Worth the Wait: New Toric Contact Lens Innovation is HereThe much-anticipated launch of Total1 for Astigmatism and Precision1 for Astigmatism contact lenses in Australia and New Zealand provides the perfect opportunity to analyse our approach to soft toric contact lens fitting, especially when we review the data on patient satisfaction.

WRITER Helen Gleave

LEARNING OBJECTIVESOn completion of this CPD activity, participants should be able to:

1. Understand the impact of astigmatism on vision and ocular health,
2. Be aware of the design features of Alcon Total1 for Astigmatism and Precision1 for Astigmatism contact lenses that manage stability on eye,
3. Understand the features contributing to improved ocular comfort for astigmatic patients, and
4. Be aware of the patients who will benefit from each of these lens options.
With so many wonderful innovations in optical products and equipment, as optometrists we can continually seek to optimise our clinical offering. Taking and incorporating new technology into a practice is an opportunity to reflect on our routine examination protocols and assess the effectiveness and efficiency of the ways we manage our patients. We can think critically for example, about our approach to patients, their symptoms and management, how we explain the procedures we are undertaking and why we are conducting them, and also how we convey the steps we would like patients to take in their ongoing clinical care.

Sometimes though, it is easier to think, “if it ain’t broke, you know what, I am not going to try and fix it… I don’t have the motivation today to try a different approach…” But what happens if there are cracks we do not become aware of by having this attitude? What is the consequence to the patient and ultimately, the practice? And would it change if we knew we had a 99% chance of being successful with a new option and that it would not take us significantly more time?

New innovation gives us the opportunity to take a bite sized approach to self-development and focus on one area of clinical practice at a time.

Contact lens technology has come so far in the last ten years, but astigmatic patients wearing toric soft contact lenses report an increased level of dissatisfaction compared to their spherical wearing counterparts.1Astigmatic patients are more likely to struggle with dryness and discomfort: 42% of toric lens wearers report dryness compared to 35% of spherical lens wearers, 35% complain of end-of-day discomfort compared to 26% of spherical lens wearers 1(Figure 1). Twice as many toric lens wearers report problems with their vision compared to spherical lens wearers 1and toric contact lens wearers are more likely to discontinue lens wear. 1
Figure 1. Impact of uncorrected astigmatism on patients’ vision and ocular comfort.Interestingly, in Australia and New Zealand, there is a significantly reduced number of options available in daily disposable soft toric contact lenses when compared to spherical lenses.2Optometrists in Australia have a high preference for fitting daily disposable silicone hydrogel lenses, with 52% of all fits in this lens category 3(Figure 2). The average across the rest of the world is only 22%. 3However, in Australia, there are half as many options available to optometrists in daily disposable toric lenses compared to daily disposable spherical contact lenses, with nineteen spherical contact lenses versus nine toric contact lenses. Even if reusable lens options are included, there are still one-and-a-half times more spherical options.3This, together with lower patient satisfaction, shows the need for more options in this category and the benefit of having not one but two new daily disposable toric lenses to choose from.

Figure 2. Fitting habits are influenced by availability.ONE NEW DESIGN, TWO TECHNOLOGIES

The launch of Precision1 for Astigmatism contact lenses provides a compelling new mainstream silicone hydrogel daily disposable toric lens option and Total1 for Astigmatism contact lenses provide a compelling new option for astigmatic patients who need or want a premium lens wearing experience.

What is the lens design, what are the technologies behind these innovations and how do they seek to improve patient outcomes?

Both lenses use the proven Precision Balance 8|4 design for stability. With this lens design, the thickest parts of the lens are positioned at eight o’clock and four o’clock, with reduced thickness at the six o’clock position (Figure 3). In comparison, traditional prism balance lens designs incorporate lens thickness across the whole lower half of the lens. By increasing the lens thickness at eight o’clock and four o’clock, interaction with the lower lid is reduced and oxygen transmission at the six o’clock position is increased compared to a traditional prism balance design.4This lens design has been shown to provide 99% first lens fit success with Total1 for Astigmatism and Precision1 for Astigmatism contact lenses: lenses settle on eye within one minute of insertion, settle within three degrees of the ideal orientation, and show oscillation of five degrees or less. 5,6These statistics show how these new water surface lenses meet astigmatic patients’ needs for clear, stable vision with a soft toric contact lens in clinical trials.

Figure 3. Thickness profile of the toric contact lens, which uses Precision Balance 8|4 design for stability.“ Responses to questions regarding lifestyle show that wearers were able to get on with their busy lives without worrying about their contact lenses ”REAL WORLD OBSERVATIONS

To find out how this lens design performs for astigmats in the real world, 245 patients were fitted with Precision1 for Astigmatism contact lenses by 50 eye care professionals from Austria, Germany, Switzerland, Italy and the United States of America. 7The lenses were worn for 10–14 days, for a minimum of six hours per day. Participants were asked questions regarding their real-life experience with the contact lenses. Responses to questions regarding lifestyle show that wearers were able to get on with their busy lives without worrying about their contact lenses. When asked if their contact lenses supported their active lifestyle, nine out of 10 participants either agreed or strongly agreed, and agreed with the statement ‘The lenses allowed me to focus on the moments that matter, not my lenses’. 7

With clear, stable vision being an important attribute of a toric lens, nine out of 10 respondents agreed or strongly agreed with the statement, ‘The lenses provide clear distance vision while I am engaging in activities such as driving, biking, watching TV’. Eighty-four percent found the lenses provided clear vision while they were looking at digital devices, such as their mobile phone or computer screen.7

When participants were asked about comfort with Precision1 for Astigmatism contact lenses, 87% either agreed or strongly agreed with the statement, ‘I feel comfortable from the time I put the lenses on until I want to take them out’. When asked about their own lenses, only 34% agreed or strongly agreed with the statement, ‘My lenses felt as comfortable at the end of the day yesterday as they did when I first put them in’, demonstrating improved comfort with Precision1 for Astigmatism contact lenses, particularly towards the end of the day.7

Research tells us that lubricity and wettability are key contributors to contact lens comfort.8Precision1 for Astigmatism contact lenses are made from the silicone hydrogel material, verofilcon A, and feature SmartSurface technology, a micro thin layer of moisture, two to three microns thick, stepping up from 51% water content at the core to greater than 80% at the outer surface. 9#This material has been shown to have excellent wettability through in vitro surface moisture characteristics (30 seconds compared to 16 seconds for its closest competitor 10,11) and demonstrates low shear stress, the factor of the co-efficient of friction and contact pressure, to the ocular surface tissues. 12

The Total1 for Astigmatism contact lens is different in that it is a water gradient material in which the water content of the lens changes from 33% in the core to over 80% at the surface, approaching 100% at the outermost surface.14This is due to a different method of manufacturing, which results in a thicker cushion of moisture of approximately six microns. 13,14Total1 contact lenses also incorporate SmarTears Technology, the release of phosphatidyl choline into the tear film to support the naturally occurring phospholipids of the lipid layer. 15These technologies result in a longer surface moisture break up time of 39 seconds 16and, once again, low shear stress on the ocular surface. Both lenses have been shown to provide up to 16 hours of comfortable wear. 17,18

Avoiding Drop Out

This brings us back to one of our initial thoughts: the importance of optimising our approach to patients, their symptoms and management and ultimately, improving clinical outcomes. With soft toric wearers showing increased dissatisfaction with their existing lenses compared to spherical lens wearers, and an increased chance of discontinuation of lens wear, 1could taking the opportunity to prescribe these new innovations help manage the cracks before toric lens wearers break away from contact lens wear altogether? With a first fit success of 99%^5,6and nine out of 10 patients agreeing they could wear them all day long,7trialling the new lenses would seem to be worthwhile, especially as the patient is statistically likely to appreciate the performance of the new lenses. 7

A different approach can also be considered with another group of patients – those with low levels of astigmatism who are wearing spherical soft lenses. Fitting a spherical equivalent is an alternative to prescribing soft toric lenses and it was previously thought lower levels could be satisfactorily masked by a spherical contact lens, particularly by thicker or higher modulus lenses. However, this approach has now been shown to not be as effective.19Even low levels of uncorrected astigmatism have been shown to decrease both distance acuity and near acuity, 20negatively impact reading speed, fluency 21and stereoacuity, 22resulting in headaches 22,23and increase symptoms of ocular discomfort and dry eye. 22,24The consensus report, CLEAR recommends fitting toric lenses as a first choice in soft lenses for levels of astigmatism of 0.75DC or higher. 8Interestingly, despite 47% of astigmatic patients having at least 0.75DC cyl or greater in one eye, 24only 22% of soft contact lens fits are toric lenses, 25indicating there is much potential to improve the visual outcome with this group of patients.

Soft toric lenses have been shown to be as easy to fit as a spherical and take only an extra minute of time.26This ties into our early thought about the benefits of taking a new approach with more success but with little significant increase in time.

WORTH THE WAIT

Hopefully these two new lenses are worth the wait, providing optometrists with daily disposable soft toric lenses which settle quickly on eye, remain stable on blink with little oscillation 5,6and exhibit excellent comfort scores. 7Incorporating these new lenses provide optometrists with the opportunity to assess their approach to fitting astigmatic patients and also look for astigmatic contact lens wearers who are not broken yet, but with whom cracks may be starting to appear.

FURTHER SUCCESS STORIES

Eleisha Dudson, an optometrist in Wellington, New Zealand, said, “When I got the opportunity to trial the new Total1 for Astigmatism contact lenses I was excited. This lens with water gradient technology offers us something different for our patients. And with toric lenses being larger, having a different thickness profile for stabilisation, and coming with rotation engravings; I feel the surface lubricity is more important than ever.

“The Precision1 technology, as a sister product, is a great adjunct. This material can help us provide our mainstream patients with the handling and smart surface technology comfort they are currently lacking.”

Ms Dudson presented the following patient case studies to demonstrate her findings.

Case One

Ms Cadence* was a long-term dailies wearer, but when she came to see me for the first time, she had recently dropped out of wearing lenses. She had dropped out because by day three or four she was unable to wear her contact lenses as they would cause discomfort to the point where she could not wear them.

Ms Cadence’s lenses had never been changed, despite improvements in technology, which highlights that although patients are happy, sometimes they are settling for some level of discomfort. In this case, and probably in more patients than we know, this leads to intolerance or dropout of contact lenses.

I ruled out papillary conjunctivitis but made a diagnosis of mild blepharitis. With the mild blepharitis there was no reason why Ms Cadence shouldn’t be able to wear contact lenses comfortably, so I thought she was a great candidate for the new astigmatism lens and because this patient was price conscious, Precision1 for Astigmatism contact lenses were a great option for her.
“ With the mild blepharitis there was no reason why Ms Cadence shouldn’t be able to wear contact lenses comfortably, so I thought she was a great candidate for the new astigmatism lens... ”Upon trialling Precision1 for Astigmatism contact lenses, the initial comfort was good, but a trial to see if she could achieve comfort for longer than three days was needed. And the review came back positive. The handling was easy, and she could achieve all day comfort with no issues over multiple days. Ms Cadence was extremely happy to be able to wear contact lenses full time again.

Case Two

Total1 for Astigmatism contact lenses have allowed me to offer some of my regular astigmatic patients a premium contact lens option – patients like Mr Dungog*, who, like many patients we experience, would love to wear contact lenses full time but is unable to due to comfort. They come in for their annual reviews and have tried the ‘best of the rest’, trialled multiple other lenses, and yet they still struggle for full day comfort.

I trialled Total1 for Astigmatism contact lenses on Mr Dungog, and even though his eyes were dry on the day of consultation, on insertion he was not even aware there was a lens on his eye. I remember when Total1 contact lenses were first launched and it was said this was the lens that people would say feels like nothing on the eye, and I thought, ‘patients won’t say that’. But they did. It is exciting to see this is also the case for the astigmatism lens for this patient. Mr Dungog has taken the lenses away and we will see if he can achieve full day comfort, something he could not get in his previous lenses.

Case Three

Mr Evans* presented to me for an examination having stopped wearing his contact lenses due to poor comfort and fluctuating vision. Working as a pilot, he found the issues particularly occurred on his long-haul flights, despite these flights being infrequent over the last year.

When we trialled the lens, the first thing Mr Evans said was “It feels like there is nothing there!” and that it felt like the lens had settled straight away, even in the left eye, which was the eye that had felt unsettled with previous lenses. I received more feedback from Mr Evans, as he wore them to a rugby match that evening.

“I wore the lenses for 13 hours and the comfort level remained very high the whole time. Definitely the most comfortable lenses I’ve worn. I didn’t get the dry feeling I normally get towards the end of the day with my other lenses,” he said.

Now the true test for this lens is going to be, whether we achieve good comfort even in, what I would consider the most challenging environment, the airplane…?
*Patient names changed for anonymity.

To earn your CPD hours from this article visit: mieducation.com/worth-the-wait-new-toriccontact-lens innovation-is-here.

This article was sponsored by Alcon. © 2022 Alcon Laboratories Pty Ltd. Australia: 1800 224 153. Auckland, New Zealand: 0800 101 106. ANZ-DTA-2200050

#In vitro measurement of unworn lenses.

^ Based on lens movement, centration, and rotation at initial fitting, n=78

References
1. Multi Sponsor Surveys Inc. The 2014 Gallup target market report on the market for toric contact lenses.
2. Optometry Connection Contact Lens Resource Guide. September 2021, Optometry Australia.
3. Optometry Connection December 2020, Optometry Australia.
4. Edrington TB. A literature review: The impact of rotational stabilization methods on toric soft contact lens performance. Cont Lens Ant Eye 2001 (344):104-110.
5. Alcon data on file, 2020. In a clinical trial to evaluate stability of axis orientation of DAILIES TOTAL1 for Astigmatism lenses where n=47 Ref 09861.

6. Alcon data on file, 2020. CLA306-C003 Clinical Performance of a Daily Disposable Toric Silicone Hydrogel Contact Lens - claims support document. Ref 10364.
7. Perez-Gomez I, Valente R, Vonbun H. Survey of patient and ECP satisfaction with a new daily disposable toric contact lens. Poster presented at 2021 American Academy of Optometry Annual Meeting; November 3-6; Boston, MA.
8. Wolffsohn JS, Dumbleton K, Huntjens B, Kandel H, Koh S, Kunnen CME, Nagra M, Pult H, Sulley AL, Vianya-Estopa M, Walsh K, Wong S, Stapleton F. CLEAR -Evidence-based contact lens practice. Contact Lens and Anterior Eye 2021; 44: 368-397.
9. Alcon data on file, 2018. Technical Review (Available on Request) Ref 04452
10. Alcon data on file, 2019. PRECISION1 and competitor OOP iDDrop evaluation report; Pg 7. [A01660-REP-043567].
11. Alcon data on file, 2019. PRECISION1 (DDT2) Lens with Smart Surface study [A01660-REP-044605]. Ref 10364.
12. Hart SM, McGhee EO, Uruena JM, et al. Surface Gel Layers Reduce Shear Stress and Damage of Corneal Epithelial Cells. Tribology Letters 2020; 68: 106.
13. Thekveli S, Qui Y, Kapoor Y, et al. Structure-property relationship of delefilcon A lenses. Contact Lens Anterior Eye. 2012;35(Suppl 1):e14.
14. Angelini TE, Nixon RM, Dunn AC, et al. Viscoelasticity and mesh-size at the surface of hydrogels characterized with microrheology. Invest Ophthalmol Vis Sci. 2013;54:E-abstract 500.
15. Pitt WG, Jack DR, Zhao Y, Nelson JL, Pruitt JD. Loading and release of a phospholipid from contact lenses. Optom Vis Sci. 2011;88(4):502-506.
16. Alcon data on file, 2019. iDDrop Comparative Study Oasys 1 Day and TruEye; Pg 6. [A01660-REP-180369].
17. Alcon data on file, 2021. Evaluation of Wear Experience with PRECISION1 for Astigmatism contact lenses over a long day of lens wear. IIT 64882539.
18. Maissa C et al. Evaluation of the lubricity of delefilcon A daily disposable contact lenses (Dailies Total1) after wear. Poster presented at the American Academy of Optometry Annual Conference; Nov. 2014, Denver, CO. REF-01219.
19. Walsh, Jones and Moody. Addressing common myths and misconceptions in soft contact lens practice. Clin Exp Optom, DOI: 10.1080/08164622.2021.2003693.
20. Wolffsohn JS, Bhogal G, Shah S. Effect of uncorrected astigmatism on vision J Cataract Refract Surg 2011; 37: 454–460.
21. Wills J, Gillett R, Eastwell E, et al. Effect of simulated astigmatic refractive error on reading performance in the young. Optom Vis Sci 2012; 89: 271–276.
22. Al-Qahtani H, Al-Debasi H. The effects of experimentally induced graded monocular and binocular astigmatism on near stereoacuity Saudi J Ophthalmol 2018; 32: 275–279.
23. Walsh, Jones and Moody. Addressing common myths and misconceptions in soft contact lens practice. Clin Exp Optom, DOI: 10.1080/08164622.2021.2003693.
24. Luensmann D et al. Spectacle prescriptions review to determine prevalence of ametropia and coverage of frequent replacement soft toric contact lenses. Cont Lens Anterior Eye 2018;41(5):412–20.
25. Morgan et al, 2022. International contact lens prescribing in 2021. Contact Lens Spectrum. Image from: Morgan & Efron. Global contact lens prescribing 2000- 2020, Clin Exp Optom, 105:3, 298-312, DOI:10.1080/081 64622.2022.2033604.
26. Cox SM, Berntsen DA, Bickle KM, et al. Efficacy of Toric Contact Lenses in Fitting and Patient-Reported Outcomes in Contact Lens Wearers. Eye Contact Lens 2018;44:S296-S9.
Helen Gleave BScOpt(Hons) MCOptom is part of the Professional Affairs team for Alcon Australia and New Zealand. She is responsible for training and education programs in contact lenses, contact lens care and dry eye, including Alcon Dry Eye Academy and Dry Eye Academy Online. Ms Gleave has delivered education to a broad range of audiences, spoken at numerous optometry conferences, educational events and webinars across Australia and New Zealand. She has also authored articles for the ANZ optometry magazines. She qualified as an optometrist from City University in London and owned a practice focused on contact lenses for 15 years. During this time she developed a special interest in contact lenses and the business of optometry. Through her practice she has been a clinical investigator for different contact lens manufacturers and a member of their advisory panels.
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