Torics, bifocals: industry experts provide fitting advice, market predictions

Round Table Participants
Michael D. DePaolis, OD, FAAO, Editor of Primary Care Optometry News, is in private practice in Rochester, N.Y.	Richard P. Franz, OD, FAAO, is vice president of professional relations for Ocular Sciences, San Francisco.
Ron Seger, OD, FAAO, is director of professional services for CooperVision Inc., Fairport, N.Y.	Michael D. Pier, OD, is director of professional relations for Bausch & Lomb, Rochester, N.Y.
Dwight H. Akerman, OD, FAAO, is director of professional services for Wesley Jessen, Des Plaines, Ill.	Stanley J. Yamane, OD, FAAO, is vice president of professional affairs for Vistakon, Jacksonville, Fla.
Nikki Iravani, OD, is director of clinical and professional services for Specialty Ultravision, Campbell, Calif.	Richard E. Weisbarth, OD, FAAO, is executive director of professional services, North America, for CIBA Vision, Duluth, Ga.

Michael D. DePaolis, OD, FAAO: Let’s start by talking about astigmatic corrections. Is it now, more than ever, important that optometrists view small amounts of uncorrected astigmatism in a completely different light than they have before?

Dwight H. Akerman, OD, FAAO: Throughout the 1970s and 1980s, practitioners talked about masking astigmatism with spherical soft lenses. That term has finally fallen by the wayside, and during the past 3 to 5 years, that terminology is not heard anymore in lectures or in conversations. Practitioners understand that the astigmatic soft lenses that are available today really do a much better job of correcting astigmatism than any spherical soft lens, including the very stiff spherical soft lenses.

Michael D. Pier, OD: The number one attribute contact lens patients seek in their vision correction from eye care practitioners is clear vision. If patients become frustrated with the visual performance of their contact lenses, they are more likely to stop wearing them. In a multicenter investigation of more than 800 low-cylinder astigmatic patients wearing spherical lenses, we found that 90% of these patients preferred the vision provided by the SofLens66 Toric over their previous spherical lens. New design technology for toric lenses allows practitioners to improve the visual performance of many low-cylinder astigmats who are currently wearing spherical lenses.

Nikki Iravani, OD: Patients’ lifestyles today really demand that practitioners address that issue and correct for that uncorrected astigmatism. Years ago, maybe their lifestyles weren’t such that they were bothered by residual astigmatism. With all the computers and the detailed work in which most professionals are involved, you really don’t have any choice but to address those issues and to correct patients’ vision properly. That is why we’ve seen such excellent growth in the specialty lens segment, especially in the toric segment, in the past few years, and we will continue to see an extremely high growth, probably more than we will see in the other segments of the market.

Stanley J. Yamane, OD, FAAO: Colleagues have shared that when existing spherical contact lens patients with low amounts of residual astigmatism are shown, with -.75 D hand-held trial lenses, the improvement a toric lens can provide, they usually prefer the sharper vision. Leaving uncorrected low amounts of astigmatism is a thing of the past.

Richard P. Franz, OD, FAAO: While the patient is still in the phoroptor, I dial out the cylinder correction for astigmatism, and then dial it back in so the patient can actually visualize the difference and see the effect of 0.75 D of astigmatism. Some patients are sensitive at 0.50 D of astigmatism, especially if they have 0.75 D of cylinder in one eye and 0.50 D in the other and you’re correcting the 0.75 D on one eye.

Word is getting out

Richard E. Weisbarth, OD, FAAO: The word is finally getting out. For a long time, many patients were told that they had astigmatism and that, subsequently, they couldn’t wear contact lenses. It’s almost as if the patients are waiting for the practitioners to tell them that there are new advances, and the practitioners are waiting for the patients to ask. It has been a standoff, but the word is finally getting out that there are contact lens options available for patients who have astigmatism.

Dr. DePaolis: The 20-year-old with 0.75 D of cylinder and unlimited focusing reserve certainly is a different scenario from the 38-year-old software engineer who’s spending 8 or 10 hours a day in front of a computer. At what level do you start thinking about using a toric soft lens?

Ron Seger, OD, FAAO: If a patient has 0.75 D refractively, I always demonstrate it so that he or she understands that it is an option. I find that two-thirds, maybe even 80%, of patients will opt for it when you show them the improvement in quality of vision. They will especially appreciate it while driving at night and in those low light situations where the pupil is dilated and there’s not a great depth of focus and depth of field. Sometimes cost is a factor, but costs have come down dramatically. Additionally, predictability and comfort are good. It really is a different scenario than it was 5 or 6 years ago when new technology, in terms of improved quality of toric lenses, was introduced. It really has been a breakthrough.

Spherical aberrations

Dr. DePaolis: Does putting a little asphericity on the front surface of the lens help with small amounts of astigmatism or does it help more with spherical aberrations?

Dr. Seger: Clinically, they’re not different. If you reduce aberration, then you’re going to improve quality of vision, and that’s the bottom line. That’s what patients take home with them at the end of the day. They are separate aberrations, but the reality is that they’re cumulative, so if you can reduce the spherical aberration effect and still have some astigmatism left, patients will appreciate that difference, especially at higher powers.

Dr. Iravani: I absolutely address astigmatism, starting with 0.25 D. I mention it to the patient, and I offer him or her options that are available, especially at 0.50 D to 0.75 D. I always start with an aspheric design in that low of a prescription because it will address issues such as a little bit of a haze or blur. But then after 1 D, toric contact lenses are definitely the best option.

Empirical fitting

Dr. DePaolis: Let’s discuss expediting contact lens fitting while minimizing the number of diagnostic lenses. Given what’s available in terms of toric soft lenses today, do you feel empirical fitting, that is, selecting the initial lens strictly on keratometry and refraction, should be done? Or are you still entrenched in the thought that it’s best to put a lens on an eye and evaluate it?

Dr. Yamane: You should select your initial lens on an empirical basis. Putting the initial lens on the eye is the only way to really evaluate how it fits, because the lens may fit differently as it settles in. You can then make the appropriate compensation if any is necessary.

Dr. Akerman: I would generally prescribe a soft toric lens, but I think 0.75 D should be the cutoff point for all directions of astigmatism, whether it be against-the-rule, with-the-rule or oblique. As we know, approximately 45% of the refractive population has 0.75 D or more of astigmatism, so the potential patient pool is, indeed, huge.

Regarding fitting soft toric lenses, studies we have conducted with our lenses have shown that we get about an 80% success rate by empirically fitting our soft toric lenses, but, indeed, a full 20% do require some adjustment. It’s comforting to the practitioner that eight out of 10 times they will be able to prescribe the correct lens the very first time. That is a huge reduction in chair time, which is very important in today’s managed care scenario.

Diagnostic lenses

Dr. DePaolis: If you don’t have the exact lens in inventory, do you order the diagnostic lens simply based on Ks and refraction? Or do you prefer to diagnostically fit an approximate lens, overrefract and then order?

Dr. Seger: All the products work well and are reasonably predictable, but, in terms of chair time and efficiency, it’s so much nicer to have an inventory. Working from an inventory is a real asset in terms of my time and patients’ time because there’s one fewer office visit. Additionally, you can get immediate feedback — if you put on a diagnostic lens, you have an idea of where to go next. You still may need to order another lens, so it’s very helpful to have the fitting inventory whenever possible.

Dr. Franz: A few things have to take place, and they’re dependent on each other. The first is that lenses have to improve in the area of reproducibility and manufacturing consistency. Additionally, practitioners need to better understand their ability to fit low cylinder patients, because a lot of what’s gotten us to the point where practitioners don’t fit low cylinder is the frustration of putting a lens on and not having it perform or not having the patient respond.

If you can put a –0.75 D cylinder on and have it work consistently, why wouldn’t you do it if the patient is going to get better vision? You will probably have better fees and better margins. All the way around, it makes sense to correct that low cylinder if it works the way that we think it should.

We’re getting ready to launch a new toric lens. This has been a joint project between the CCLRU [Cornea and Contact Lens Research Unit, University of New South Wales]/Institute for Eye Research and Ocular Sciences. We started this project by benchmarking every toric lens we could find. We were all surprised, to some degree, by the amount of variability that exists, even in today’s products.

Private practitioners don’t understand how complex manufacturing a product like a toric lens is. It is difficult to develop a disposable product at a high volume and low cost.

Dr. Weisbarth: The availability of trial lenses has made a difference over the years. The initial trial lens is fit empirically. Depending on how it performs, you may have to reach for the next one, but the wide availability of trial lenses has totally changed the way the practitioner looks at toric lens fitting. In addition to the improvements in manufacturing technology, that’s probably the single biggest thing that’s affected the practitioners’ ability to pragmatically fit patients in a profitable fashion.

Large inventory

Dr. Iravani: Still, with the toric lens designs, even with the best ultimate design, you need to provide the practitioner with an inventory of thousands of lenses just to have the entire spectrum. If you had two base curves, it would be a few thousand.

We need to have a lens available that will allow practitioners to fit astigmatic patients with an inventory of 200 lenses. So, 10 base curves in 0.1-mm steps will cover your entire spectrum. You can have that available in your inventory. Doctors can put it on the eye, dispense that same day and let the patient go. Potentially, physicians can replace their stock and not have to bring the patient back for an extra visit. That’s where the market will be in the next generation.

Maximum degree of rotation

Dr. DePaolis: What is the maximum degree of rotation you would expect from your particular product?

Dr. Yamane: It’s not so much the magnitude of rotation, but whether or not it stabilizes and settles in consistently at a particular position. We only have one base curve/diameter combination, so, consequently, if the lens continues to rotate on the blink, I would tell the practitioner to try a competitor’s lens, because our lens will not work. We believe we have our process down so tight that every lens will fit exactly the same.

So, if the first lens settles in at 20°, whether you put on another lens or another 1,000 lenses, every one will rotate that same magnitude. So, your second lens, based on the axis adjustment you make, will result in the visual performance you want.

Dr. Akerman: The markings on all Wesley Jessen contact lenses are 20° apart, because if a lens rotates more than 20°, it will not ultimately be stable on that patient’s eye. Therefore, we believe that a soft toric contact lens can rotate up to 20° as long as it’s stable.

Dr. Pier: Predictability is essential for making toric lenses easier to fit for practitioners and for providing improved visual performance for patients. In an evaluation of more than 5,000 eyes fit with our newest toric lens, we found that 96% of the lenses had rotation of 0 to 10°. This should improve the fitting success dramatically when ordering directly off the spectacle Rx. We believe this will also improve patient satisfaction with the visual performance of the lens. If lenses are rotating 30° or more, the patient will experience less success than if the lens is rotating 0 to 10°.

For toric lens designs, it is also important to evaluate the effect of lid tension on the lens in a dynamic setting. After evaluating the lens in primary gaze, the lens should be rotated 45° and allowed to resettle. The lens should quickly return to its original orientation. The orientation recovery is a more dynamic indicator of stability. Patient satisfaction with the visual performance of the toric lens should be greater when the lens quickly returns to its original orientation.

Dr. Seger: It depends on the amount of astigmatism you’re trying to correct. There may not be just one answer. If you look at the lens on the eye and you look at the marking, one clock dial time (6 o’clock to 5 o’clock or 6 o’clock to 7 o’clock) is 30°. Some lenses on some eyes rotate that amount and are stable. It’s unrealistic to say you can only do a certain number of degrees, because it depends on the patient.

For some patients, the anatomy of the lid is such that the lens will rotate a lot. No matter what lens you put on, it’s still going to rotate. Vision will be stable, and other factors then start to play a role in what you end up with for the patient in terms of the overall service you get from the manufacturer and the quality of the product. Reproducibility has risen dramatically.

Dr. Franz: A lot of variables are involved. From the results of the testing we’ve done, there are some significant differences in the stability of the products based on design. If you get a design that is stable on the eye, typically, we’ve found that most cases will be within 10° to 15°. When you get outside of 20°, you’ll see more variability in rotation.

Dr. Iravani: Outside of 15°, you’re just not too comfortable with the product.

Dr. Weisbarth: In work we’ve done, the base curve you use dramatically impacts the amount of rotation. If you get excessive rotation, going to a looser fitting base curve typically will reduce the amount. If they have problems with rotation, we encourage practitioners to back off to a flatter base curve.

Toric clinical pearls

Dr. DePaolis: What clinical pearls do you have regarding expediting toric soft lens fitting?

Dr. Weisbarth: I encourage our colleagues to use the manufacturers’ consultation lines. Consultants are there, and they can help analyze the case. Each particular patient is dealt with on a case-by-case basis.

Dr. Pier: Practitioners should select a soft toric that offers consistent fitting performance across all sphere and cylinder powers. This predictability will allow for greater fitting ease. Predictability of advanced designs will also allow low-cylinder spherical contact lens wearers and spectacle wearers to experience the crisp visual acuity offered by true innovations in toric lenses.

Dr. Akerman: The technique I find most helpful in determining whether a patient will be a good candidate or not is counseling the patient at the initial visit. Doug Becherer calls this technique the Becherer Twist. Once the refraction has been completed, the patient is instructed to look at the 20/20 and 20/25 lines. The cylinder axis is rotated, and the patient is asked to call out when he or she first notices blur. If the chart blurs after only rotating 3° to 5°, that gives you a good indication of how difficult that patient will be to fit.

Dr. Seger: Occasionally, patients will have an unpredictable refraction with their toric contact lens. Under those circumstances, just going to a flatter base curve will reduce or eliminate that problem completely.

There’s value in having the ability to change design or material within an organization. This makes a multiplicity of options available to you, both in base curve diameter and cylinder power.

Dr. Franz: It’s important that practitioners have an open mind and try the many new products entering the market.

Multifocal lenses

Dr. DePaolis: What are your opinions on lifestyle and occupation demands of patients wearing multifocal lenses?

Dr. Seger: In spite of the limitations that exist with these products, there’s clearly patient demand. Patients are interested in an alternative to spectacles for correcting their presbyopia. Monovision remains the gold standard for relatively early presbyopic correction with contact lenses, but as you increase the disparity between the distance correction and near correction, the success rate tends to go down.

CooperVision has been evaluating a potential new product that marries monovision and multifocal or bifocal soft contact lens correction. For some patients, this is the modality of choice. Having the availability of trial lenses so you can quickly ascertain whether this patient is truly a candidate or not is the key.

Another key is how you communicate with the patient. You need to identify the patient’s expectations and needs.

Dr. Akerman: With the advent of disposable bifocal soft lenses, practitioners are once again able to fit most patients in a binocular fashion. Secondly, in terms of patients, the risk of spending a whole lot of money with very little reward and very little satisfaction is now a thing of the past. Patients don’t know if they should be wearing monovision or bifocal lenses, but they do know that they don’t want to spend $300 or $400 and have it not be successful.

Dr. Yamane: A lot of the credit for the bulk of the bifocal segment growth has really come from the success that practitioners and colleagues have had with the Acuvue bifocal contact lens. If I were in practice today, I would definitely be recommending bifocal contact lenses as a first option to all of my presbyopic patients.

Dr. DePaolis: Unlike the toric soft lenses that we all empirically fit, with bifocal soft lenses, you really need to learn to diagnostically fit them. For diagnostic fitting, how long should the lenses be on before patients should look at eye charts?

Dr. Weisbarth: It varies with different lenses, and I highly encourage colleagues to find out the recommendations from the manufacturers.

Dr. DePaolis: What would you recommend for CIBA progressives?

Dr. Weisbarth: Ten minutes max.

Dr. Yamane: Our recommendation is to allow the lenses to settle on the eyes for about 20 minutes.

Dr. Akerman: In general, front surface bifocal contact lenses will equilibrate more quickly than back surface bifocal lenses. The FreshLook Progressive Bifocal is a front surface design, so our research indicates that 10 minutes, 15 minutes max, is the recommended equilibration time.

Dr. Iravani: A minimum of 10 minutes.

Dr. DePaolis: Part of the reason for going with a multifocal lens is to get that additive effect, that synergy, that binocular summation. Should we be checking vision binocularly or monocularly? What are your recommendations?

Dr. Seger: With the product we’re developing, we’re really pushing the importance of monocular refraction. For troubleshooting, it’s important to do a monocular refraction so you can problem solve and help meet patients’ needs.

For Your Information:

• Dwight H. Akerman, OD, FAAO, can be reached at Wesley Jessen, 333 East Howard Ave., Des Plaines, IL 60018; (847) 294-3283; fax: (847) 294-3962; e-mail: dwight.akerman@w-j.com.
• Michael D. Pier, OD, can be reached at Bausch & Lomb, 1400 N. Goodman, Rochester, NY 14603; (716) 338-6106; fax: (716) 338-0825; e-mail: Michael_D_Pier@Bausch.com.
• Nikki Iravani, OD, can be reached at Specialty Ultravision, 307 Orchard City Dr., Suite 100, Campbell, CA 95008; (888) 208-5872, ext. 215; fax: (408) 341-0717; e-mail: niravani@ultravision.com.
• Stanley J. Yamane, OD, FAAO, can be reached at Vistakon, 7596 Centurion Pkwy., Jacksonville, FL 32256; (800) 876-6644; (904) 443-1829; fax: (904) 443-1704; e-mail: syamane@visus.jnj.com.
• Richard P. Franz, OD, FAAO, can be reached at Ocular Sciences Inc., 475 Eccles Ave., South San Francisco, CA 94080; (800) 972-6724, ext. 3418; (650) 583-1400; fax: (650) 583-1108; e-mail: rfranz@ocularsciences.com.
• Richard E. Weisbarth, OD, FAAO, can be reached at CIBA Vision, 11460 Johns Creek Pkwy., Duluth, GA 30097-1556; (678) 415-3560; fax: (678) 415-3151; e-mail: rick.weisbarth@cibavision.novartis.com.
• Ron Seger, OD, FAAO, can be reached at CooperVision Inc., 200 Willow Brook Office Park, Fairport, NY 14450; (650) 967-5789; fax: (650) 967-4106; e-mail: rseger@coopervision.com.