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Thank you to Johnson and Johnson Vision for their support of this podcast episode. Dr. Erin Rueff is a consultant for Johnson and Johnson Vision.
When we prescribe a contact lens and our patient returns stating that they are unhappy with the performance, we often ask our patient to categorize their complaints into two separate buckets: vision or comfort? When a patient comes in and says that their eyes are uncomfortable at the end of the day with their contact lenses, we often think that must mean the lens is dry. But discomfort to a patient can be as driven by eye strain due to a vision clarity issue as it is by dryness or lens awareness. On this podcast episode, we discuss deciphering the patient contact lens experience with Dr. Erin Rueff, Chief of the Cornea and Contact Lens department at the Marshall B. Ketchum University Eye Center.
It’s important to start a contact lens fit with a recipe to maximize success. As an optometrist a spot-on refraction is what a patient depends on – they might not remember that you caught that retinal tear, but if they can’t see well in their glasses, they will definitely judge you as a doctor based on that outcome. “I always am really careful to not over-minus, balance my refraction, and being very detailed oriented with my cylinder refraction,” Dr. Rueff explains about her refractive philosophy. Every year at their annual exam she makes sure that her patient’s new manifest refraction data is aligned with their contact lens prescription – for patients that have been coming for years and years, these prescriptions can start to drift away from each other and it’s important to always check the contact lens prescription even on a “happy” existing wearer.
One of the most frequent mistakes that doctors make when transitioning from refraction to contact lens selection is ignoring even low amounts of cyl in favor of spherical equivalent. Studies have shown that low amounts of astigmatism (even just -0.75 DC) can greatly impact a patient’s clarity and subjective comfort. An estimated 47% of patients of patients have at least 0.75 DC of astigmatism in at least one eye, but toric contact lenses are only fit on approximately 25% of soft contact lens wearers. Fitting patients with toric lenses compared to spherical equivalent lenses have been shown to improve high and low-contrast visual acuity as well as subjective, patient-reported comfort (judged by a Convergence Insufficiency Symptom Score) in even mild and moderate astigmats.
When it comes to multifocal contact lenses, Dr. Rueff encourages doctors to consider that “presbyopia doesn’t happen overnight.” She checks near vision on every single patient, and she finds that even in their 30s, many of her patients start benefitting from a low amount of plus at near. Dr. Rueff recently published a study looking at the effect of multifocal contact lens prescribing on the comfort of patients in even younger wearers. Researchers found that many 35- to 40-year-old wearers preferred multifocal contact lenses for vision and/or comfort, suggesting that early and emerging presbyopes may benefit from multifocal lenses before they experience sustained blur.
When it comes to add selection, it’s important to determine functional add and not over-plus patients at near. That’s where utilizing the fitting guide is so important to multifocal contact lens success. “I always say lose your pride, follow the fitting guide!” jokes Dr. Rueff about how she educates her students about successful contact lens fitting strategies.
So, if a patient says “my lenses are uncomfortable”, and we now know that could mean anything from dryness to visual eye strain, how can you best troubleshoot their discomfort? Dr. Rueff encourages doctors to provide the patient with more vocabulary to define their discomfort. “I ask my patients about their symptoms throughout the day and with specific activities,” Dr. Rueff explains. She asks her patients if they notice symptoms only at the end of the day or after computer use? If their symptoms are mostly after fine detail acuity tasks, vision is a potential comfort. Are they feeling a pulling sensation behind their eyes or a headache over their eyebrows? This would lead her to think visual strain. If the lens is dry or causing ocular surface irritation, she looks for her patients to talk about “feeling the lens” or burning, stinging, and redness. If the patient states their lenses are uncomfortable, and evaluation shows no ocular surface irritation, she always thinks vision as a culprit. The lens could be over-minused or maybe the patient needs astigmatism or even a move to a multifocal contact lens and over-refracting with loose lenses at the visual target the patient is noticing discomfort with is essential to trouble shooting.
Think refractive causes that could be associated with over-minused lenses or the need for additional plus at near like moving towards a multifocal lens option: pressure behind the eye, pulling sensation, headaches. These complaints can also be associated with uncorrected astigmatism, so comparing your lens selection to your refraction is essential to differentiate!
Think refractive causes that could be associated with uncorrected astigmatism: night driving complaints, fine detail acuity like sports scores on the TV, vision coming in and out with small detail work (like computer use), or reports that lenses are just “ok” but patients are having difficulty verbalizing what’s not working well.
Dr. Rueff encourages doctors to reconsider any misconceptions that toric lenses are uncomfortable. Studies show that today’s astigmatism lenses are very comfortable for patients and stabilize quickly. If a patient is struggling with comfort with a vertical prism ballast design, switching to a different lens design with dual horizontal thin zones like that utilized in ACUVUE OASYS astigmatism lenses. Feel confident that vision is a driving force behind a patient’s contact lens comfort, and if you improve their visual strain by moving to a toric contact lens, the patient’s comfort will also improve!