Every eyecare provider has encountered that one patient who complains endlessly of glare. Glare is classified as increased sensitivity to bright light, resulting in reduced visual acuity or contrast, and can be debilitating.1
It’s a common symptom among low vision patients, of whom there are an estimated 295 million worldwide as of 2020.2 Low vision (20/40 BCVA or worse in the better eye) can result from a wide range of ocular disease, many of which cause significant glare disability.3
In low vision clinics, tinted lenses are often recommended to help patients alleviate glare symptoms and have proven to enhance quality of life.4,5 In the age of digital devices associated with increased dry eye and anterior segment disease, glare is becoming a prevalent complaint amongst the primary care patient population as well.6,7,8
This article will explore and break down the approach eyecare providers can take to selecting the best tint to help their low vision and non-low vision glare patients.
Common conditions associated with glare
Glare can result from any part of the eye that is affected by disease processes, and thus, many ocular conditions are associated. In some cases, glare can be alleviated if the disease is treated, but there are also chronic conditions where glare persists despite treatment.
Working from the front of the eye to the back, here are some common conditions that can elicit glare:
- Dry eye disease, conjunctivitis, blepharitis
- Ocular inflammation (iritis, uveitis, scleritis, keratitis)
- Corneal scarring and ectasia
- Iris atrophy or transillumination defects
- Cataracts
- Retinal dystrophies and inherited retinal conditions (IRDs)
- Ocular and oculocutaneous albinism
- Retinal tears / detachments
- Significant panretinal photocoagulation (PRP) scarring, laser scars from retinal hole repair
- Retinal staphylomas / changes from myopic degeneration
- Macular degeneration
- Diabetic retinopathy
- Optic neuritis, papilledema, optic atrophy
- Glaucoma
- Migraines, traumatic brain injuries (TBIs)
The role of the tinted lens
The goal of a tinted lens is to reduce glare sensitivity by filtering out the wavelengths of light that are causing symptoms. Based on this theory, specific colors of tints are often associated with certain disease processes due to the specific wavelength of light that can be problematic for that condition.
For example, research has shown that patients with cone dystrophy are able to successfully alleviate glare symptoms by wearing red tints.9 Alternatively, amber tints are often well received by low vision patients with reduced contrast sensitivity, as they are able to filter out certain wavelengths of light to allow enhanced contrast.10
Specific colors in combination with a visible light transmission (VLT) percentage, or the amount of visible light that passes through a material, can provide the most optimal tint for a given task. It’s important to keep in mind that the lower the VLT %, the less light is let through a material and the darker the tint will be.
A guide to recommending tints
When a low vision or non-low vision patient presents with significant glare complaints, it can be overwhelming to know where to start in determining the colors and darkness of an ideal tint recommendation.
Below is a step-by-step approach for the simplest and most efficient way to perform a tint evaluation:
1. Perform an accurate refraction and stabilize the ocular surface
An accurate refraction is important to the success of any tint evaluation. This will ensure best corrected vision and minimize refractive glare. For patients who have reduced vision, it is best to confirm a comfortable prescription with a trial frame.
Additionally, ocular surface conditions should be treated and stabilized before a glare evaluation.
2. Determine if the patient is a good candidate for tints.
After the ocular surface is treated and an accurate prescription is confirmed, it is important to evaluate other reasons for glare and decide if a patient is a viable candidate for a tint. If there are other pathologies contributing to light sensitivity, one should see if glare will resolve once a patient’s condition is treated or if it will persist despite other treatments.
For example, a patient with an acute idiopathic uveitis will likely not see the value of wearing specific tints as much as a patient with geographic atrophy from long-standing age-related macular degeneration (AMD).
3. Have appropriate materials on hand.
Be prepared with appropriate trial materials to show the patient when they come in for an evaluation. Ideally, it is best to have some of the most common colors with the option of two or more VLTs for each color.
Clinically speaking, some of the most commonly recommended tint colors include:
- Amber
- FL-41 / plum
- Orange
- Grey and or grey-green
It would be best to have these available in the office, either as basic fitover frames, clip-on lenses, or lens blanks.
4. Emulate the setting in which the patient is having symptoms.
Attempt to the best of your ability to recreate the setting in which the patient is experiencing glare and show them tints in these conditions. If a patient has difficulty with outdoor glare, show them tints through a sunny window or have them briefly step outside to try the tints on. Similarly, if someone complains of glare specifically at the computer, show them trial tints in that setting.
5. Have the patient choose a color.
Ideally, it is beneficial to present patients with two colors at ~50% VLT to choose from to start. Certain colors are associated with relieving glare for specific conditions, so keep these in mind when choosing a starting point.
These tints can be presented in a “1 or 2” fashion to help patients narrow down their choice. Clinically, glare alleviation can be subjective, so do not be surprised if patients don’t respond to certain colors the way research suggests they should!
Here are some suggestions on color filters that are associated with certain conditions to guide you:
- Amber / yellow / orange: Good for patients with complaints of reduced contrast and glare (patients with AMD, retinal scarring, glaucoma)4,10
- Red: Good for cone dystrophies, color vision deficits9
- Plum / FL-41: Good for glare secondary to TBIs, migraines11,12
- Grey / grey-green: Good for generalized glare and contrast complaints without impacting color perception13,14,15
6. Have the patient choose the darkness level (VLT %).
After the patient selects a preferred color, they can then determine how dark the color needs to be (VLT %). In most clinical settings, you may have one or two VLT options available per color, and they will choose between a lighter and darker tint.
If you work in a setting where you have more options available to you, you can start at around 40 to 50% VLT and then bracket in either the darker or lighter direction, depending on patient preference. A general rule of thumb is to trend towards lighter tints (higher VLT %) for complaints of indoor glare and darker tints (lower VLT %) for outdoor glare complaints.
7. Recommend a modality for how the patient will wear this tint.
The easiest way to initially trial a tint is to send patients home with fitover glasses. These function well and are cost-effective, but may not be aesthetically pleasing.
Keep in mind that there are many ways that patients can use tints, so once the patient feels satisfied with the tints shown in fitover form, you can make recommendations for other ways to wear tints tailored to the patient's needs.
Here are some examples:
- Fitover shades
- Clip-on tints
- Tinted contacts (can be custom-made to fit over the pupil zone)
- Getting prescription glasses tinted through a specialty optical or TransitionsR (if the patient has mainly outdoor glare complaints)
- Acetate paper over a screen (for computer screen glare)
Currently available tint options
Though this list is not comprehensive, it represents the tint options that can be found on the market today.
- Low vision device companies: Companies that sell low vision devices will typically sell fitting sets of fitovers in popular colors and VLTs to show your patients and sell (i.e., Eschenbach, Cocoons, etc.).
- NoIR: NoIR tinted lenses are often used in the low vision world. They have a range of inexpensive fitovers in a wide range of colors and VLTs to suit most glare needs.
- Thera-specs: This company makes many styles of frames to use with a limited range of tints (including FL-41) that can come as non-Rx or Rx glasses.
- Transitions: Transitions Gen S can be useful for patients who respond well to certain colors and want the convenience of not switching to sunglasses when going outdoors. They currently have eight colors available, including amber, blue, plum, and grey-green hues.
- Specialty opticals: If a patient has a particular tint and VLT that they want to use with certain frames, you can always work with a local specialty optical lab to make prescription glasses for them. A specialty optical that is used frequently in many vision rehabilitation clinics is Chadwick Optical.
- Tinted contact lenses: There are a few companies that make custom-tinted contacts in limited colors and VLTs. BioMed tinted lenses are commonly used in situations where patients would prefer tinted contacts and have a range of options for lavender, plum, amber, and red tints.
- These contacts are extended soft lenses that are replaced annually, and can either be fully tinted or have the tint limited to the pupil area only. Additionally, ALTIUS Performance Tinted Lenses are daily disposable lenses that come in amber or grey-green options.
5 key takeaways
- Tints are a beneficial device that have been traditionally used to help low vision patients, and can help alleviate glare complaints when appropriately recommended.
- Tints work by filtering out specific wavelengths of light to reduce glare, which is why certain colored tints are typically recommended for patients with certain disease processes.
- A successful tint evaluation requires emulating the type of glare a patient experiences, and having them select a color and VLT preference that best alleviates their symptoms.
- Patients who are not technically “low vision” by definition can still suffer from glare sensitivity, and making tint recommendations can help to improve their quality of life greatly.
- Consider getting creative with the ways patients can use tints—it does not always have to be a fitover frame!
