomes more challenging. Though today’s presbyopic astigmat tends to see their eye care practitioner at least once a year, they are still less likely to be aware of multifocal contact lens options, despite recent advances in optical design, ease of fitting, and lens materials – particularly soft silicone hydrogels (6). Understanding this gap, eye care practitioners can differentiate themselves and impact patient satisfaction by proactively discussing multifocal toric contact lenses to eligible patients.

Ideal candidates may be astigmatic contact lens wearers showing early signs of presbyopia or presbyopic astigmats who want to reduce dependence on reading glasses and favor a youthful appearance, active lifestyle, or the convenience of contact lenses. Beyond introducing the option, effective conversations may also include questions to identify patients’ key visual demands, expectations, and preferences/experience with lens care, as well as education around different contact lens materials and design features. Eye care practitioners may consider using real-world examples of challenging visual situations (driving at night, digital device use), hobbies and athletic activities (cycling, tennis), or social occasions (reading a restaurant menu) to describe the effectiveness of multifocal toric contact lenses (1). 

Fitting process strategies

Fitting contact lenses in presbyopes can be more challenging than in other demographics – both for optical reasons and because of age-related changes to the ocular surface (7). Likewise, fitting soft toric contact lenses involves its own set of challenges, including on-eye rotation and stability assessments (8). For multifocal toric contact lenses, being intentional about establishing and adhering to a fitting process can help maximize efficiency and patient satisfaction.

Toric, multifocal, and toric multifocal lenses of different optical designs often come with distinct fitting processes, typically articulated in helpful manufacturer-provided fitting guides specific to each particular lens. Developed by members of the lens design and medical teams, fitting guides ensure that eye care practitioners are given the solution to be successful. Practitioners who attempt their own fitting techniques may inadvertently increase chair time, leading to more follow-up visits and potential frustration. The use of a well-tested, predictable fitting guide together with dependable optical design technologies can help build confidence and ensure the best results.

Successful outcomes

As an illustration, when practitioners used the fitting guide for Bausch + Lomb Ultra Multifocal for Astigmatism lenses, nearly 90 percent agreed that it was possible to get a successful fit on the first visit (9). The lens has also shown good performance in terms of centration, movement, and rotational stability (with rotation of ≤5 degrees at dispensing for 95 percent of eyes (10). 

In a survey of nearly 3,000 patients and over 500 eyecare practitioners trialing the Ultra, 92 percent of practitioners agreed that the fitting guide was simple and straightforward and 94 percent agreed that the lenses were easy to fit (11). Notably, the Ultra Multifocal for Astigmatism lens has a wide range of parameters and requires only two add powers, resulting in a straightforward and predictable fit. 

Another lens in this category, CooperVision’s Biofinity soft toric multifocal lens, uses four add powers and cites a 93 percent success rate when the fitting guide is used (12). 

Though each fitting guide is designed to optimize outcomes with a given lens, some common recommendations for fitting soft toric multifocal lenses include using an up-to-date refraction and add power, allowing lenses to equilibrate on the eye for 10–15 minutes before assessing, and checking vision binocularly, with normal room illumination. It is also helpful to allow patients to test lenses with “real-world” activities – reading their phone or a computer screen, for example.   

A convenient resource

The contact lens selection and fitting process can be further simplified with proprietary web- and app-based tools designed to support eye care practitioners with lens recommendations and fitting guidance. The recently launched Bausch + Lomb FitBetter app features a lens selection tool, instantly accessible fitting guides, and product information resources in one simple platform for eye care practitioners (13). The CooperVision OptiExpert app includes prescription and cost comparison calculators, as well as other reference materials (14).

Given the commonly cited complaints from presbyopic astigmats – that correction options have not kept up with their visual demands – a multifocal toric soft contact lens with a predictable fitting process and established performance can make a key difference in wearer satisfaction.