Astigmatism is highly prevalent; approximately 47% of individuals have clinically significant levels (> 0.75D) in at least one eye.1 While countries such as Portugal, Argentina, and Colombia report toric prescribing rates approaching 50% of all soft lens fits, others lag well behind, with some practitioners continuing to rely on spherical equivalent correction, even when a toric option would provide a better visual outcome.2 This discrepancy has real consequences for patients: even low levels of uncorrected astigmatism can lead to visual discomfort, nighttime driving difficulties, increased glare sensitivity, and digital eye strain.3-6These issues often go unreported, but can significantly affect quality of life, particularly in today’s screen-heavy environment.

So, what is stopping wider adoption? Across multiple markets, eye care practitioners (ECPs) continue to voice similar concerns: that toric lenses are more complicated or time-consuming to fit, that they compromise either comfort or vision (or both), or that patients will not see enough added value, especially low astigmats, to justify the perceived cost. Others worry about stabilisation issues, prismatic effects, or past experiences when toric lenses did not meet expectations. While these concerns may have been valid in the past, today’s toric SCL designs and clinical data tell a different story.

Let’s take a closer look.

MYTH #1: PATIENTS MUST CHOOSE BETWEEN COMFORT AND VISION

It is not uncommon to hear that astigmatic patients must sacrifice either comfort or vision when fitted with SCLs. But this belief no longer reflects the reality of modern toric lens design. In fact, the evidence strongly indicates that modern toric soft lenses are capable of providing both excellent visual quality and comfortable wear throughout the day.7-14

For example, Berntsen et al.8 and Cho et al.9 both reported statistically significant gains in high- and low-contrast visual acuity with toric lenses. In patients with astigmatism between -0.75 and -1.75D, toric lenses provided improvements of approximately four to 5.5 letters. This equates to nearly one full line of visual acuity compared to spherical lenses, a difference that is both statistically and clinically meaningful.8,9 Patients also report improved subjective vision quality.7,9,12,14 Chaudhry et al.12 found that 79% of participants preferred toric lenses over spherical, with significantly better clarity and lower visual fatigue during wear.

Equally important, this improvement in vision does not come at the cost of comfort. Multiple studies have shown no significant difference in comfort between toric and spherical lenses. In Chaudhry et al.,12 both lens types were rated as almost equally comfortable. Cho et al.9 similarly reported no significant differences in initial comfort between spherical and toric designs. More recently, Morgan et al.14 also found no significant difference in comfort scores between the two lens types in their crossover study.

What these studies show is that patients are not being forced to compromise with modern toric lenses. Patients can enjoy the improved vision that comes from fully correcting their astigmatism, without sacrificing comfort throughout the day.

MYTH #2: LOW ASTIGMATISM DOES NOT NEED TORIC CORRECTION

It is sometimes assumed that low levels of astigmatism, typically below 1.25D, do not require toric correction. In practice, this leads many ECPs to prescribe spherical equivalent lenses, being under the impression that the difference in visual performance is negligible. However, research suggests that this approach may cause significant visual compromise, especially at the 0.75D threshold, which is often treated as the lower limit for toric fitting.

Evidence shows that astigmatism of 0.75D can produce consistent and measurable reductions in visual acuity. Atchison and Mathur15 demonstrated that 0.75D of crossed-cylinder blur produced losses in high- and low-contrast visual acuity approximately twice those caused by defocus of the same blur strength. Moreover, the impact of cylinder blur was shown to vary with axis orientation, suggesting that even small amounts of uncorrected astigmatism may lead to inconsistent vision in real-world settings.

Villegas et al.16 found that while astigmatism below 0.50D typically had a limited effect on acuity, correction of astigmatism at or above 0.50–0.75D provided measurable improvements in high contrast vision, although with some intersubject variability. This is supported by recent work from Read et al. who demonstrated, using a novel pupil-controlled system, that uncorrected astigmatism of 0.75D or more significantly reduces visual acuity, and that toric lenses or spectacle correction offer superior vision compared to spherical lenses in this range, across varying pupil sizes.17 These findings are important because they suggest that although the visual impact of very low astigmatism may be minimal, the threshold for meaningful improvement lies well within the range that is often ignored in practice.

Clinical studies reinforce this point. Multiple trials involving patients with 0.75–1.25D of refractive astigmatism have shown that toric lenses deliver better high- and low-contrast visual acuity compared to spherical equivalents.8-10,12

In summary, while extremely low levels of astigmatism (< 0.50D) may not always warrant correction, the evidence clearly supports toric fitting for patients with 0.75D or more. Relying solely on spherical equivalent correction in this range risks underdelivering on both clarity and comfort, especially as visual demands continue to increase in digitally driven environments.

MYTH #3: 6/6 VISION MEANS THE FIT IS GOOD ENOUGH

In clinical settings, 6/6 (or 20/20) visual acuity is often treated as the benchmark for a successful contact lens fit. However, this standard can be misleading. Research has shown that the average visual acuity of healthy adult human eyes is actually significantly better than 6/6.18 This becomes particularly relevant in the context of uncorrected or under corrected astigmatism, where achieving 6/6 with a spherical equivalent lens may still fall short of the patient’s true visual potential.

More importantly, visual acuity alone is an incomplete measure of lens performance. It captures only one dimension: the ability to resolve high-contrast letters in a controlled environment. It tells us nothing about how the lens performs during real-world visual tasks, or how the patient feels about their vision in day-to-day life. Patients may read the chart in a clinical setting well, but still experience ghosting, fluctuating clarity, or visual fatigue, particularly when low-to-moderate astigmatism is left uncorrected.

Several clinical studies comparing toric and spherical lenses highlight this disconnect. Toric lenses have been shown to provide superior high-contrast visual acuity, often surpassing 6/6, as well as improvements in contrast sensitivity and subjective visual quality.8-10,14 These improvements matter, even if the spherical lens already provides 6/6, because toric lenses can take patients beyond that standard, both in acuity and visual quality.

The real question is not whether the patient can read a line of letters in the distance but whether they can see clearly, comfortably, and consistently throughout the day. That requires going beyond Snellen acuity as the sole marker of success and recognising that true visual performance is multidimensional.

MYTH #4: TORIC LENSES ARE TOO COMPLICATED TO FIT

Toric lenses are sometimes seen as more difficult to fit than spherical lenses, requiring more chair time due to increased trial lenses required, more adjustments, or more follow ups. However, recent evidence shows that this perception no longer holds true for modern toric designs.

Cox et al.7 found that the average number of lenses required to reach a successful fit was 1.2 for both toric and spherical lenses. The initial lens selected by the examiner was successful in 84% of toric fits and 79% of spherical fits. Similarly, Sulley et al.19 reported that 88% of toric lenses were fitted successfully at the first attempt, with overall success rates of 70–80% depending on the wearer group, including neophytes and former contact lens dropouts. Even earlier observational data suggested that over 90% of toric fits were satisfactory with the first lens selected, and nearly all others were resolved with just one adjustment.20

These findings demonstrate that modern toric lenses are not more complicated to fit than spherical designs. High first-fit success rates and minimal need for lens changes support their use as a routine option, even for new wearers or those returning to contact lenses after previous issues.

MYTH #5: TORIC LENSES TAKE TOO LONG TO FIT IN CLINIC

It is often assumed that toric lenses are more time-consuming to fit. However, recent evidence shows that fitting times are comparable to spherical lenses. Cox et al.7 reported average fitting times of 10.2 minutes for toric lenses and 9.0 minutes for spherical lenses, a small and statistically insignificant difference.

More recently, Smith et al.21 found average chair times of 25–28 minutes across spherical, toric, and multifocal fits, with no significant differences between lens types.

These findings confirm that toric lenses do not take longer to fit in practice, and certainly not enough to justify avoiding them when they are clinically indicated.

MYTH #6: IF A TORIC HAS FAILED BEFORE, IT WILL FAIL AGAIN

A common belief among practitioners is that if a patient has previously discontinued toric lens wear, they are unlikely to succeed if refitted. Many of these dropouts, however, discontinued wear not due to inherent unsuitability, but because of discomfort, difficulty handling the lenses, or general inconvenience; issues often rooted in older lens designs, materials, and limited fitting options.19,22,23

When comparing outcomes a decade apart, the contrast is striking. In a study by Young et al.,22 only 69% of previous toric wearers were successfully refitted with toric lenses after drop out. By contrast, Sulley et al.19 reported a 94% success rate among lapsed wearers fitted with modern toric soft lenses over a one-month period. This apparent improvement highlights the significant advances in lens design and materials over the past decade, including more stable orientation systems, thinner profiles, and enhanced surface technologies that collectively improve comfort and ease of use.

These findings make one thing clear: a previous failure with toric lenses should not discourage refitting. With today’s technologies, most former dropouts can now succeed and often thrive in toric lens wear.

MYTH #7: GRAVITY OVERPOWERS TORIC STABILISATION DESIGNS

There is a long-standing misconception that gravity disrupts toric lens stability; that a wearer lying sideways or moving into non-upright positions will experience lens rotation and loss of vision. While gravity does play a role in toric lens orientation, particularly in prism ballasted designs, modern research shows it is only one of several stabilising forces and not a cause of instability.24-26

As Young et al.25 explained, lens orientation results from a complex interplay between gravity, lid forces during blinking, and the physical design of the lens. For example, gravity may initially contribute to reorienting a prism ballasted lens after rotation, but once that effect tapers off around 30°, lid interaction takes over, particularly the sweeping motion of the upper eyelid against the lens surface within the palpebral aperture.25,27 Double slab-off and dynamically stabilised lenses, in contrast, rely more heavily on lid-lens interaction and show little to no gravitational influence at all.

Critically, the idea that gravity introduces unreliability in toric performance is a misconception: gravity helps lenses settle into position rather than causing instability. Moreover, manufacturers have responded to these biomechanical insights by optimising lens designs to minimise the influence of head position, lower lid variability, and blink dynamics, resulting in toric lenses that are both more predictable and more stable across a wide range of eye shapes and activities.

MYTH #8: PRISMATIC EFFECTS IN TORICS COMPROMISE PATIENT EXPERIENCE

A common concern surrounding prism ballasted toric soft lenses is that they may introduce unwanted optical effects, such as vertical imbalance or image distortion, particularly in patients wearing a toric lens in one eye only. However, recent research suggests that these prismatic effects are generally well tolerated by most patients with normal binocular function.28-30

For instance, Nilsson et al.28 found that fitting a prism ballasted soft toric lens in only one eye induced a small vertical vergence error, but this was rapidly and fully compensated for through normal fusional adaptation mechanisms. Subjects in the study showed no significant change in vertical fixation disparity after just 15 minutes of wear, indicating that the induced imbalance did not interfere with binocular vision in healthy wearers.

Similarly, Sulley et al.29,30 quantified the vertical prism present in a variety of commercially available toric lens designs and found that while many lenses do contain measurable prism in the optic zone (ranging from ~0.5Δ to 1.1Δ), symptoms such as asthenopia or reduced stereopsis are primarily a concern for monocular astigmats or patients with pre-existing binocular anomalies. In the general population, however, the level of prism typically induced is unlikely to result in noticeable disruption.

It is important to remain aware of vertical prism effects in specific clinical situations, particularly when fitting toric lenses unilaterally or in patients with pre-existing binocular vision anomalies. However, for the vast majority of wearers, these effects are minimal and do not compromise visual performance or comfort. Rather than avoiding toric lenses due to concerns about prism, clinicians should focus on selecting the most appropriate design for each patient.

Many modern toric lenses incorporate advanced stabilisation systems that minimise or eliminate prism in the optic zone, making them suitable for routine use in a wide range of patients.

This article was sponsored by Alcon Vision Care. ANZ-AST-2600001.

References

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