Astigmatism/Toric Contact Lens Failure Rates

I don't know if there are a lot of published numbers about what I'm going to talk about. I know we hear all the time about why contact lenses fail and the big one is "dry eye", or at least dryness in contact lenses, if not a clinical diagnosis of dry eye. But in my opinion one of the biggest contact lens failure rates is among people who have a low to moderate amount of astigmatism and not much else going on. I'm talking about low mixed astigmats, low simple myopic astigmats, and low compound myopic astigmats who have more cyl than sphere. These people are usually 20/25 or 20/30 without any correction, and they are 20/15+ with their glasses on. At some point they have the same idea as every other glasses wearer: "I sure with I could see clearly w/o these clunky glasses because sometimes they get in the way", which is of course true. But in my estimation these cases have a really high failure rate. I personally believe it to be over 50%, and the reason will surprise you: they're "not bad enough.". What I mean is that there is no "wow" factor when they put their contacts on. They usually go from their uncorrected 20/25 or 20/30 to a messy 20/20- with strain while wearing low-astigmatism soft toric contacts, and it's nothing like the crystal clear 20/15+ they get in their glasses, and they're disappointed. Not only that but they assume we've done something wrong and somehow haven't got their Rx right yet. This is especially true if they have a myopic friend who constantly wears and loves soft contacts who tells them how great contacts are and how much better they see than when they wear glasses. Those are apples and oranges, however. What they don't know is a lot of those high myopes who *love* their soft lenses can only reach 20/25 or so in their contacts, which they think is amazing and a vast improvement over their uncorrected vision. They're going from AWFUL to normal. But the low astigmats in question aren't doing that; they're going from almost normal 20/25 vision to superhuman vision in their glasses and they expect that same "wow factor" in soft, disposable, low-cyl, toric contacts and it's just an unrealistic expectation. So they come back and talk to me some more and I explain all of this again (because I have already warned them at the initial fitting about my low expectations), and some of them are okay with it and some of them still think I'm somehow not trying hard enough or haven't made the lenses "strong" enough or whatever. Just because a -0.25-0.75x020 toric lens is manufactured doesn't mean it's going to work. The folks who have that Rx in glasses we already know something about them: they're pretty high acuity demand. They're pretty "picky" about their vision. If they weren't, they'd just be perfectly fine with going w/o glasses and walking around with 20/25 acuity all the time. The fact that they are in glasses at all tells me they want to see AWESOME, and when they ask about soft contacts I already know "awesome" is a pipe dream and so I'm immediately skeptical of their success in contacts. Then add in the feel of torics, the "dry eye" or dryness issue mentioned at the beginning as the #1 culprit of contact lens failure, and you can see how I come up with such a low estimated success rate in these types of prescriptions.


  1. Wouldn't fitting them in RGPs satisfy their pickiness in many cases? Overkill? 15 years ago when I was super picky so my OD threw me in RGPs. I loved the acuity coming from soft torics. (Although I'm now trying to move to soft daily disposable torics. The irony.)

    Although as someone how has more sphere than cylinder, I'd take their uncorrected 20/25 or 20/30 any day of the week!

    1. "I'd take their uncorrected 20/25 or 20/30 any day of the week!"

      you would, but many won't. RGP's are a tough sell. "order these custom lenses that you have to pay for up front. no, you can't try them 1st. no, no guarantee they will work oh yeah they feel terrible but you'll probably get used to it"


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