AOA 2024: Maximizing comfort and acuity during a toric lens fitting

Ahead of AOA Optometry's Meeting 2024, Susan Gromacki, OD, MS, FAAO, FSLS, sat down with Optometry Times to discuss her presentation on fitting toric lenses for patients with astigmatism.

Video transcript

Editor's note: This transcript has been lightly edited for clarity.

Emily Kaiser Maharjan:
Hi, everyone. I'm here with Dr. Susan Gromacki, who is here to discuss comfort attributes and astigmatism in contact lenses. So welcome, Dr. Gromacki. I'm so glad that you're here with me today.

Susan Gromacki, OD, MS, FAAO, FSLS:
Thank you for having me. It's a pleasure.

Kaiser Maharjan:
Of course. So first, can you tell me a little bit about the importance of comfortable contact lenses for patients with astigmatism?

Gromacki:
Of course. So our patients need and deserve good comfort. They want to wear lenses all day, every day; it's just impractical to have to take them out, put a rewetting drop in, so they need optimum all-day comfort, and they deserve it. They also want the best vision they can have. And with astigmatism, that can be tricky sometimes. I've been doing this now for 30 years and years ago, it was difficult to find a contact lens for astigmatism that was stable and reproducible. Now we've got that, and it's exciting because we can help our patients right then and there in the chair and see that wow factor right away, which is awesome.

Kaiser Maharjan:
Yeah, it's so fantastic. So what is your experience as a clinician in finding comfortable contact lenses for patients with astigmatism?

Gromacki:
There's so much science involved in this. I think, you know, we, we go back to our roots of when we were learning about the science of optometry, and if you look at each individual contact lens, you can see where all the research and development went into making an optimal experience for a patient.

So with comfort, for example, we look at things like edge design. And what I look for is, I look for the thinnest edge possible because that is going to be the most comfortable. If you look at the profile of a contact lens, and if it's a very thick edge, when the eyelid blinks over that, the patient's going to feel that and that is not good. It also might cause excessive movement, which in a toric lens can do a couple things. One, if it's moving too much, they feel it, but also it can contribute to that lens rotating. If that lens rotates, and it has the astigmatism correction, that patient is going to experience decreased vision, too. So those are a couple of things I look at with comfort.

I also look at things like coefficient of friction. I want a very low coefficient of friction, a material that's extremely wettable. For example, polyvinylpyrrolidone is a an amazing wetting agent, and it is embedded within the lenses that J&J makes, and it really contributes to decreasing that coefficient of friction and enhancing comfort for our patients.

Kaiser Maharjan:
That's fantastic. And when you are fitting a patient for contact lenses, do you do anything differently for your patients with astigmatism versus other refractive errors?

Gromacki:
Absolutely. I think first of all, we can't be afraid to fit toric lenses, I think because, especially my generation and older, because we had those experiences where oh my goodness, if I grab a toric lens, and the patient is 0.75 D CYL, oh my goodness, if it rotates, if it moves too much, if it's not comfortable, if it's too thick, because it's prism ballasted, all these things, we think, oh my gosh, I'll just fit a sphere and just try and mask it. But we don't have to do that anymore. So we don't have to overthink it, we just grab that lens that the patient needs and fit it. And I think you know, the numbers bear this out. There's 47% of vision corrected patients in the US have at least, you know, three quarters of a diopter of astigmatism, but only 31% of the market of soft contact lenses is soft toric. So you know, we're not doing it yet.

And we really just kind of need to trust the process. And also grab a brand that we know is going to work. And for me, I have zero doubt in my mind when I grab a J&J lens, that that lens is going to be stable and very comfortable for the patient and provide optimal vision. And I don't have to worry about that. So the science is taken care of. We know all the science that goes into developing these lenses. And at this point, I just choose the brand that I know is going to work, and we want to satisfy the patient. That's number one, obviously. But also, in this day and age, we kind of want to make things easier for ourselves. We don't want to choose a lens that we think oh my gosh, is it going to is it going to be comfortable? Is it going to be stable? I just grab the lens that I know is going to work and that's the J&J toric lenses.

Kaiser Maharjan:
Are there any particular attributes or personality traits that you are or you know for? physical traits that you've acquired in a patient that signal they would be a good candidate for contact lenses.

Gromacki:
Well, all the typical things that I do in a contact lens exam. I always check for dry eye. I think it's imperative in this day and age to do tear break up time, to do a dry eye questionnaire. I always evert lids; we don't want any surprises with allergies, with papilla, that could cause that lens to move too much ultimately. Basically, you know, we want to screen out patients who may not be good candidates in the first place. But honestly, in this day and age, that's few and far between with with the technologies that J&J has, we can fit a patient with a touch of dry eye or a touch of GPC. So unless there's something that's extremely an outlier, I think, you know, we really don't have a lot to worry about with that first fit.

Kaiser Maharjan:
So comfortable lenses mean happy patients. We all know this. But do you recommend any other measures to help keep patients safe and healthy in their contact lenses? And specifically in their toric lenses?

Gromacki:
Absolutely. I would recommend looking at the brand that you're fitting and making sure that they have UV filtering in there. Because this generation, they're active, they're outside, they're doing things. Our country is moving south, we have a lot of people that are living in areas closer to the equator, and they need that UV protection. Of course, no soft contact lens is going to take the place of sunglasses, that's still important to have over the contact lenses, but for my patients, I want that built-in UV filtering that I think is critical to ocular health.

Kaiser Maharjan:
And is there anything else that you'd like to add that we haven't touched on?

Gromacki:
Just to not be afraid of going for it. If you have a patient that has some cylinder, don't mask the astigmatism. You know, you're really giving a compromise to their vision. And then the other thing I haven't mentioned yet, too, is with regards to comfort, the J&J design is a blink-stabilized design. And what that means is, there's actually 4 activation areas that naturally aligned with the blink. And you know, all that verbiage just means that there is no prism ballast in that lens. And we all know that with a prism ballasted toric lens, it's less stable and also it's thicker at the bottom. And we're always cognizant of Dk/t, right, and the T is thickness. And when we have increased thickness at the bottom of that lens, less oxygen is going to get to the cornea. And we've all seen these patients who have worn prism ballasts, the toric lenses over the years who have inferior neo, and that is just not healthy. But in addition to that, the prism ballasted toric can do a couple other things that are maybe not the greatest. And first of all, it's thicker, so it's less comfortable. And you and I did discuss comfort, and that's something that can contribute to decrease comfort is just having that thicker prism ballast. In addition, you know, we have a lot of patients now in monovision. And we may or may not have a patient who has a sphere in one eye and a need for a toric in the other. And when you have those monocular toric patients with that prism ballasted design, there's prism in the optic zone. And that could be an issue, having prism in the optic zone causing some disparity there, and some discomfort with your, your ocular summation. And you know that could be an issue.

So with the blink stabilized design, we eliminate prism from the optic zone, so we don't need to worry about a vertical imbalance. So there's a lot that goes into it with the technology. And I think, you know, as optometrists, we need to kind of step back and realize that all this technology is in there to benefit our patients and, and just go ahead and utilize it. You know, we don't have to think about it. Just have to choose a lens that has all these features that's best for a patient and then and then sit back and enjoy watching them succeed.

Kaiser Maharjan:
Absolutely. Well, thank you so much for taking the time to chat with me today. Dr. Gromacki. I really appreciate you taking the time to tell me a little bit more about comfort and contact lenses and toric lenses and, you know, what that's going to look like for us in the future. It's really been fun.

Gromacki:
Thank you for having me.

Kaiser Maharjan:
Thank you.