When presbyopia meets astigmatism: the contact lens fitting challenge

Unfortunately, as with all presbyopes, whether astigmatic or not, we cannot turn back the clock and restore their failing accommodation. It’s often a tricky conversation anyway, that first one informing patients that they now have presbyopia… and even more so if they wear toric contact lenses, then we need to discuss their options.

Currently, we cannot simply move daily disposable toric wears into multifocals due to market availability. And, if we don’t make the right choices, they may well drop out of contact lens wear altogether. So, what are our options…

1 Continue and use readers over the top for near work

For someone who has been used to wearing contact lenses out and about most of the time, with maybe glasses at home in the evening, the option of using readers over the top of their current contact lenses for near work can be a depressing one. Using reading glasses shows everyone else they’re getting older… It’s also often annoying to keep taking glasses on and off during the day. The patient might try and do without as much as they can, and this might result in headaches and eyestrain, and ultimately wearing lenses less, and less. Maybe they’ll only wear them now for gym or sports and revert to varifocal glasses during the day. Ultimately, this might lead them to drop out of contact lens wear.

2 Adjust prescription to monovision

Monovision is often seen as an easy fitting approach and means the cost to the patient is likely the same as their distance lenses, so there is no need to discuss changes in price with them.

Monovision is achieved by assessing ocular dominance and then reducing minus/ adding plus to the non-dominant eye, creating either partial or full monovision.

However, it does have some disadvantages. There is a reduction in stereopsis (depth perception) and contrast sensitivity with monovision correction, which can affect their real-life vision, even if the visual acuity in the consulting room seems good. Their intermediate visual acuity and range also suffers as the near add increases.

While monovision is often well-tolerated in early presbyopia, as the patient ages and their near addition increases, the prescription difference between the eyes needs to increase. There is often a reduced tolerance to monovision in patients with higher adds, and, at this later point, they are often less able to adapt to wearing multifocals. Therefore, they will often start to wear lenses less or drop out due to unsatisfactory vision.

3 Refit patients with a reusable multifocal toric lens

In the absence of availability of a daily disposable multifocal toric lens, the only way to provide a patient with better binocular vision in contact lenses is to swap to a monthly disposable lens. This requires ordering a new trial lens based on fitting guides and waiting, sometimes for several weeks, for the trial lenses to arrive as they are often made-to-order.

Selecting the correct lens is often complex due to the number of parameters available and if the power needs adjusting on collection another long wait ensues. If fitted successfully, the result can be better than monovision, with improved stereopsis and contrast sensitivity, and therefore better “real-world” vision. However, the patient now has the added task of cleaning the lenses properly, which they’ve not been used to doing. Plus, wearing a reusable contact lens rather than a daily disposable puts them at higher risk of eye infections. The length of the fitting process and added cleaning regime can both put patients off continuing with lens wear and, again, lead to drop out.

So what next?

Vision is the biggest single reason (41%) for patients dropping out of contact lens wear¹, and what practitioners cannot do, just yet, is move current daily disposable toric wearers who become presbyopic into a daily disposable multifocal toric. Using readers over distance lenses, monovision or reusable multifocal torics all have disadvantages that might lead to a patient dropping out of contact lens wear.

This spring, a long-awaited innovation arrives. ACUVUE® OASYS MAX 1-Day MULTIFOCAL for ASTIGMATISM will launch, bringing the world's first daily disposable toric multifocal² designed specifically for the complex needs of these patients.