Contacts for the "Hard-to-Fit" Patient

By Nancy Del Pizzo; reviewed by Arthur B. Epstein, OD

If you've had trouble wearing contact lenses, you may simply be "hard to fit." If you're not sure this describes you, check the list below. Chances are, if one or more of these conditions apply, then you are hard to fit.

Don't worry — it doesn't mean you can't wear contact lenses. You just need to know your options and how to find an eyecare practitioner ready and willing to provide them.

Are Your Eyes Hard to Fit?

People who are hard to fit with contact lenses may have moderate to severe cases of one or more of these conditions:

• keratoconus
• astigmatism
• dry eyes
• giant papillary conjunctivitis (GPC)
• post-refractive surgery (such as LASIK)
• presbyopia

If you're hard to fit, getting contacts is as easy as finding a practitioner who welcomes trickier cases like yours. Those who work with hard-to-fit people tend to be better aware of the different lens options, outfitted with advanced equipment and ready to take the time to adopt a goal-oriented approach to fitting you.

Contact Lenses for Keratoconus

A practitioner who is familiar with hard-to-fit cases is likely to fit a keratoconic patient with an GP (gas permeable, also known as RGP or rigid gas permeable) contact lens. Unlike a soft lens, it retains its shape on the cornea. However, when the cornea is so irregular it needs cushioning, a piggyback technique may be best. Piggybacking means you wear two lenses on each eye. A soft lens drapes over the cornea and a GP rests on top.

Another option for some patients is a contact lens that has a rigid middle with a soft skirt around it.

Contact Lenses for People With Astigmatism

Toric lenses are specially designed to correct astigmatism. However, the process of finding the best lens can be tedious, since there are varying degrees of astigmatism and each person's cornea measures up differently.

There are two types of hard-to-fit astigmats. One is the person in whom a toric lens rotates too much, causing blurred vision. Another is the person with very high astigmatism.

If you find that several different types of toric soft lenses rotate too much, it's important to be patient. An eyecare practitioner who has experience fitting a wide variety of toric contact lenses should be able to find a lens that provides a stable fit and good vision.

Patience also comes in handy if you have very high astigmatism. While a custom soft lens might work well, those with significant astigmatism may be best off getting gas permeable lenses for optimum visual clarity. Clinicians can custom-make any kind of lens to fit any type of astigmatism.

Contact Lenses for People With Dry Eyes

An estimated 15 percent of contact lens wearers in the United States were diagnosed with dry eyes in a large-scale study from Harvard. Unfortunately, some practitioners who fit contact lenses never test for dry eyes. As a result, those with dry eyes may find contact lens wear uncomfortable.

Some symptoms of dry eyes are:

• feeling as if something is in your eye
• tearing for no reason
• frequent red or burning eyes
• having very watery tears

If you have chronically dry eyes, you are better off seeing a practitioner who understands how different lens materials react with the eye. A very thin lens dries up too fast. Frequently, a fairly thick, soft, one-day disposable lens can work well in people with dry eyes. Practitioners generally recommend soft lenses made with a low water content because these lenses dehydrate less than high-water lenses do in a dry environment. However, different types of dry eye may require different contact lens approaches.

Some practitioners prefer special-material soft lenses for dry eyes. Your eye doctor may also suggest GPs because rigid lenses do not absorb water from your eyes.

Another technique a practitioner may use involves punctal plugs. These tiny collagen or silicone devices are inserted into the tear ducts to block tears from leaving the eye, thus creating a moister environment for the contact lens. The procedure only takes about three minutes. Once punctal plugs are inserted, most people can't even feel them.

Read more about solving contact lens discomfort.

Contact Lenses for People With GPC

Giant papillary conjunctivitis (GPC) is an inflammatory reaction caused by proteins secreted in your eyes. Soft contact lens wearers who have GPC may find their lenses coating with protein deposits, making them uncomfortable and visually annoying.

Practitioners have several options to fit a person who has this condition. Sometimes soft daily disposable contact lenses will do the trick, since you just throw them away each day. There's no time to accumulate protein deposits.

GPs also are a good option because proteins do not cling to them like they do with soft lenses. GPs that are cleaned each night will be free of residue for the next day's wear; soft lenses tend to retain deposits over time, even with daily cleaning.

A practitioner also may prescribe medicated eyedrops to reduce the allergic reaction.

Contact Lenses After Corrective Eye Surgery

It may seem odd even to consider contact lenses after corrective eye surgery. After all, aren't LASIK and other procedures supposed to eliminate the need for glasses or contacts? Theoretically, yes. In practice, LASIK doesn't always bring the visual results patients want or need. In these cases, contact lenses may be in order.

For example, if you have very high astigmatism, you may require toric lenses to correct the residual refractive error following LASIK. Soft lenses can work well, and large-diameter GPs are also an option. If you've had LASIK performed in a monovision fashion — in which one eye is corrected for distance and the other for near — you may wish to obtain a contact lens for occasional use in the latter eye for activities demanding the best possible distance vision.

Contact lenses can help to address LASIK complications. The most common instance of a complication would be if the procedure resulted in irregular astigmatism, with a loss of two to four lines of vision on the standard eye chart. The proper GPs can often correct the vision to the preoperative level. Excessive glare is another potential problem following LASIK. Here, too, GPs are your best choice (in this case, ones with a large diameter). In rare instances, a surgeon may perform LASIK which results in an off-center ablation. Here, the resulting optical status of the eye resembles that of irregular astigmatism, and, again, an GP is the lens of choice. When fitting an RGP lens following complicated LASIK, it may take several fits before you find the lens that works for you.

Contact Lenses for Presbyopia

Unlike some of the other categories in this article, it's not a specific set of physical characteristics that can make a presbyopic person hard to fit with contact lenses. Rather, it's because there are many different kinds of lens designs for presbyopia, and different designs work better for different people.

There are also more variables to consider for each lens, because even the simplest designs involve some form of near power and distance power in the same lens. Fitting a presbyopic person can require some trial-and-error and then fine-tuning, making for a time-consuming — and more expensive — process.

The good news is that today, more people are successful with multifocal contact lens designs than in the past. A few years ago, many people who tried multifocal or bifocal contact lenses weren't able to adapt to them. Improvements in lens design have changed that; if you are determined to wear contacts your chances of success are better than ever.

Read more about monovision.

Why Fitting Hard-to-Fitters Costs More

Expect to pay more when you go to an eyecare practitioner who will take the time to fit the hard-to-fit person. You're paying for the time involved, the expertise of the practitioner and the type of lens you'll receive.

Prices vary considerably. If fees are important to you, make sure you ask how the practitioner charges for contact lens fittings. There may be a flat fitting fee of several hundred dollars or more, which is typically separate from the cost of the lenses.

Finding a Practitioner Who Fits the Hard-to-Fit Contact Lens Patient

You can locate an optometrist or ophthalmologist in your area with expertise in contact lenses by visiting our Find an Eye Doctor page.

[Page updated March 2006]