In my practice, I’ll admit that most of my bitoric GP lens orders are for those patients who have been wearing the lens design for many years. They have adapted to wearing GPs, they realize the optical benefits, and they are committed to the modality. As the options in soft toric contact lenses continue to expand, it’s getting easier for us to just order trials for our new contact lens patients. We can then troubleshoot vision with over-refraction or the LARS (left add, right subtract) rule. Occasionally, a patient may need a custom design to improve rotational stability or centration.

With all of these advances in soft contact lens technology, when does a bitoric GP lens become the first-line option for patients who are new to contact lenses and have moderate or higher astigmatism?

Kids Are Great Candidates

My favorite time to introduce bitoric GP contact lenses is to young kids who have moderate astigmatism. If they are the ones interested in contact lenses (versus only their parents), their motivation will remain high through the adaptation period, which will help them to eventually become successful GP lens wearers.

I have found that realistically preparing children—with regard to what the lenses will feel like—pays off during the first visit. I usually say something like, “Every time you put the lens on your eye, you will feel it less than you did the time before, until you eventually don’t feel it at all,” and “Yes, you can feel the lens, and that’s OK. It isn’t hurting your eye or eyelids.”

After lens application, I’ll also have them maintain a downward gaze for the first few minutes to decrease the edge awareness and improve confidence. I may or may not use anesthetic drops on the first visit, depending on our discussion about how the lenses will feel and the child’s maturity level. I will also educate the patients’ parents about what to expect at home. Experiences such as eye watering and lens awareness are OK, while increasing eye redness and pain (even after the lens is removed) would warrant a phone call to our office.

GP or Soft Lenses?

There are significant long-term corneal health benefits with GP lenses for our young patients. It’s been reported that 10% to 30% of contact lens wearers develop corneal neovascularization, with GP lens wearers having the lowest risk (Alipour et al, 2017). Yes, there are toric lenses available in silicone hydrogel, but the oxygen transmission and tear exchange of a well-fitting GP lens will always win the oxygen battle due to the smaller diameter and lens movement. GP lenses also carry the lowest risk of microbial keratitis at just 1.2 per 10,000 wearers (Stapleton et al, 2008). Promoting safe, lifelong contact lens wear should be a top priority for our young patients.

Certain children may do better in soft contact lenses. For example, those who wear contact lenses part time, or those who are active in a physical or acrobatic sport, such as soccer or gymnastics, may prefer to wear soft lenses to decrease the risk of lens ejection.

Don’t Fix What’s Not Broken

In the future, scleral contact lenses may be a more mainstream recommendation for children who have astigmatism, but at this point, more research and long-term outcomes are needed before I will start shifting my recommendations. Bitoric corneal GPs remain a first-line option for the right patients in my practice. I appreciate the vision and corneal health benefits, and my patients appreciate having a high-performing, custom option for their vision correction. CLS

For references, please visit and click on document #267.