Prescribing for Astigmatic Patients

Can We Do More?

Highlights from a roundtable discussion held during the 2010 Global Specialty Lens Symposium in Las Vegas

Prescribing for Astigmatic Patients: Can We Do More?

Eyecare professionals have access to a wealth of information from numerous sources: conferences and congresses, medical books and periodicals, peer-to-peer discussions and industry representatives, to name just a few. Sometimes, however, patients can be significant sources of information. Understanding patients' perspectives is the key to providing them with the best visual solutions for their lifestyles and needs, which, in turn, allows practices to thrive.

A panel of eyecare professionals met during the 2010 Global Specialty Lens Symposium in Las Vegas to discuss providing optimal vision correction to astigmatic patients. Among the topics they covered were the results of national surveys that revealed untapped opportunities in the astigmatic population. Some of the most compelling findings reflect the prescribing patterns of contact lens practitioners. For example, in a 2009 survey by the Gallup Organization, 41% of patients reported having astigmatism. Another survey, conducted in 2005 by Health Products Research, however, revealed that of the 34 million patients using soft contact lenses, only 21% were wearing soft toric contact lenses.

Surveys can also shed light on patients' perceptions of their astigmatism and their vision-correction options. In a 2008 survey by Decision Analyst, which was sponsored by Bausch + Lomb, 40% of patients believed their astigmatism precluded them from wearing contact lenses, yet only 12% indicated their astigmatism was severe. These surveys highlight not only the prevalence of this vision disorder, but also the large percentage of astigmats who are still unaware of the contact lens options for astigmatism.


As surveys have revealed, patients may not be wearing soft toric contact lenses because: 1) they think they can't wear contact lenses because they have astigmatism; 2) they don't know there are contact lenses for astigmatism; or 3) they had poor experiences with previous generations of toric lenses. The roundtable panelists agreed that educating patients about all of their vision-correction options — and for astigmats, that includes soft toric lenses — is pivotal.

"Patients want to know what's new and better for them," said Timothy B. Edrington, OD, MS, who suggested that a discussion of these options should be combined with a trial fitting. "The best thing you can do is be proactive in inviting patients to experience the comfort and excellent vision that is possible with soft toric lenses. Patients are going to enjoy their vision and comfort."

This attention to educating patients has the potential to produce positive results. A 2008 survey by Decision Analyst found that 66% of astigmats who had never worn contact lenses and 44% of previous contact lens wearers would be highly motivated to wear toric lenses. "Patients are looking for freedom from their glasses," said Kaaryn Pederson, OD. "All we have to say is, ‘There are contact lenses that can do almost everything your glasses can do. Are you interested?’"

Keeping current with technological advances in lens designs and materials is an ongoing process for eyecare professionals. "When I think about what's different since I started fitting toric lenses, I realize the lenses today are significantly improved," Dr. Edrington said. "They are reproducible. There are many more options in silicone hydrogel materials, and we have an extended range of available parameters."

In addition to meeting the needs of patients with higher cylinder, these practitioners also offer soft toric contact lenses to their patients with lower cylinder, some of whom may have been wearing spherical lenses in the past.

"If my patient's chief complaint is decreased vision with his contact lenses — let's say the previous practitioner was trying to mask 0.75D of cylinder with a spherical lens — he can easily be converted to toric lenses," said Susan J. Gromacki, OD, MS. "This is especially true with patients who notice an improvement in vision through the phoropter."

Dr. Edrington agrees: "If I put a half diopter of cylinder in the phoropter and the patient says he sees remarkably better, then I'm apt to talk to him about trying a toric lens. In the past, I never would have considered doing that, but when patients say, ‘I see more clearly through my glasses than I do with my contacts,’ even with low astigmatism, I know a toric lens will be beneficial for them."

As Dr. Gromacki noted, providing optimal vision is the goal of all eyecare professionals. "Practitioners don't think twice about correcting small amounts of cylinder with spectacles or refractive surgery," she said. "So why change our standard of care when we prescribe contact lenses? We can now give our patients that three-quarters of a diopter in a soft toric lens."

The panelists agree there is a misperception among some eyecare practitioners that fitting toric contact lenses requires more chair time compared with fitting spherical lenses, but that is no longer true. "With today's stabilization methods, materials and reproducibility, the chair time for fitting toric contact lenses is much less than in the past," Dr. Gromacki said. "It's similar to fitting a sphere." As Dr. Pederson noted, "A recent study by Young and colleagues1 showed that four popular toric lenses stabilized from a 45-degree mislocation in 39 blinks or less or in approximately 2 minutes."

What adds time to a patient's visit is not the contact lens fitting, the panelists agreed, but the dialogue with the patient that surrounds it. These discussions are necessary to learn about a patient's lifestyle, work environment and economic situation, as well as to determine his vision needs and current eye health. The aspect of patient communication that is most time-intensive, however, is providing background information on treatment options.

"The discussions you have with patients about their contact lens options, what they can expect from each type, and the differences between them, usually takes the most time," Dr. Pederson explained. The panelists agreed that office staff can play an important role in this portion of patient communication. (See "Educating Efficiently.")

"Educating your staff on how to talk to patients is key," said Katrina E. Parker, OD. As Dr. Gromacki noted, "Your staff needs to be in line with your philosophy. That way, patients receive the same message from everyone in the practice."

According to Dr. Edrington, when staff members realize how important a role they play in preserving and enhancing vision, they tend to take a greater interest in the practice and its patients. "Staff members aren't always aware of what takes place in the examination room, and often, they may not share the excitement generated by contact lens wear," he said. By explaining the tests and procedures performed in the office and how they improve patients' lives, staff will feel that they are integral members of a healthcare team.

Educating Efficiently

Educating patients about their contact lens options can start as soon as they enter your office. In addition to having pamphlets, posters and videos about astigmatism and toric lenses in their offices, the panelists make sure their staff members know how to identify astigmats and what to say to them. In the practice of Katrina E. Parker, OD, the staff member who handles pretesting may begin the education. "If she sees from the autorefraction printout that a patient is astigmatic, she starts a conversation about what that means as she walks the patient to the examination lane."

Not only educating staff, but also fitting them with new products creates a positive environment in the practice, underscoring the value of their services. "It's important to get the staff excited about what you do," said Timothy B. Edrington, OD, MS. "If someone in the office wears toric lenses and exudes confidence and excitement about the product, she will share her positive experiences with your patients."


Once astigmats are wearing toric contact lenses, the challenge is to ensure they continue to be successful with them. Once again, effective patient communication is key.

In the 2009 Decision Analyst survey, 84% of toric wearers said they experienced blurred or fluctuating vision that may be related to rotational recovery issues. According to the panelists, it's important to tease out patients' impressions and experiences with their lenses, whether they're new to soft toric lenses or long-time wearers, to assist the practitioner in optimally addressing a patient's concerns.

"Many times, patients won't say they have a problem," Dr. Pederson said. "They may not know exactly how to communicate their visual symptoms. By asking a simple question — Does your vision ever fluctuate during the day? — I can find out what I need to know." For example, if a patient reports his vision occasionally becomes blurry but clears up after he blinks a few times, this may merely be an observation, not a complaint, Dr. Parker noted. If blurry or fluctuating vision becomes problematic, however, these practitioners may consider switching the patient to a lens with a different stabilization design to address rotational recovery issues.

Rotational recovery refers to how quickly a lens returns to the desired orientation after a disruption, such as eye rubbing. Rapid rotational recovery reduces the potential for variable vision or loss of visual quality. (For more information on rotational stability, see "Toric Lens Performance: Insights Into Orientation Stability" in this supplement issue.)

Dr. Edrington noted that it's important to find out what patients are experiencing. "We tend to focus on the numbers as opposed to what the patient is telling us," he said. "I want to find out what level of happiness and excitement will ensure they remain successful toric lens wearers."


Consumer polls and surveys reveal a large, motivated but underserved population of astigmats, many of whom are not aware they can wear contact lenses. By combining their technical skill and knowledge with information about patients' perceptions and desires, practitioners can deliver optimal vision correction to all patients. Advances in contact lens materials, such as greater oxygen permeability, and in toric lens designs, such as improved stabilization and faster rotational recovery, make it possible for most astigmats to enjoy consistent, crisp vision with contact lenses. According to surveys, a significant segment of the astigmatic population is just waiting to be introduced to toric lenses, and another segment would appreciate switching from spherical to toric lenses.

Putting these opportunities into historical context, Dr. Edrington said: "It's rewarding to be able to offer our patients new and improved contact lens options. For example, I loved it when we went from PMMA to GP lenses, and recently from hydrogel to silicone hydrogel lenses. We have the same opportunity with today's soft toric lens options. They are making patient care more exciting, especially when I see the smiles on patients' faces.

"I often hear that practitioners don't want to ‘rock the boat,’" Dr. Edrington said. "I would encourage everyone to rock it a little bit. Offer your patients new options. They will want to return to your practice."


1. Young G, McIlraith R, Hunt C. Clinical evaluation of factors affecting soft toric lens orientation. Optom Vis Sci. 2009;86:1259-1266.