Hello,
I have never had RS and have had problems in the last several years with my custom made soft torics that I presume are due to poor tear quality (most of the OD I have seen in the past agree). I have tried punctal occlusion, doxy, flaxseed, etc with no change. I am now resorting to wearing glasses but want to try other contact lens options. I have tried Macrolenses but had too much fogging. I have tried every soft lens under the sun and the Westcon Westthin was the only one that gave me crisp nonfluctuating vision. I had a horrible fit with RGP - bounced around my eyes all day for months. Should I try a wavefront lens, the synergeyes, or revisit the rgp's?
Finally, I do not have a good CL fitter/OD in this area (Louisville, KY) - any suggestions for someone at least within driving distance?
Thanks, Browneyedgirl

Hi, browneyes.

There is no simple way to answer your question. Obviously if your RGPs moved too much, there was a fit problem. And an RGP on a dry eye tends to move less, not more.

In regard to soft lenses, there are two basic possibilities. One is the dryness issue which you mention. The other is the fit issue. There are many soft torics on the market but not nearly so many choices. By this I mean that a number of lenses are very limited in sizing and the lenses that you have received may be too snug. A snug fit is going to feel dry and, if you already have dry eyes, they will perform even worse. Custom lenses should have enough sizing to cover the bases but too many fitters rely on the measured corneal curvature (central 3 mm) of the keratometry readings to "fit" the lenses. Soft torics are usually at least 14.0 mm in diameter and extrapolating from the central 3.0 mm doesn't always work well.

For dry eyes it is usually better to use a soft lens plastic that is low in water content. Unfortunately, some of the best plastics (silicone hydrogels) don't come in enough sizes. The fact that you tried so many torics without success but found crisp vision only with a "thin" toric may suggest a sizing problem with other lenses. A thin lens might contour to the eye better and give better vision but feel dry. A thicker lens that is not the right curve could throw the vision off. Without any data about your prescription, the shape of your eye and the lenses you have tried, it is impossible to know the true nature of the problem.

SynergEyes lenses are no guarantee but if they fit centrally and the soft flange does not seize on the eye, they could be the answer for you. So much depends on the fit. SynergEyes has four different curves available for the peripheral flange and yet people report difficulty removing the lenses from their eyes, suggesting snug-fitting lenses again. So, while the lenses may give you the crisp vision you need, the combination of the central curve and soft flange has to be "on", particularly with your dry eyes. Contact the company and explain your persistent difficulties with contact lenses. Ask them who is their top fitter in the Louisville area. A practitioner who is using the lens a lot suggests he/she has the necessary knack for getting the lenses to work. Simply owning a trial set (i.e, having an account with the company) does not indicate proficiency.

You know the old saying about the three keys to success in business - location, location, and location? I think the three keys to success with contact lenses are - fit, fit, and fit. This is my experience over the years as I have seen many patients with supposed dry eye issues who did well with the right lenses. Dry eyes are more challenging, obviously, but how much of the problem is dryness and how much is the fit? There is no obvious answer. As I intimated earlier, we may have twice as many lenses available today than ten years ago. Unfortunately, we don't have twice as many choices.

Dr. Hartzok,
Thanks for your reply. Let me give you specifics to clarify my situation. My current lenses are Westcon Westthin Torics (38% Polymacon) which are a dual slab off design. They are not actually as "thin" as the other torics I have tried. I have tried Bausch & Lomb (Optima Toric, Soflens 66, Gold Medalist Toric), Ciba Vision (Optifit D2, Torisoft, Hydrasoft Toric), Cooper Vision (Preference Toric XR), Ocular Sciences (Sunsoft Multiples Toric), Purevision, Acuvue Advanced. The only other Toric that did not give me blurred vision due to rotation was the Torisoft, which was also a dual slab off design. I had been wearing the Westcon for about 8 years with no problems but then started developing blurred vision and subsequent eyestrain that was attributed to poor tear quality. I tried a steeper base curve but the lenses seemed to rotate more. I went from a high water content (55%) to a low water content (38%) in the same lens design which made a big difference for 3 years but my hazy vision has recurred so I am assuming my tear quality has changed again. The only other change is that Aosept hydrogen peroxide cleaner is in a new package but it appears that the solution is the same. My prescription is OD -7.25/-1.75 and OS -6.25/-1.75 with a base curve of 8.6, Diameter of 14.5.
I have not noticed any symptoms associated with dry eye, just assume that this is why all the sudden my lenses are not giving me crisp vision again. What is most odd to me is that this happened when I ordered duplicate lenses. My optician sent them back thinking it was a manufacturing defect but I am having the same problem 2 new pairs later. The last time this happened (3 years ago) I had ordered a new pair as well. Could this issue be due to subtle differences in custom cut lenses?
Additionally, I have not been happy with any OD in Louisville so I was wondering if you knew of anyone in Nashville, Cincinnati, or Indianapolis as I would be willing to travel for a good fitter.
Sorry for the barrage of questions.
Thanks BrownEyes

Dual slabs can work better for patients with tight lids (are you of Asian ancestry?) Since you had success with two dual slab designs, and going to the 38% Polymacon material extended your success, it does sound like dryness is thwarting your performance.You mentioned trying a steeper base curve. Does Westcon make a flatter lens curve than the 8.6 - even if it means going to a 15.0 diameter? The 38% Polymacon is an old plastic but it has low water content and a decent surface. However, if Westcon changed the manufacturing in some way, like switching the back surface to a molded rather than a lathe cut design, or any other design change, it could have altered the fit. Companies do alter designs and thicknesses without acknowledging the changes. If you gained better performance when switching to 38% Polymacon, maybe a slightly flatter base curve could help. Lenses that rotate too much can be too tight.

If you need a low water content material with a good optic, consider a 14.0/8.6 CSI Toric. They do well with dry eyes. They also hold up well to daily cleaning (for years). Daily cleaning (rubbing) is critical, especially for dry eyed patients. Peroxide won't always clean lenses well. Do the lenses seem stiffer after the lenses come out of the peroxide system?
Inconsistency in the manufacturing process is always possible but Westcon has been around for awhile so they should be fairly consistent in manufacturing unless they purposely changed design features.

Hello again,
I was fit with the SynergEyes lens and initially was very excited as my vision in these almost surpassed vision in glasses. To summarize my earlier post - I have severe myopia and moderate astigmatism and some sort of tear film issue which has occurred in my 30s and prevented me from continuing to wear my soft torics. I have never has any refractive surgery.
Unfortunately, the SynergEyes lenses are quite irritating (which is unusual as I have never had comfort issues with any lenses before) and after even one hour, my eyes are intensely red. My OD tells me the fit on one eye could be steepened but the other eye fits perfectly.
Is there a period of adaptation to these lenses with regard to comfort and should I persist on to try to adapt? I'm so disappointed as I love the crisp vision in these things and really want to get out of my glasses, even just a few days a week.
Thanks for the help.

Hi again, BrownEyes.

I am confused. You say that the SynergEyes lenses (plural) are quite irritating and your eyes (plural again) are intensely red and yet your OD tells you that the one lens is fit perfectly. If discomfort and redness are present in both eyes, how could one lens be fit perfectly?

If the redness is beyond the edge of the lens, it is likely due to a tight fitting flange (the soft skirt). The skirt should be looser so it doesn't compress the conjunctiva.

Redness around the edge of the cornea but under the lens is probably due to hypoxia (a lack of oxygen getting into the peripheral cornea). Again, the flange could be too tight OR the rigid portion of the lens may well be too steep. Doctors presume that the gas permeability of soft and RGP lenses, that the material alone, permits the necessary oxygenation of the cornea. This is not the case. If the lenses are uncomfortable immediately upon insertion, then it certainly suggests a significant problem with fit. If the initial comfort is not so bad but increases the longer you wear them, this suggests a lens that is too tight. This does not suggest a need for a steeper lens.

You have a highly myopic Rx. This makes the rigid lens center thicker at the point where it attaches to the soft skirt. A flatter rigid section is more likely needed - not steeper.

Many SynergEyes wearers complain of difficulty removing them. The lens needs to be loose enough to allow for a slight movement on the eye. You may feel the lens on insertion until it settles in a little but then it should be more wearable without the redness. A little tightening as you wear them is not unusual but significant dryness may cause the lenses to seize while on the eye.

In all cases, if the lenses are "quite irritating" and "intensely red" after wearing them, these are not for you. Maybe the definition of fit is at issue here. Red eyes indicate conjunctival swelling and, with swelling, the fit must be adjusted. Again, steepening is not the way to go. Steepening implies tightening. Redness implies tightness. Going tighter when the eyes are red is not logical.

One other consideration would be an allergy to the lens soaking solution. An allergic reaction will make your eyes red and the lenses very uncomfortable. Your doctor certainly need to rule this out. Dry eyes are more sensitive. And, since there are fewer tears to flush away the solution, the lens solution remains in the eye longer.

Thanks so much for your help. The redness happens in both eyes, much more so on the right eye, which is the one that my OD suggested might be too tight. The redness is definitely on the periphery of the lens and not directly under the GP portion. I'll have to get her to adjust the fit. I am questioning the possibility of an allergy to the solution - I have developed a contact dermatitis on my face where the solution (clear care) and drops (blink) have dripped down onto my skin. I previously used Aosept without as much of a problem. I just purchased the Purilens system (ionic cleaning system) and was wondering if that would be a better option. My OD said the clear care should be the least sensitizing, but I just wanted your opinion.

"The redness happens in both eyes, much more so on the right eye, which is the one that my OD suggested might be too tight."

This is different. If she feels the lens is "too tight" then it would need to be flatter and not steeper, so I would defer to her plan on this. Actually, both may need to be looser. I'm rooting for you.

Clear Care is a peroxide-based system as is AOSept. The peroxide is to be neutralized by a catalyst-coated disk that fits onto the bottom of the lens holder. If the "neutralized" solution causes redness on your skin, then perhaps the solution is not so neutralized. This could certainly cause redness in the eyes so it might be a good idea to try the Purilens system. I personally have no experience with it. It relies on UV light, so as long as the saline is not sensitizing, it should be okay.