The scenario
As a locum optometrist working across a range of practices, I frequently encounter patients with astigmatism. When talking to potential new contact lens wearers who are astigmatic, what are your recommendations for educating them about astigmatism and managing patient expectations for contact lens wear for this sometimes harder to fit group?
Sarah, locum optometrist
The advice
Nadia Siddiqi, optometrist, Johnson & Johnson Vision professional affairs consultant and faculty member
As an optometrist, when I encounter a patient in my testing room who has astigmatism, first and foremost I always emphasise that it is something that is really common. There can be a misconception that astigmatism is something serious or sinister, which it is not – demystifying is a priority.
When explaining to patients what astigmatism is and what they may experience with their vision as a result, I find that analogies work well. I will discuss how, instead of their eye being shaped like a football, it is more like a rugby ball which can lead to distortions in the vision– this allows the patient to visualise it themselves.
For astigmatic patients, as a locum optometrist, before I recommend contact lenses, there are a few steps that I will consider. Most importantly, after assessing the health of the eyes, I will look at their prescription and consider whether it is something that can be corrected. What’s useful in supporting my decision at this stage is understanding what products are available in the practice that I’m testing in that day – different practices can offer different lenses.
The last thing I want to do is discuss contact lenses with a patient and promise a lens that the practice doesn’t have on catalogue, or that the parameters I require are unavailable. Understanding what a practice offers allows me to be prepared for contact lens conversations with each patient.
For patients with very high levels of astigmatism, if a practice doesn’t offer specialist lenses, I would also want to be aware and be prepared to signpost that patient to a specialist clinic, if appropriate, or at least explain that there may be scope to have their high astigmatism corrected.
As clinicians, it’s important to have up to date knowledge so that ultimately the patient can make an informed choice.
There can be a misconception that astigmatism is something serious, which it is not – demystifying is a priority
Raising contact lenses in conversation
I am very passionate about contact lenses as I have first-hand experience of how life-changing they were for me when I started wearing them. Consequently, I always endeavour to provide contact lenses as an option for all patients, unless I can really foresee a problem.
There are a range of key factors that I listen out for with astigmatic patients when considering recommending contact lenses, but ultimately these all revolve around lifestyle and visual demands.
It’s important to understand lifestyle. Patients are so complex and as clinicians we only see them for around 25 minutes in an artificial environment – the testing room.
I will ask patients about their hobbies and so on, but I also try to understand their day-to-day – as people, we do so many different things in a day. This is done through building rapport and asking questions to find out about their needs. Do they go for long walks after work with their dog, or are they doing activities such as netball or rugby, is there a place for contact lenses to meet their visual needs?
We don’t wear the same pair of shoes every single day, we don’t wear the same clothes every single day – we have different options for different purposes. It’s the same with vision correction - contact lenses should form part of a patient’s optical wardrobe. Ultimately, by understanding the lifestyle of each patient who is sitting in the chair in front of me, I can understand if there is a place in their life where contact lenses could work. If I believe there is, I simply ask, ‘How would it feel to be able to play netball without needing your glasses?’ and then I explain what benefits they would bring.
As practitioners, spending a little bit of extra time where possible getting to know a patient’s lifestyle can support us in making the right recommendation. If we don’t make the right recommendation, they may try a contact lens that doesn’t quite work and then believe lenses are not for them long-term.
As a locum we only see a snapshot of the patient who we may never see again. However, to our advantage, we see lots of different patients, and when speaking to those with astigmatism, I am often able to draw upon and share examples of patients who have similarities in prescription and lifestyle, and who love to wear their contact lenses.
It is often quite common to see patients who have trialled contact lenses many years prior that haven’t worked for them. In these situations, if I see a benefit for the patient, I explain the vast amount of technological advancements that have been made and let the patient know that a new and more appropriate product is now available for them.
We don’t wear the same pair of shoes every single day, we don’t wear the same clothes every single day – we have different options for different purposes. It’s the same with vision correction - contact lenses should form part of a patient’s optical wardrobe
Considerations and expectations
For the clinician, there are a few additional considerations for successfully fitting an astigmatic patient, and it is important to understand the designs of contact lenses in order to do so.
When selecting a lens, I consider if a patient is a monocular astigmat so I can choose a prism free toric lens design, to eliminate the risk inducing differential vertical prism. This is something that sometimes can be overlooked but can be crucial in understanding why a patient may have excellent vision but is experiencing asthenopic symptoms. Adjusting the prescription is also important. For example, it’s important we adjust the spectacle prescription for BVD (back vertex distance) in both meridians, not just the principal one.
As a locum, clinics can be jam-packed; you may be working at pace. I recommend using tools that support and make life easier, such as toric calculators. Once you know what lens you want to fit, go onto the manufacturer’s website and use their calculator. This means that you don’t promise a lens that doesn’t exist and the calculator will do the BVD calculations for you too.
As a locum, I also recommend making clear and comprehensive notes at any contact lens consultation. If you have made any adjustments to the fitting of the lens, write it down. It’s important that the next clinician gets a good insight into what happened in that interaction in order to be able to support the patient on their next visit. You can involve the patient in this, discussing a follow-up plan and next steps. We don’t want to get too technical, but we want the patient to feel involved in the lens selection and the decisions we make about their care.
Spending this extra time explaining and reassuring a patient can make or break their experience and determine whether they become a long-term contact lens wearer or not
The patient
When it comes to the patient, I reassure them that there can be an adaptation period when trying a new lens. I highlight that if they happen to experience any slight blurring of their vision, there may be scope for adjustments, but don’t judge the lens too quickly. You must have a little bit of patience in the trialling process.
Spending this extra time explaining and reassuring a patient can make or break their experience and determine whether they become a long-term contact lens wearer or not. Returning to analogies, I sometimes share that, just as you can buy three pairs of shoes in the same size and they can all fit differently, adjustments may be needed during a contact lens trial to ensure the right fit and visual outcome.
When managing a patient’s expectations, it’s important not to overpromise but equally not come across as negative. You should be positive, but realistic to avoid disappointment. When the right lenses are fitted, it can be life changing for the patient.
Nadia’s one fitting tip for clinicians
“As clinicians, when we assess the fitting of a contact lens on the eye, we ask the patient to look in different directions (up, down left, right) and return to primary position of gaze. However, when I fit a toric lens, I find it useful to additionally ask the patient to look supero-temporally and then back to the primary position. Looking at the toric markings at this point can reveal instability in what was otherwise perceived to be a stable fit. I’ve incorporated this into my practice. It only takes a couple of extra seconds and gives me a much better understanding of how a lens will perform for the patient in their day-to-day life.”
