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Hard and Soft Contact Lenses for Astigmatism End of Lecture, You

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Hard and Soft Contact Lenses for Astigmatism End of Lecture, You End of Lecture, You Will Be Able To… • Determine good candidates for toric lenses • Determine most appropriate toric lens Hard and Soft Contact Lenses • Differentiate soft toric stabilization techniques for Astigmatism • Assess soft toric fits: power, rotation • Know GP toric options Jeffrey J. Walline, OD PhD The Ohio State University College of Optometry • Empirically fit GP toric lenses Toric Market When Soft Versus GP Toric? • Soft toric • Can’t tolerate GP lens • Corneal toricity ≠ refracve asgmasm • Example • K Readings: 43.00 / 44.00 @ 090 MC • Refraction: ‐2.00 ‐3.00 X 180 20/15 • Example • K Readings: 42.00 / 44.00 @ 090 MC • Refraction: ‐3.50 ‐1.50 X 045 20/15 • Nichols, et al. Contact Lens Spectrum Jan 2014 When Soft Versus GP Toric? Who Are Better Candidates? • GP • Both: Poor VA with spherical lens • Corneal toricity = refractive astigmatism • Soft: GPs difficult to fit or not tolerated • Poor vision with soft toric • ATR astigmatism, discomfort, 3‐9 staining • Poor fit with spherical GP • 3‐9 staining • Excessive bearing • Spectacle blur • Reduce flexure 1 Who Are Worse Candidates? What Affects Fit of Soft Toric Lens? • Cylinder greater than sphere • Gravity • Example • Surface tension / tear film quality • ‐4.00 ‐6.00 X 090 • Lid / lens interaction • +0.25 ‐3.50 X 180 • Watermelon seed effect OS • Oblique cylinders • Powers in each meridian -4.25 -2.00 • Example Lens interact w/ thick • ‐3.00 ‐2.00 X 045 meridian and rotate lens temporally Watermelon Effect Stabilization Techniques Prism Truncation Thin Zones Peri-ballast Picture courtesy of Jason Nichols Prism Ballast Prism Ballast 100 • 0.75∆ to 2∆ • Oxygen Transmissibility Map • Stabilized by 80 • Thickness difference • Weight (very minimal) 60 • Disadvantage 40 • ↓ O2 transmissibility • Discomfort lid‐lens interact 20 • Visual problems with unilateral • Vertical prism 0 2 Truncation Thin Zones • Truncated lens lines up with lower lid • Thinning at top and bottom of lens Peri‐Ballast Stabilization Techniques • Minus carrier over entire lens then thin • Affect lens design superiorly • Physiological considerations • No prism in optic zone Fitting Soft Torics Fitting Soft Torics • Diameter • Lens should settle ~15 mins • Typically slightly larger • Assume first trial will have no rotation • Base curve • Typically no choice; may consider steeper first • Power • Trials rarely have exactly what you need • Use power cross and vertex each meridian • If limited cylinder power, adjust sphere • If cylinder power not available, lower power 3 Fit Assessment Assessing Rotation • Centration (coverage) • Bottom of lens Same as spherical lenses • Movement • As you look at lens OD • Orientation • Nasal (must indicate eye) • Rotation must be consistent • Right • Wait until lens settles • Counter‐clockwise • Assess re‐orientation • Assess rotation • Don’t guess! Assessing Rotation Measuring Rotation • Bottom of lens • Nasal (must indicate eye) OD • Right • Counter‐clockwise Measuring Rotation Measuring Rotation 4 Measuring Rotation Measuring Rotation Measuring Rotation Measuring Rotation Toric Markings Toric Markings • Tyler’s Quarterly 5 LARS Adjust for Consistent Rotation • Try to align rotated contact lens axis with • CL: ‐2.50 ‐2.25 X 090 refractive astigmatism • Rotation: 10° right (counterclockwise) • Look at… • Bottom of lens • Order: ‐2.50 ‐2.25 X 080 • As you look at lens Lens Rotation Axis Compensation Left (clockwise) Add Right (counterclockwise) Subtract Adjust for Consistent Rotation Adjust for Consistent Rotation • CL: ‐2.50 ‐2.25 X 180 • Rotation: 10° ? • Order: ? 10° Left Rotation 10° Left Rotation Axis adjusted: lens marking still in same place Assessment of Soft Toric Poor Visual Acuity • Visual acuity • Confirm rotational stability • SOR • Tighter base curve or different lens • Slit lamp • Compensate for stable rotation • Contact lens fit • Spherical over‐refraction • Movement • Spherocylindrical over‐refraction? • Centration (coverage) • • Rotation SCOR, CL power, and cross cylinder effect • Ocular health • Recheck baseline data • New lens 6 Example Example • MR: ‐4.00 ‐3.50 X 180 -7.50 -7.00 • Proclear Toric vertex -4.00 -4.00 • What is your first contact lens order? • ‐4.00 ‐3.00 X 180 • Only comes up to ‐2.25 DC • Spherical equivalent • ‐4.25 –2.25 X 180 Example Example: Final Rx • Base curve = 8.4 • Diameter = 14.4 • Power = ‐4.25 ‐2.25 X 165 15 degree rotation How GP Corrects Astigmatism Fitting Philosophies –All Back Torics • Lacrimal lens • Full alignment (saddle fit) • Typically 2.00 to 2.50 D K toricity • On K for each meridian • Tighter fit, more centered • Smaller diameter, interpalpebral fit • Toric front and / or back surface 7 Fitting Philosophies –All Back Torics All Back Surface Torics ‐ Base Curve • Low toric simulation • Ks: 42.50 / 45.50 @ 090 • Typically when K toricity >2.50 D • Base curve undercorrects corneal toricity • Saddle fit • BC aligns (± 0.25 D) with flat meridian and • undercorrects steep meridian BCflat: 42.50 • Typically 75% of corneal toricity • BCsteep: 45.50 • Small amount of “rock” over flat meridian • Low toric simulation • Diameters can be bigger • BCflat: 42.50 • BCsteep: 44.75 GP Toric Options Bitoric • Back surface toric (spherical front surface) • Specify BC/Power for each meridian • Front surface toric (spherical back surface) • It is as though you are fitting a spherical lens on • Consider spectacle cylinder, corneal cylinder, each meridian independently residual astigmatism • Use optical cross • Bitoric • Power for toric CL not written in • ≈ 98% of toric GP lenses spherocylindrical notation • Two curvatures on back surface and two curvatures on front surface Calculating Bitoric Lenses Empirically Order Bitoric • Empirical • Manifest Rx: ‐1.00 ‐3.00 X 180 • Optical crosses • Ks: 43.00 / 46.00 @ 090 • Mandell‐Moore Bitoric Worksheet • http://www.gpli.info/mandell‐moore/ • Diagnostic • Spherical trial lens • SPE trial lens 8 Empirically Order Bitoric Order a GP Lens • Secondary Curve • Example: Low Toric 46.00 45.25 -0.75 • BC + 1.0 mm; 0.4 mm wide • Peripheral Curve 43.00 42.75 -0.25 • BC + 3.0 mm; 0.2 mm wide Cornea BC LL • OZD -4.00 (-3.87) -0.75 45.25 / -3.12 • OAD = (2 * SCW) + (2 * PCW) + OZD -1.00 -0.25 42.75 / -0.75 • CT Spec LL CL • Use power that yields greatest CT (most +) • CTminus lens = 0.18 + 0.01 (power) • CTplus lens = 0.18 + 0.02 (power) Empirically Order Bitoric Mandell‐Moore Bitoric Guide • Saddle fit • Manifest Rx: ‐1.00 ‐3.00 X 180 • Ks: 43.00 / 46.00 @ 090 7.90/7.46 8.90/8.460.3 10.90/10.46 0.2 9.5 8.5 -0.75/-3.25 0.17 Mandell‐Moore Bitoric Guide Mandell‐Moore Bitoric Guide 43.00 180 46.00 090 -1.00 -3.00 180 43.00 46.00 -1.00 -4.00 -1.00 -3.87 0.25 0.25 0.75 0.75 42.75 -0.75 45.25 -3.25 9 Mandell‐Moore Bitoric Guide Assessing GP Torics • SOR • ScOR if not 20/20ish • Contact lens fit • Movement • Centration • Rotation (front surface toric only) • Fluorescein Back Surface Toric Back Surface Toric Summary • Fitting is exactly the same as bitoric • Example • When refractive astig = 1.5 * corneal toricity, • then front surface is spherical Manifest Rx: +1.00 ‐3.00 X 180 • Ks: 42.00 / 44.00 @ 090 • If you know, you could save $10 when you order Back Surface Toric Order a Back Surface Toric 44.00 44.00 0.00 • Manifest Rx: +1.00 ‐3.00 X 180 • Ks: 44.00 / 46.00 @ 090 42.00 42.00 0.00 K BC LL -2.00 0.00 -2.00 7.67/7.42 8.67/8.42 0.3 10.67/10.42 0.2 8.7 7.7 +1.00 0.00 +1.00 +1.00/-1.50 0.20 RE LL CL 10 Front Surface Toric Front Surface Toric Example • ≥ 1 D residual astigmatism • Ks: 41.00 / 41.50 @ 090 and • MR: ‐1.00 ‐2.00 X 180 • ≤ 2.00 corneal toricity • CL: BC = 40.75; Power = ‐3.00 • Typically soft toric, but patient may not like vision Toricity Initial BC Spherical 0.50 D flatter than flat K 0.12 D - 0.75 D 0.25 D flatter than flat K 0.87 D - 1.37 D flat K ≥ 1.50 D (0.33 X diff b/t K’s) steeper than flat K Front Surface Toric Example Summary • Toric contact lenses are often necessary for 8.28 9.28 0.411.28 0.2 9.2 8.0 clear vision • Soft toric are most common -0.75 -1.50 X180 • GP bitoric provide excellent vision • Front and back surface GP torics rarely used 11.
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