Introduction

Even though the vast majority of contact lenses fit today are soft contact lenses,
the hard contact lens is simply another tool available to the contact lens
practitioner. Some practitioners never fit a hard lens, others fit a hard lens as
their first choice. The soft vs. hard philosophy of the practitioner, I think,
depends very much on where he or she went to school, who his instructor may
have been, and/or what contact lens publications she reads. s ophthalmic
technicians, we simply need to be familiar with the basic characteristics of both.

!ard lenses offer some different modes of correction for astigmatism which have
some advantages over soft toric correction. !ard lenses are generally less
e"pensive for the patient #less fre$uent replacement%, and hard lens wearers are
less susceptible to corneal diseases than soft lens wearers. !ard lenses are not
comfortable initially, re$uiring a build up of wearing time, and may never be
comfortable if not fit properly.


&nce upon a time, there was but one predominant hard contact lens material.
That was '(( #polymethylmethacrolate%, otherwise known as ple"yglass.
)es, I do remember those days, and no, Teddy *oosevelt was not president.
lthough very durable and optically efficient, '(( plastic had an o"ygen
transmission capacity near +ero. ,e know from corneal anatomy and
physiology that the cornea usually gets most of its o"ygen through the
epithelium, from contact with the air. So, how did the cornea get its o"ygen
when covered with '((- &"ygen came from the tear layer, which was
continually being .pumped. under the contact lens as the lens moved with each
blink. The '(( lens fit had to be adjusted not only for good vision, but also for
good movement and good tear circulation. The practitioner could vary the base
curve, the peripheral curves, the edge design, and the diameter to arrive at an
acceptable fit. It was not unusual to see small diameters #/ to 0mm% in hard
lenses. s you might e"pect, a small diameter was not conducive to optimum
vision. Some practitioners busied themselves thinking up new ways to improve
o"ygen transmission so that larger diameters could be used. &ne method was
to drill small holes near the edge of the lens #fenestration%.


Then along came silicone acrylate, and later fluorinated silicone acrylate. These
materials allowed some o"ygen to pass through the lens material to the cornea,
enough o"ygen so that tear e"change became less important and larger
diameter hard lenses became practical. The rigid gas permeable lens #*1'%
was born #also known as a hard gas permeable, !1'%. These lens materials
were not without their problems, such as not wetting well. Some of these
problems persist to this day, such as susceptibility to scratching and cracking.

&"ygen transmissibility is e"pressed in terms of the 2k value, or the diffusion
coefficient value. The higher the 2k value is, the higher the o"ygen transmission
through the material. It is usually given as 2k/3, with 3 being the center
thickness of the lens. This means that, no matter what material is being
measured, o"ygen transmission will decrease as lens thickness increases. 4o
matter what material is used, thinner is better as far as o"ygen transmission is
concerned. The down side of ultra thin lenses is undesirable fle"ing on an
astigmatic cornea and decreased durability.

Hard Contact Lenses:

Lens parameters

The Base Curve

The base curve #56% is also known as the central
posterior curve #6'6%. s the name suggests, this
is the curve in the center of the lens on the posterior
surface, the surface that touches the cornea. The
base curve is adjusted relative to keratometer
readings, which give the curvature of the corneal
cap, or ape".


,ith regard to the keratometry readings, .7. usually refers to the flattest of the
two readings. 8or e"ample, with readings of 9:.;; " <0; and 9=.;; " >;, 9=.;;
would be the flatter reading and would be the value of 7. contact lens can be
fit .on 7., which would be a base curve of 9=.;; in our e"ample. The lens can
be fit steeper than 7. n e"ample would be a base curve of 9=.:;. The lens
can be fit flatter than 7. n e"ample would be a base curve of 9<.:;.

The initial base curve is typically selected relative to the amount of corneal
cylinder present. The protocol is usually supplied by the manufacturer of the
lens, or it can come from another source. (ore on this when fitting methods are
discussed.

s discussed in the soft contact lens modules, the shape of the cornea is
comple" #aspherical to be more precise%. 6onventional keratometry only
characteri+es a small portion, the corneal cap. hard contact lens has to be fit
more precisely to the shape of the cornea because it does not .drape. over the
surface like the soft lens does. It would be helpful to have an instrument that
would more precisely measure the shape and guide you in designing the lens.
lthough hard lenses have been successfully fit for many years using the
keratometer, the corneal topographer is a relatively new tool which will advance
the art and science of hard contact lens fitting.


Corneal topography

corneal topographer is an instrument that makes a
contour map of the shape of the cornea, much like the
topographical maps of the earth?s surface. In recent
years topographers have become more portable and
pricing has come down, so that what was once a
research tool has become a more common clinical
tool. The keratometer is limited to measuring 9 points
of data within the corneal cap #central 9mm%. The
corneal topographer measures thousands of points
over the entire surface of the cornea.


There is more than one
method for obtaining the
measurement.
common method is
based on 'lacido?s disk,
which projects an image
of concentric rings upon
the corneal surface. &n
the immediate right is a
picture of an anti$ue
'lacido?s disk, with a
more modern version
pictured on the far right.
,ith a computeri+ed
topographer, the
computer compares the
shape of the reflected
rings to the shape of the
projected rings and a
contour map is
produced, as pictured
above.


n e"ample of such an instrument is the &culus
Easygraph #we have no financial interest in this
instrument%.


The contour maps are color coded to make
evaluation easier, with the hotter colors representing
more height/curvature/power and the cooler colors
representing the opposite. The &culus claims that
the Easygraph also functions as a keratometer,
providing .real. 7 readings instead of .simulated. 7
readings.


The corneal topographer has most commonly been
used to screen patients for keratoconus and irregular
astigmatism prior to refractive surgery, and to provide
additional data to determine how much corneal tissue
should be removed in refractive surgery. It is also
used to diagnose and manage diseases and conditions
that affect the corneal curvature, such as keratoconus,
irregular astigmatism, corneal scars, and corneal
transplants.

The corneal topographer may come with software that aids in the fitting of *1'
lenses. 5ased upon the topographic map, the software will recommend *1'
lens parameters for an .optimum. fit, and some software will provide a simulated
fluorescein pattern. The parameters can be altered by the practitioner and the
software will present a predicted fluorescein pattern based upon the changes.



Calculating the initial lens power
The initial power of the *1' lens is selected as follows@
<. 6onvert the manifest refraction or the glasses correction to minus cylinder
form. E"ample@ A/.:;B<.:;"<0; transposes to AC.;;A<.:;">;.
=. 2rop the cylinder power and use only the sphere component of the
prescription. E"ample@ AC.;;A<.:;">; becomes AC.;;.
D. djust for verte" power. )ou will need a table or a verte" calculator for this.
)ou are changing the verte" distance from around <=A<9 mm to +ero #corneal
contact%. Esing the free optics calculator from eyetec.net, a AC.;; lens power at
<= mm changes to a A:.C= lens power. If the lens was BC.;;, then the power
would adjust to BC.:;. This is an important concept to keep in mind. s the
verte" distance is reduced, minus lens powers go down, and plus lens powers
go up.
The initial power for the trial lens in our e"ample will be A:.C= 2. &f course, if
working from a trial set, you would choose the lens power closest to A:.C= 2. 5ut
what happened to that A<.:; 2 cylinder power, you might be asking yourself, how
does that get corrected- This is where the .tear lens. comes into effect.
The Tear Lens
Suppose that we fit our lens on 7. This of course means that the base curve
corresponds to the flattest meridian of the corneal cap. 3et?s continue with our
e"ample of a A:.C=A<.:;">; correction. Suppose our 7 readings are 9C.;; " <0;
and 99.:; " >;. Since we are fitting on 7, our base curve would be 99.:;. In
the >; degree meridian, our lens would have the same #appro"imate% profile as
the cornea. In the <0; degree meridian, however, the corneal curvature is
steeper than the contact lens curvature #9C.;; vs. 99.:;%.


This creates a gap
toward the periphery of
the lens. This gap is
filled by the tear layer
#red layer on the <0;
degree image%.
&ptically, this tear layer
acts like cylindrical lens
power to correct for the
astigmatic curvature.
Thus, the .tear lens..

The tear lens of the *1' contact lens is more efficient than the cylinder
correction in the soft toric lens, because the tear lens fills the gap perfectly, and
rotation of the lens has no effect on the performance of the correction.
The base curve / lens power relationship
s discussed earlier, sometimes a base curve is selected that is steeper or
flatter than 7. !ow does this affect the tear lens and lens power- 8itting the
base curve steep or flatter than 7 modifies the tear lens. If the base curve is
flatter than 7, then the power must be adjusted by the same amount in the plus
direction #flatterAaddAplus, or 8'%. If the base curve used is steeper than 7,
then the power must be adjusted by the same amount in the minus direction
#steeperAaddAminus, or S(%. Esing our e"ample, suppose that we choose to
use a 9:.;; base curve. This is .: 2 steeper than our flat 7 of 99.:;. ,e would
add .: 2 more minus to the A:.C= power to arrive at an adjusted power of
appro"imately AC.;; 2. The final lens power should be confirmed by an overA
refraction once the trial lens has stabili+ed on the patient?s eye.
Lens diameter and the optical zone
*1' contact lenses are usually designed with a diameter = to D mm smaller than
the hori+ontal visible iris diameter #!FI2%. The visible iris diameter is similar to
the corneal diameter, which is also similar to the measurement known as
.hori+ontal white to white..
If you were to measure these anatomical distances with a microscope, you
would find a microscopic difference in the numbers. 8or you or me eyeballing it
with a millimeter ruler, there is no difference. 8or a <= mm cornea, a typical
*1' lens would have a diameter from > to <; mm, depending upon the fitting
techni$ue.
s it is with soft contact lenses, for a given base curve, a larger diameter lens
will fit tighter, and smaller diameter lens will fit looser.
,hen determining the diameter, other factors to consider are the palpebral
aperture #the lid opening%, the corneal curvature, and the patient?s activity level.
s will be discussed, the si+e of the lid opening will influence what type of fit is
used, which in turn will affect the diameter. steeper than average cornea
generally re$uires a smaller diameter lens for a good fit. 'atient?s involved in
sports activities have more stable vision with a larger lens diameter and optical
+one diameter.
The lens diameter and the optical +one diameter go hand in hand. The optical
+one is the area of the central posterior curve #6'6%, otherwise known as the
base curve.
s pictured above, the optical +one is the lighter colored central area and the
peripheral curves are in the darker area at the edge. )ou can see that the larger
the optical +one diameter is, the smaller the area available for the other curves.
1enerally, the optical +one is <.; to <.: mm smaller than the overall lens
diameter. The optical +one must be large enough to cover the pupil, otherwise
the patient will complain if glare, especially when the pupil gets larger in low light
situations.
The &G2 can have a dramatic effect on the fit of the lens. s with the overall
diameter, a larger &G2 makes the fit tighter, and a smaller &G2 makes the lens
fit looser. *1' lens manufacturers have standard specifications for the &G2
and the other parameters for a given lens diameter. (any practitioners don?t
vary these values, but a skilled and e"perienced fitter can manipulate these
values to optimi+e the fit of the lens. In other words, be aware that a change in
the optical +one diameter can change the fit of the lens, even if the overall
diameter is not changed.
Other lens parameters
side from the power, base curve, diameter, and optical +one, the *1' lens has
the following design parameters, which are pictured below@
intermediate #secondary% curve
peripheral #tertiary% curve
transition between curves
edge design
lens thickness
The cornea is aspherical, meaning it is steeper in the center and flatter toward
the periphery. 5ecause of this, transitions +ones are needed in the contact lens
to make the lens fit better. These +ones are the .intermediate curve. and the
.peripheral curve.. Their shapes are progressively flatter than the central .base
curve..
These curves are usually determined by a .nomogram., which is a formula
based upon other lens characteristics. Skilled contact lens fitters can modify the
intermediate and peripheral curves to optimi+e the fit of the lens. In general,
making these curves steeper and narrower will steeping #tighten% the fit of the
lens. (aking these curves flatter and wider will flatten #loosen% the fit of the
lens. The edge of the lens should not be tight against the cornea. It should
allow enough clearance for tears to circulate under the lens, but not too much
clearance, which may adversely affect the fit of the lens. Edge clearance can be
evaluated with fluorescein, as will be discussed.
*1' lens fitting techni$ues generally work best with very thin lenses. (inimal
lens thickness should be ordered and should be modified only if e"cessive lens
fle"ure occurs on the cornea. 3ens thickness is e"pressed as center thickness,
which is a function of lens power and lens diameter. minus lens will be
relatively thinner in the center and a plus lens will be relatively thicker in the
center.
Lens itting designs
1as permeable contact lens fitting designs vary with the fitter and are influenced
by who the fitter learned from, the fitter?s own e"perience, manufacturer
recommendations, what they had for lunch, and other factors. ,hen the fog
clears, there are generally two main fitting methodologies@ .apical clearance. and
.corneal alignment..
!pical clearance design
This method has also been termed .interpalpebral lens design. or .central
palpebral design.. s the terminology implies, the objective is to get the lens to
center on the corneal between the eyelids. This method can be useful for the
patient with tight lids and/or a small lid opening and it can also be useful for the
patient with a large lid opening that will not support an alignment or lid
attachment type of fit. The fit is accomplished with a lens fit steeper than the flat
7 and with a relatively smaller diameter. The base curve selection is dependent
upon the amount of corneal cylinder and the lens diameter. The lens diameter is
dependent upon the corneal diameter and the lid opening. 5ase curve and
diameter selection tables vary according to the source, but typical numbers are
represented below.


Corneal cylinder BC selection
;; to .: 2 .=: 2 steeper than 7
./: to <.=: 2 .D/ 2 steeper than 7
<.: to =.; 2 .:; 2 steeper than 7
=.=: to =./: 2 ./: 2 steeper than 7
D.; to D.: 2 <.;; 2 steeper than 7

Corneal diameter Lens "iameter
<= mm plus >.< mm
<< to <= mm 0.C
less than << mm 0.=


*emember that a larger diameter lens will re$uire a flatter base curve to fit the
same as a smaller diameter lens, and vice versa. smaller diameter may be
re$uired for the lens to .float. between the lids if the lid opening is small.
,ith this fitting method, plus power lenses might re$uire a slightly steeper fit
than minus lenses to improve centering. *emember that plus power lenses are
thicker in the center of the lens and minus power lenses are thicker at the edge
of the lens. If the lens is thicker in the center, it tends to ride lower due to gravity
and the lid pushing downward on the lens.




bove is an animation of an apical clearance #interpalpebral% fitting. The lens
diameter is smaller than the diameter of a corneal alignment lens. The lens fits
between the lids. s the lid blinks, the lens rides upward with the lid and then
sinks downward on the cornea. The lens should not sink to the lower lid margin.
It should float between the lids.


Corneal alignment design
This method is also termed, .upper lid attachment., .lid attachment., .7orb
design., .modified 7orb design., and .lid interactive.. There seems to be
endless variations of the basic design. The idea is for a relatively large diameter
lens, fit flatter than 7, to ride high on the cornea and be supported by an
overlying upper lid. The apical clearance fit moves freely on the cornea. The
lens fit with corneal alignment moves only when the lid blinks. The vision is
supposed to be more stable with less lens awareness and a more natural blink
compared to the apical fit. This fit does not work with a high upper lid that covers
little or none of the cornea.
s with the apical fit, the initial base curve selection depends upon the amount of
corneal cylinder. 6omparing the apical fit table with this corneal alignment fit
table, you will notice that these base curves are generally flatter than 7 as
opposed to the steeper than 7 base curves of the apical table.

Corneal cylinder BC selection #for >.: diameter lens%
;; to .: 2 ./: 2 flatter than 7
./: to <.=: 2 .:; 2 flatter than 7
<.: to =.; 2 .=: 2 flatter than 7
=.=: to =./: 2 .on 7
D.; to D.: 2 .: 2 steeper than 7


The diameter of the corneal alignment lens is not so dependent upon the corneal
diameter, it just needs to be relatively large. good place to start is at >.: mm.
This can be adjusted according to how the lens behaves when on the cornea.
*emember, for a given base curve, a larger diameter will fit tighter and a small
diameter will fit looser.




bove is an animation of a corneal alignment #lid attachment% fit. The lens has a
larger diameter than an interpalpebral lens. The lens is always .attached. to the
upper lid and tends to ride high. There is less movement with the blink than
there is for an interpalpebral lens.


#valuation o the contact lens it

In my opinion, for the first time *1' contact lens wearer, it is absolutely critical
that the lens be inserted the first time with a topical anesthetic drop instilled prior
to insertion. This permits the patient?s critical first impression to be pleasant and
pain free. It also gives you time for a fair evaluation of the lens fit without
e"cessive tearing and s$uee+ed lids. The patient will gradually e"perience the
inevitable foreign body sensation as the anesthetic wears off.

The following discussion of lens evaluation applies to the patient returning for a
.yearly e"am. as well as for the new fit.

The visual acuity with the contact lenses should be tested before any other
testing is done. )ou do not want the bright light from a slit lamp e"am to affect
the reading.

The fit of the *1' contact lens should be evaluated according to the following
criteria@
1. 'ositioning and movement
2. 6ondition
3. Fisual acuity
4. 8le"ure
5. *esidual astigmatism
6. 6omfort
7. 8luorescein pattern
8. 6orneal and eyelid integrity
<. $ositioning and movement@ This depends to upon the fitting method, that is,
apical clearance design vs. corneal alignment design. lens fit for apical
clearance should center on the cornea, between the lids. It should move upward
slightly with the blink and settle to a centered or slightly below center position.
lens fit for corneal alignment will ride high, under the upper lid. It will tend to
move with the lid. In either case, the lens should not drift off to one side or the
other, and it should not ride low.

(odification to an initial fit of an apical clearance design generally begins with an
adjustment of the base curve of the lens. 8or a given diameter, a steeper base
curve #e.g. changing from 99.;; to 99.:;% will fit tighter and a flatter base curve
#e.g. changing from 9:.;; to 99.:;% will fit looser.

(odification to an initial fit of a corneal alignment design generally begins with an
adjustment to the diameter of the lens. 8or a given base curve, a larger
diameter with fit tighter and a smaller diameter will fit looser. larger diameter
will also tend to have more coverage by the upper lid, increasing the .lid
attachment..

The amount and type of corneal astigmatism will affect the fit of the lens. So
called .withAtheArule. astigmatism is created when the vertical corneal curvature
is greater than the hori+ontal corneal curvature #e.g. 99.;; " >;, 9=.;; " <0;%.
.gainstAtheArule. astigmatism is the opposite. lens on a ,T* cornea will tend
to decenter vertically. lens on an T* cornea will tend to decenter
hori+ontally. !ori+ontal decentration is more of a problem than vertical
decentration. steeper than recommended base curve for the T* cornea will
sometimes solve the hori+ontal decentration problem. I think it is best to try the
recommended base curve first, before going to a steeper 56.

These are general guidelines, however. E"perienced practitioners have their
favored methods for modifying the fit. The diameter of the optical +one, the
peripheral curves, and the edge profile can also be modified to affect the fit.

8or the patient new to your practice, who is already wearing *1' lenses, it is
best not modify the design unless necessary. The old saying, .if it ain?t broke,
don?t fi" it., certainly applies to contact lens management.

=. Condition@ This has to do with the optical $uality of the lens. Is it clear, and
does it wet well with the tears- The tear layer should coat the lens evenly so
that a continuous, clear optical surface is created, without any dry spots or oily
spots. (any times a good cleaning can remove surface deposits and improve a
lens that wets poorly. new lens may need a few cleaning and rinsing cycles
before it wets properly. The manufacturer of the lens material usually has
specific recommendations as to cleaning and wetting solutions.

few superficial scratches generally do not cause problems with comfort or
acuity. 3ens polishing can remove superficial scratches and improve wetting.


D. %isual acuity@ The proof of the pudding for most contact lens wearers is their
visual acuity. If the vision is good, most of the time they are happy. If their
vision is not good, usually they are not happy. The lens positioning and the
condition of the lens should always be evaluated before evaluating the vision.
#s stated earlier, the visual acuity with the lenses should be checked first thing,
before any other testing or e"amination is performed%. If the lens centers poorly
or is covered with deposits, you are wasting your time with a vision analysis,
because those other problems must be dealt with first. The following discussion
assumes that you have a well positioned, clear lens that has a good tear coating.

fter e"amining the lens positioning and movement with the slit lamp, allow a
few moments for the patient to recover from the bright light, and then perform a
spherical overArefraction with a phoropter, or with loose lenses. If the vision is
good and crisp with the overArefraction, and it seems stable with blinking, then
you can generally assume that fle"ure is not a problem and that residual
astigmatism is not a problem.

The power of the lens can be adjusted according to the results of the overA
refraction. If the overArefraction is B;.:;, then you will want to adjust the lens
power by .:; 2 in the plus direction, meaning a B<.;; power becomes a B<.:;
power, or a A=.;; power becomes a A<.:; power. In almost all cases, a plus
power adjustment should be made to the contact lens power if indicated by overA
refraction, but beware of the minus power adjustment. Hust because you get an
overArefraction of A;./: 2, do not assume that the power adjustment is in the
best interest of the patient. (any older #D:B% patients may do better with the
improved intermediate/near vision of the current situation, rather than give that
up for a slight improvement in distance vision. ,ith minus adjustments, make
sure your patient understands what is changing.

If the visual acuity with spherical overArefraction is not good, stable, and sharp,
then you must test for fle"ure and residual astigmatism.

Subject matter continued on (odule DC #(odules D: and DC each have their own
'ostATests

9. &le'ure@ ,ith the patient still behind the phoropter for the spherical overA
refraction, it is a good time to test for lens fle"ure. 8le"ure occurs when the
contact lens .bends. over the astigmatic ridge of the cornea when the patient
blinks. 8le"ure can be observed by performing retinoscopy with the contact lens
in place. 8le"ure is indicated by changes in the refle" after a blink. 8le"ure can
also be tested for using the keratometer. ,ith the lens in place on the eye,
observe the pattern of the mires reflected on the lens through the keratometer,
particularly after the patient blinks. 8le"ure will be indicated by changes in the
shape of the mires. 8le"ure can be decreased by slightly flattening the base
curve #.: 2% and/or by increasing the center thickness of the lens by .= to .9 mm.

s you might suspect, fle"ure is also a function of the amount of corneal
astigmatism. The patient with DB diopters of corneal astigmatism may be better
off with a biAtoric lens design. The biAtoric lens has two different base curves >;
degrees apart, so that the lens fits the shape of the corneal surface. The biAtoric
design is comple" and is beyond the scope of this module.

:. (esidual astigmatism@ nother possible cause of imperfect vision with a hard
contact lens is residual astigmatism. This is astigmatism that is other than
corneal astigmatism, and it is not corrected by the tear lens of the spherical hard
contact lens. The usual suspect is lenticular astigmatism. In other words, the
shape/optics of the crystalline lens inside the eye is not spherical. This can be
measured by performing retinoscopy and a complete refraction #not just
spherical% over the contact lens. *esidual astigmatism of one diopter or less is
usually tolerated by employing the spherical e$uivalent power. *esidual
astigmatism not well tolerated may re$uire a reAfit with a toric lens.

problem with residual astigmatism can, to a degree, be predicted. If the
refractive cylinder correction is significantly different from the corneal astigmatism
as measured by the keratometer, residual astigmatism must be suspected. 8or
e"ample@

(* &2 A9.;;AD;;I<0;

7 &2 9C.;; " >;, 99.;; " <0;

The amount of refractive cylinder correction is AD.;;, but the corneal astigmatism
as measured by the keratometer is =.;; 2 #9C minus 99%. The difference #< 2%
may be residual astigmatism. 7nowing this may save you the trouble of a trial fit
with a spherical *1' lens, but the only way to know for sure if this would be a
problem would be to refract over the spherical *1' lens and get feedback from
the patient.

C. Comort@ The first time *1' contact lens wearer will not be comfortable until
wearing time has been gradually built up. If the established wearer complains of
discomfort, you must find the underlying cause of the discomfort. It can be as
simple as dryness, which may be alleviated by the use of reAwetting drops. The
fit of the lens may need to be evaluated, as well as the integrity of the cornea and
the lids.

/. &luorescein pattern@ It is possible to judge the dynamics of the hard contact
lens fit by instilling a drop of fluorescein into the eye wearing the contact lens.
The fluorescein temporarily stains the tears. The depth of the tear layer under
the lens can be judged by the appearance of the fluorescein under the lens.
deeper layer of tears will appear brightly fluorescent when observed with the
cobalt blue light of the slit lamp microscope. shallow layer of tears will appear a
lighter shade of green.

The illustration below depicts a contact lens that is fit well to a spherical cornea.
There is a large, central pattern that is light green, indicating a close fit of the
base curve of the lens to the central cornea. The bright green at the edge of the
lens indicates a deeper layer of fluorescein under the peripheral curves of the
contact lens.


contact lens that fits flat will show a smaller area of light green in the center and
a larger area of a deeper tear layer at the periphery of the lens. n .alignment fit.
lens may normally have some flat fit characteristics.


steep fit is illustrated below. The central area of the lens vaults the the central
cornea, creating a pool of bright fluorescein in the center. n .apical clearance
fit. lens may normally have some steep fit characteristics.


lens fit on a significantly astigmatic cornea will demonstrate a .dumbbell. type
pattern, as shown below.




'roper fluorecein pattern evaluation re$uires e"perience. The basic idea is to
avoid .apical bearing. and .midAperiphery bearing.. pical bearing is caused by
the lens rubbing against the corneal ape" #too flat%. (idAperiphery bearing results
from too much apical clearance #too steep% and a lens periphery that is .stuck.
against the cornea, not allowing tear circulation.

0. Corneal integrity: This evaluation applies more to the returning contact lens
patient rather than to the initial contact lens evaluation, although some problems
can show up almost immediately.

The cornea should be evaluated for fluorescein staining patterns. This is done
with the slitAlamp biomicroscope. ,ith hard contact lenses, the fluorescein
evaluation of the cornea can be done with the lenses in, or with the lenses out. If
there is a significant staining pattern, it will persist for some time after the lenses
are removed. Soft lenses should not be evaluated in the eye with fluorescein
because the soft lens material will stain with the fluorescein.

6orneal staining patterns appear because the corneal epithelium has been
disrupted. The dye stains compromised cells and pools in disruptions in the
smooth corneal surface. 2isruptions can e"tend into the layers under the corneal
epithelium. Staining patterns can be caused by mechanical rubbing, chemical
e"posure, o"ygen deprivation, or infection.

$unctate staining #pictured below% is an area of small, pinpoint like disruptions in
the epithelium. The more faint variety is sometimes termed stippling. 6ommon
causes are o"ygen deprivation or some type of chemical e"posure.


corneal abrasion is an area where the corneal epithelium has been stripped
away. It is usually caused by mechanical action and the shape depends upon the
agent and the action. E"amples include a central area of abrasion caused by a
flat lens, or a linear abrasion caused by a foreign body under the contact lens.


) and * o+cloc, staining is punctate like staining that occurs in these clock hours
of the cornea. It can be caused by mechanical rubbing of the periphery of the
lens, usually made worse by inade$uate lubrication, poor blinking action, and/or
overAwearing the lenses.


!rcuate staining occurs in the shape of an arc in the periphery of the cornea. It
is caused by rough blends between the peripheral curves.


"imple veiling has a stippled appearance and is caused by air bubbles trapped
under a lens that is either too steep #central staining% or too flat #limbal staining%.


Significant corneal edema will show up as central clouding of the cornea, which
can be seen without the aid of fluorescein. 6orneal edema secondary to contact
lens wear can be due to poor corneal metabolism. The contact lenses must be
refit for better o"ygen transmission or the contact lenses must be discontinued.

If corneal o"ygen metabolism is chronically depressed, as can be the case with
e"tended wear soft lenses, new blood vessels may encroach across the limbus
and grow into the cornea #neovascularization%.


lso of concern is the loss of corneal endothelial cells that can result from poor
metabolism secondary to contact lens wear. The problem is that the endothelial
cells do not regenerate. The neighboring cells enlarge to fill in the void
#polymegathism%.


The endothelial cells are pumps that keep the cornea dry #free from edema% and
clear. Significant endothelial cell loss can compromise the ability of the
endothelium to keep the cornea dry and clear.

Serial 7 readings #e.g. 7 readings at least once a year over a period of years% can
be used to assess changes in corneal curvature over time. The shape of the
cornea can tend to mold to the shape of the contact lens over time. This can be a
bad thing or a good thing, depending upon your point of view. 6orneal molding
an make it difficult for the patient to see well with glasses, and make it difficult to
reAfit contact lenses.

So called .spectacle blur. is blurry vision with glasses following the removal of
contact lenses. It is caused by the cornea molding to the contact lens and it is
common with hard contact lenses. fter removing the contact lenses, the cornea
tends to revert to the original shape. The changing shape of the cornea causes
the blurriness with glasses. It should not last more than <: to =; minutes,
otherwise the fit may need to be reAevaluated.

type of spectacle blur can result from corneal edema secondary to contact lens
wear. fter the lenses are removed, the edema resolves and the vision
improves.

Some practitioners use corneal molding on purpose to reduce the patient?s nearA
sighted correction by using contact lenses to flatten the shape of the cornea. So
called .ortho,eratology. has been around for a long time. In =;;=, the 82
approved corneal refractive therapy #6*T%. The patient wears a contact lens
overnight that gradually changes the shape of the cornea, reducing and
sometimes eliminating myopia up to si" diopters. If the patient stops wearing the
lenses, the cornea gradually returns to the original shape and the myopia comes
back.


(-$ lens inventory management

There are two schools of thought regarding how many *1' lenses to have on
hand in your practice. There is the .empirical. fitting school, and there is the
.diagnostic. fitting school.

"iagnostic itting

This involves fitting lenses from a fitting set or from a lens inventory. fitting set
can consist of a handful of lenses to over =;; lenses. lens inventory is just a
large fitting set, with perhaps hundreds of lenses. The major advantage of a
large diagnostic set is that the patient can immediately e"perience the optimum
vision that an *1' lens can offer. This is a major selling point. &ther
advantages include the ability to evaluate parameter changes immediately, and
the ability to dispense replacement lenses immediately. fairly complete set
from A<.;; to AC.;; in .=: 2 steps over a range of base curves from /.9= to 0.<D
would number around =;; lenses.

#mpirical itting

Empirical fitting means that measurements are made #7 readings, manifest
refraction, pupil si+e, lid opening, corneal diameter, etc.% and the measurement
are sent to a manufacturer. The manufacturer uses nomograms #formulas% to
determine the lens parameters. The lens is shipped to you and the patient is
scheduled for a return visit at which time the lens is evaluated. If the lens is
satisfactory in fit and performance, then the lens is dispensed. If there are
problems, then the manufacturer is consulted and changes are made for another
go at it. t first blush, this may not seem to be the best strategy, but this method
can be successful on a percentage basis, meaning you reach a point where you
have few reAfits. The significant time savings can more than make up for the
e"tra costs of reAfitting. 6orneal topography manufacturers have come up with
software programs that can increase the accuracy of empirical fitting.


Lens parameter veriication

5ecause of the nature of soft contact lens materials, we are not able #practically%
to determine the lens specifications with inspection techni$ues. !owever, we are
able to do this with hard contact lens materials. ,e are able to verify diameter,
base curve, lens power, and center thickness before an *1' lens is dispensed,
and we can read these parameters from an .unknown. lens that was dispensed
elsewhere.

The edge of every *1' lens should be inspected. The condition of the edge is
critical to a comfortable fit. Inspection can be done at the slit lamp microscope by
simply holding and rotating the lens with your fingers. &bviously, a lens with a
chipped or cracked edge should not be worn, but also inspect the contour of the
lens edge. In particular, the anterior edge profile #the surface that the lid goes
over% should be nicely rounded and smooth.

(eading the lens power

*1' lens power can be read with a lensometer. The lens is held with your thumb
and inde" finger against the lensometer port, with the concave side against the
port. The power is read just like you would read a glasses prescription. The
power will be spherical unless the lens is toric in design. 6are must be taken not
the fle" the lens between your fingers. 8le"ure may induce a cylindrical reading.
warped lens can also produce a cylindrical lensometer reading.

(eading the diameter

The *1' lens diameter can be read with a variety of tools that have a millimeter
scale. very handy tool is the millimeter ruler with a .F. groove. The lens is
placed in the groove and it slides down until it stops. The diameter is read from
the scale reading at the point where the lens stops.



(eading the base curve

The *1' lens base curve is
read with a radiuscope. This
instrument looks similar to a
microscope. The lens is
placed on a table under a
lens. The user looks through
an eyepiece to focus mires
and to take a reading from a
scale.



<. The lens holder is
removed from the table.
drop of water is placed into
the depression in the lens
holder. The contact lens
floats conve" side down on
the water drop. 6are must
be taken to have a minimal
amount of water under the
lens. E"cess water can be
removed by placing a tissue
into one of the groves
coming from the depression.

=. The lens holder with the
contact lens is placed onto
the table and the table is
moved if necessary to place
the center of the lens directly
under the green light
projecting from the lens of the
radiuscope.

D. ,hile looking into the
eyepiece, the star shaped
mire is brought into focus by
turning the focusing knob on
the right side of the
instrument.


The large part of the knob is
for gross focusing, and the
smaller part of the knob is for
fine focusing.



9. The small knob to the left
of the eyepiece is used to
move the line on the scale to
the .+ero. position.

The small knob under the
eyepiece is used to focus the
scale if necessary.

:. &nce the star is in focus
and the scale line is placed
in the +ero position, the base
curve is measured by turning
the focusing knob in the
clockwise direction #away
from you%. The star mire will
disappear at first, and then it
will come back into focus as
you continue to turn the
focusing knob. The scale
reading will be moving away
from +ero. Ese the fine focus
knob once the star mire
comes back into focus.

,hen the star mire comes
into focus the second time, it
may not be centered, with
only part of the star visible.

The star can be centered
again by moving the table
that holds the contact lens
mount.

C. The base curve is then
read at the position of the line
on the scale. The reading will
be a .radius of curvature.
value in millimeters. It can be
converted to diopters using a
conversion table. This scale
reading is about 0.9<.

If the lines on the star focus at
slightly different settings, then
this indicates that the lens is
warped.

If one line comes into focus,
with the others blurry, then
the lens is probably toric. The
line >; degrees to the first
one should come into focus
by itself when the focus is
changed.

(eading the center thic,ness

6enter thickness is read with a thickness gauge.
The most common type is the dial gauge. The
needle of the instrument is placed over the center
of the lens and the thickness is measured from a
dial.


(-$ Lens Insertion and (emoval

If this discussion seems familiar, it is because it is very similar to the discussion
you read in the soft contact lens modules. *1' lens care is somewhat less
complicated because the *1' lens does not soak up water, chemicals, or
pathogens like the the soft lens can. *1' insertion is similar to soft lens
insertion, but *1' lens removal is somewhat more complicated.

The *1' lens is inserted by positioning the lens on the inde" finger of the
dominant hand. The lids are opened and held by the remaining fingers of both
hands. The lens is guided to the cornea until contact is made. It is helpful if all
parts of the lens edge make contact with the eye at the same time. The lids are
not released until the lens has adhered to the cornea. The lens can usually be
centered with a few blinks. It is helpful for most patients to look at themselves in
the mirror during the procedure.

)es, this is a soft lens, but
the insertion techni$ue is
very similar.

The *1' lens is removed by
placing the finger on the skin
at the outer canthus and
pulling outward. This tightens
the lids against the the upper
and lower edges of the lens.
The patient then blinks, and if
all goes well, the lens pops
out of the eye.

It is best to bend over a towel on a flat surface to catch the lens. fter some
practice, the patient can pop the lens into the other hand. If the lens does not
pop the first time, make sure the lens is centered in the palpebral fissure by
looking straight ahead and be sure to apply e$ual pulling force to the upper and
lower lids. n alternative to this method is to use a lens removal tool. This has a
small suction cup on the end of a holder. The suction cup is guided to the lens
until suction is achieved and the lens is then removed. Ese of a wetting drop in
the eye prior to using the tool usually helps.

The patient should be taught what to do if the contact lens becomes deAcentered.
See the instructions in the ne"t section.

Even though your IJ* video may cover these points, be sure they are part of a
printed handout for the patient. )ou may want to add to or modify this list as your
e"perience may suggest@

lways wash your hands before handling a contact lens.
Short fingernails are better than long nails.
!and lotions and creams should not be used prior to contact lens handling.
It is best to use hair spray before contact lenses are inserted.
It is best to apply makeup after contact lenses are inserted and remove the
contact lenses before makeup is removed.
&nly use appropriate care products for cleaning, wetting, and rinsing contact
lenses. Saliva and tap water should not be used as wetting or rinsing agents.
Eye redness, discomfort, or blurry vision should be reported to your doctor
immediately.
If the contact lens becomes deAcentered from the cornea, it cannot travel
behind the eye. Esing a mirror, try to locate the lens on the white part of the eye,
or under the upper or lower lid. (ove the lens to the cornea by pushing against
it with the eyelid, which is massaged with your finger. The lens may fall out of the
eye during this relocation procedure. *eAinsert the lens in the usual manner. If
you cannot find the lens, it may have fallen out.
2o not wear contact lenses while swimming.
2o not sleep with your contact lenses unless they are approved for overnight
wear.
,ear safety glasses over the contact lenses in appropriate situations.
Initial wearing time@ This varies with the practitioner. The new *1' wearer
must gradually build up wearing time. Some practitioners like to start the patient
with = hours the first day and add = hours each day until the lenses are worn for
all waking hours if desired.


(-$ contact lens care

It is the goal of every *1' contact lens care system to remove foreign matter and
microorganisms from the surface of the lens, to neutrali+e or kill any remaining
microorganisms on the lens, and to properly .wet. the *1' lens prior to
insertion. 6are systems use various combinations of daily cleaners,
disinfectants, and wetting agents.

"aily cleaners work well only if combined with mechanically cleaning the lens.
This is accomplished by putting a drop of cleaner on the lens and rubbing the
lens gently with a finger in the cupped palm of the other hand, with the conve"
side of the lens against the palm. Enlike with the soft lens, with the *1' lens,
the cleaner can be rinsed with warm tap water. This is best done after the
contact lens is removed for the day.

"isinection can be accomplished by storing the contact lenses overnight in a
disinfecting #storage% solution.

#nzymatic cleaners are used to remove tear protein deposits from the surface of
the contact lens. These are deposits that may not be removed with a daily
cleaner. These cleaners are for the patients who are more susceptible to these
deposits than other patients. E"cessive protein deposits can block o"ygen
transmission through the lens and they may trigger a hypersensitivity reaction
under the eyelids. This is less of a problem with *1' lenses than it is with soft
lenses.

!ll.purpose (-$ lens care systems are currently popular for contact lens care.
&ne or two solutions are used for cleaning, disinfection #storage in the case%, and
wetting prior to insertion. The idea is to encourage better compliance with a more
simple system. Enfortunately, many patients think all they have to do is remove
the lenses and place them in the storage solution overnight. 5e sure to
encourage the patient to clean #rub and rinse% the lenses as described above.

Some patients may become hypersensitive to the preservatives in care systems.
Symptoms may include soreness, stinging, foreign body sensation, redness of
the conjunctiva, redness of lids. swelling of the conjunctiva and/or lids, and
punctate staining of the cornea. major offender has been the preservative
thimerosal. It is best to avoid care systems with this preservative. Switching the
patient to a care system with a different preservative may solve the problem.

1eneral instructions to the patient should include@
&nly use products that are compatible with your lenses. 6heck with your
doctor?s office.
2o not mi" care product brands unless recommended by the doctor?s office.
,ash hands before handling lenses.
2o not skip steps in your lens care routine, as instructed by the doctor?s
office.
7eep the lens care environment clean #case, counter, storage bag, etc.%.
7eep care product bottle tops from touching any surface.
,ork over a clean surface. Ese paper towels if in a public restroom.
If you drop your lens prior to insertion, rinse the lens well before insertion.
4otify your doctor?s office if you e"perience eye or lid redness and/or
irritation
/ot Contact Lenses:

Indications or Contact
Lens 0ear

(ost contact lens fittings are
performed for one or more of
the following reasons@
Cosmetics@ The patient may not like her appearance in glasses. The
patient may want to change his eye color or wear one of the contact lenses
that has a symbol on the surface #popular at !alloween time%.
Better vision@ Some patients see better with contact lenses than they do
with glasses. 'eripheral vision is better with contact lenses. Image si+e is
larger with contact lenses for the high mayope. Fision may be less distorted
for the astigmat wearing contact lenses.
!rtiicial iris@ n eye that is missing a significant portion of the iris due to
trauma or other reasons may be less light sensitive when wearing a contact
lens with a colored, opa$ue .iris.. n artificial pupil in the contact lens may
also improve the vision.
Bandage lens@ Soft contact lenses are sometimes used as a .bandage. to
protect the cornea as the cornea heals from trauma, surgery, or disease.
History Ta,ing

!istory taking, of course, is an important component of any medical e"amination.
1ood history taking is especially important for the contact lens patient. 8or the vast
majority of patients, contact lens wear is optional, and motivation plays a big role in
determining success or failure. 8or the contact lens fitter, .chair time. plays a big
role in determining the financial feasibility of a particular contact lens fitting. 1ood
history taking goes a long way toward ensuring reasonable e"pectations on the part
of patient and the practitioner.

7eep in mind that the simplest, most successful contact lens fits are generally on
young patients with spherical myopia who do not want to wear glasses. The least
successful patients include the presbyope with significant astigmatism who wants to
.try. contact lenses. The following list of history taking $ueries is not all inclusive,
but it will give you a good idea of what you should be thinking about in the contact
lens history taking process.

0hy1@ sk the patient why she wants to wear contact lenses. )ou want a
sense of the patient?s level of motivation. The teenaged girl who does not want to
be seen wearing glasses will be highly motivated. The teenaged boy who wants to
wear contact lenses for sports will be highly motivated. 2uring the history taking
process, the patient with low motivation can be steered to arrive at his own
conclusion that he is not a good candidate for contact lens wear.
!ge@ The two most important factors here are 'resbyopia and dry eyes. If
the patient is a presbyope, near correction limitations with contact lens wear
may discourage contact lens wear. 4ear correction options must be
discussed with the patient early in the process. The options include wearing
readers with contact lenses, monovision, and bifocal contact lenses. 4one
of these options offers a .perfect. solution, and the advantages and
disadvantages of each should be discussed.
2ry eye symptoms increase with age. 2ryness increases irritation when wearing
contact lenses and may limit wearing time. The patient should be asked about dry
eye symptoms and the use of lubricating drops. The patient should be informed
about the effects of dry eyes on contact lens wear.
!nterior segment e'amination: new contact lens patient typically has a
complete eye e"am before contact lenses are fit. The ophthalmologist or
optometrist will pay particular attention to the following details of the e"amination@
Health of the lids, conjunctiva, and cornea A patients with corneal diseases
or chronic blepharitis are not good contact lens candidates. pterygium or
pinguecula may be irritated by contact lens wear.
Tear production A 'oor tear production alone may cause a patient to
discontinue contact lens wear. Schirmer tear test and tear breakAup time
#5ET% may be performed.
Lids A the lids must be elastic and fit
closely to the globe. This picture
would obviously be an e"aggeration
of a loose lid.
The lid aperture must be wide enough for
the patient to be able to insert the contact
lens.
1iant papillary conjunctivitis may be in the
history of a former contact lens wearer
wanting to wear lenses again. This is
characteri+ed by large bumps, or .papillae.,
which cover the upper tarsal conjunctiva. It
is usually caused by wearing contact lenses
that are covered with deposits. The lid must
be .everted. to view the e"tent of the
condition. The patient must usually
discontinue wear for the condition to
subside. Some patients can resume contact
lens wear with a fre$uent replacement
schedule.
$upil size A if the diameter of the pupil
approaches or e"ceeds the optical
+one diameter of the contact lens, then
annoying distortion and flare occur. If
the patient has unusually wide pupils in
a well lit room, she may not be a good
contact lens candidate.

Hygiene A take a look at the patient?s
appearance during the e"am. 2irty
fingernails are a good indicator of a
contact lens problem child.

Lens type@ 5efore the actual contact lens evaluation begins, a lens manufacturer
and a particular lens model must be selected. Some practitioners have a favorite
lens that they fit the majority of patients with. The choice may depend upon
patient preference for daily, fle"ible, or e"tended wear, fre$uency of replacement,
power limitations, cosmetics #color%, and other factors. 6ommonly, a daily wear
lens with a light blue #visibility% tint is a good choice, with replacement every < to D
months. The spherical soft contact lens has three variable parameters@ diameter,
power, and base curve.

"iameter@ (ost manufacturers have a standard diameter for a particular lens
model #e.g. <9.;mm, or <9.:mm%. larger or smaller diameter may be available
for special situations.

Base curve@ s discussed earlier, for a given diameter, the fit of the lens is
adjusted by changing the base curve. There are usually three base curves
available@ steep, medium, and flat. (ost manufacturers identify the base curve by
radius of curvature. E"amples would be 0.> #flat%, 0.C #medium%, and 0.D #steep%.
Some use the Fault system@ Fault I #flat%, Fault II #medium%, and Fault III #steep%.

The starting point for choosing a base curve is
keratometry. The manufacturer gives
guidelines regarding which base curve should
be used for a given 7 reading. n average 7
reading of 9D.:; might call for a base curve of
0.C in our <9.; diameter trial contact lens.



$ower@ Since we are fitting a spherical soft contact lens, the eye should not have
more than ./: 2 of astigmatism. If it does have more astigmatism than that, a
toric soft lens or a hard gas permeable #!1'% lens is indicated for optimum vision.
Thicker spherical soft contact lenses are thought to be able to .mask. a low
amount of astigmatism. thin lens however will drape over the curves of the
cornea and the residual astigmatism will limit the visual acuity obtained with the
spherical lens. If only one eye has significant astigmatism, it is sometimes
acceptable to the patient to wear spherical lenses in both eyes, especially if the
better seeing eye is the dominant eye.

If the eye being fit has astigmatism, the refraction is converted to minus cylinder,
and the spherical e$uivalent power is used. 8or e"ample@

&2 (* K AC.;;B<.;;"<0;
(inus cyl. K A:.;;A<.;;">;
Spherical e$uivalent K A:.:;

The spherical e$uivalent power must then be adjusted for verte' distance. This
is because the refractive power is measured at appro"imately <= to <D mm away
from the cornea. The contact lens, of course, will be on the corneal surface. 8or
powers 9 diopters or less, this calculation makes little difference. The greater the
lens power is, the more difference this calculation makes in the contact lens
power. (ost contact lens publications have a table for figuring this adjustment.
)ou will need to remember that, for minus lenses, power is taken away from the
refractive lens power to arrive at the contact lens power. 8or plus lenses, power
is added to the refractive power to arrive at the contact lens power.

'ictured to the right is a !yperopes
corrected with a glasses lens. F2 is the
verte" distance, which is measured from the
back of the glasses lens to the cornea. 82
is the focal length of the compound lens
system #the glasses lens plus the cornea
and the natural lens.
'ictured here is the same hyperopic eye
corrected with a contact lens. The F2 is
+ero and the focal length is shorter.
5ecause the focal length is shorter, the plus
powered contact lens will need to be
proportional stronger than the glasses lens
to focus light on the retina. Thus the verte"
power adjustment increases the power of
the plus powered contact lens compared to
the power of the glasses lens.
'icture to the left is a myopic eye corrected
with a glasses lens. The verte" distance #F2%
and the focal distance #82% are marked.
*emember that a minus lens diverges light so
that the focus is lengthened for the
nearsighted eye.
'ictured here is the same myopic eye
corrected with a contact lens. The F2 is +ero
and the focal distance is shorter. Since the
focal distance is shorter, the minus lens will
need to be less powerful to achieve the same
focus. Thus the verte" power adjustment
decreases the power of a minus powered
contact lens compared to the power of the
glasses lens.
The clinical optics calculator that we give away free on this website has a verte"
distance calculator. ,e would enter A:.;;A<.;;">; into the calculator, along with
a .present verte" distance. of <D and a .new verte" distance. of +ero. The
calculator gives us a spherical e$uivalent, verte" adjusted contact lens power of
A:.<;, which we would round off to A:.;;. This would be the power that we would
choose for our trial lens. If a A:.;; 2 lens is not available in the fitting inventory,
choose the closest power available.

&it evaluation@ If the patient has no contact lens e"perience, you will need to
insert the lenses for the evaluation. fter insertion, wait at least <; minutes before
you evaluate the lens. This allows time for patient acclimation and time for the
water content of the lens to stabili+e. The lens will loose water after insertion, and
it will fit tighter as a result. 2uring this time, if the patient complains of a foreign
body sensation, remove, rinse, and reinsert the lens. Start the <; minute wait
again after reinsertion.

Evaluate the fit of the trial lens with the slitAlamp microscope, keeping the
following points in mind@
1. Coverage A the lens should cover the entire surface of the cornea in all
meridians and should go slightly beyond the limbus. very loose lens may
ride low, e"posing an upper portion of the cornea. solution may be a
tighter lens. lens that is loose may be too small. larger diameter may
solve the problem. *emember that a larger diameter lens will fit tighter if
the base curve is kept the same.
2. Centering A the lens should center well on the cornea. very loose lens
may ride low. high plus lens, particularly an aphakic lens, may ride low.
larger diameter lens may solve the problem.
3. "rape A the lens should fit closely to the cornea without any pockets
between the lens and the cornea. This is rarely a problem unless the
contact lens parameters are not close to what they should be.
4. 2ovement A the lens should show some movement. thin lens will
usually show less movement than a standard thickness lens. The standard
for movement will depend upon the practitioner. Some doctors like to see .
: to < mm of movement with a complete blink. To evaluate this, watch an
edge of the lens with the slitAlamp as the patient blinks. &ther doctors think
that a lens that does not move with a blink is not necessarily too tight.
!owever, every lens should show movement if it is mechanically pushed. To
evaluate this at the slitAlamp, have the patient look slightly upward. ,ith your
finder, push on the patient?s lower lid so that the lid pushes against the lower edge
of the lens. The lens should move, if not, the lens is too tight. The fit can be
loosened by going to a flatter base curve and/or a smaller diameter.

lens that is really tight will actually indent the conjunctiva at the edge of the
lens. This degree of tightness usually only shows up on e"tended wear patients
at the end of the wear period.

lens can also demonstrate too much movement. E"cessive movement may
give the patient a foreign body sensation, and the vision will be disturbed as the
lens moves on the cornea. The fit can be tightened by going to a steep base
curve and/or a larger diameter. The fit could also be tightened by using a thinner
lens. 5efore deciding that a lens is too loose, be sure to allow enough time for
stabili+ation, perhaps longer than the minimum <; minute period.
#valuate the power o the trial lens A your
power calculation should have you close to
the optimum power, if not dead on.
Evaluate the power by performing an overA
refraction with the phoroptor or loose lenses.

(ost of the time, a spherical overArefraction will be sufficient. The e"ception might
be the patient with significant astigmatism #L.:2% who is being fit with a spherical
soft lens. ny spherical error found during the overArefraction is simply added or
subtracted from the trial lens power when finali+ing the contact lens prescription.

Ordering the contact lenses A if the lenses are being fit from an inventory, and
the patient?s optimum prescription is on hand, then the patient can leave the office
wearing the lenses. Even if the optimum *" is not on hand, if there are lenses in
inventory close to the optimum prescription, then the patient can leave with those
lenses and the correct *" can be ordered. This always makes the patient happy,
and we do like to make the patient happy.

Insertion and (emoval 3I4(5 A This routine is usually only for the new contact
lens wearer, although some e"perienced patients can use the review. This duty
can be drudgery, because it is always the same thing, over, and over, and over
again. To minimi+e the drudgery, have the patient watch a videotape of IJ*
procedures. This procedure mainly has to do with the patient getting over the fear
of sticking her finger in her eye. &nce that is overcome, it is usually smooth
sailing.
Soft contact lenses can be flipped insideAout. They are usually most comfortable,
and vision is usually the best, when the lens is inserted correctAside out. lthough
with thin lenses, it doesn?t seem to make much difference. The .taco test. is used
to determine which way is the correct way.

The lens is slightly pinched
between the thumb and forefinder,
to make it look like a taco. It helps
if the lens is slightly dry. The edge
of the lens is observed. If the
edges slope inward, then the lens
is in the correct position.

If the lens edges reverse and curve
outward, then the lens is insideAout.
This phenomenon can usually be
observed without pinching the lens.

Some manufacturers print initials near the edge of their lenses. keen observer
#or someone using a slitAlamp% can then tell if the lens is insideAout.

The soft lens is inserted by
positioning the lens on the inde"
finger of the dominant hand. The
lids are opened and held by the
remaining fingers of both hands.
The lens is guided to the cornea
until contact is made.

It is helpful if all parts of the lens edge make contact with the eye at the same
time. The lids are not released until the lens has adhered to the cornea. The lens
can usually be centered with a few blinks, if not, the lens can be pushed toward
center with a finger. It is helpful for most patients to look at themselves in the
mirror during the procedure. lternatively, the contact lens can be placed on the
conjunctiva below the cornea as the eye looks upward. The lens is then moved
onto the cornea with a finger.

The soft lens is removed by pinching
the lens between the thumb and
inde" finger of one hand. s with
insertion, the lids are held open with
the remaining fingers. It is helpful to
look slightly upward, and pinch the
lower edge of the lens. Some find it
helpful to first slide the lens
downward from the cornea before
pinching the lens.

(ost contact lens patients
eventually become very adept at
insertion and removal. (any are
able to use a one handed
techni$ue that simply pulls the
lower lid down for insertion and
removal. It is best to teach the two
handed techni$ue and let them
improvise on their own.

The patient should be taught what to do if the contact lens becomes deAcentered.
7nowing ocular anatomy, we know that the lens will not become .lost behind the
eye., but the patient may not know this. 8inding a deAcentered lens is just a
matter of searching the conjunctival area after the lids have been pulled away
from the globe. The lens is then pinched, removed, and then reAinserted.

Even though your IJ* video may cover these ne"t points, be sure they are part of
a printed handout for the patient. )ou may want to add to or modify this list as
your e"perience may suggest@
lways wash your hands before handling a contact lens.
Short fingernails are better than long nails. 6are must be taken so that
long nails do not tear the lens.
!and lotions and creams should not be used prior to contact lens handling.
It is best to use hair spray before contact lenses are inserted.
It is best to apply makeup after contact lenses are inserted and remove the
contact lenses before makeup is removed.
&nly use appropriate care products for cleaning, wetting, and rinsing
contact lenses. Saliva and tap water should not be used as wetting or
rinsing agents.
Eye redness, discomfort, or blurry vision should be reported to your doctor
immediately.
If the contact lens becomes deAcentered from the cornea, it cannot travel
behind the eye. Esing a mirror, try to locate the lens on the white part of
the eye, or under the upper or lower lid. (ove the lens with your finger if
necessary. *emove the lens by pinching it with your fingers. *eAinsert the
lens in the usual manner. If you cannot find the lens, it may have fallen
out.
It is not a good idea to wear contact lenses while swimming. The lenses
can easily become dislodged and/or soft lenses may soak up some
chlorine and irritate your eyes.
2o not use eye drops with contact lenses, e"cept for lubricating drops
approved for your lenses.
2o not sleep with your contact lenses unless they are approved for
overnight wear.
,ear safety glasses over the contact lenses in appropriate situations.
Initial wearing time@ This varies with the practitioner. (any patients tolerate soft
contact lenses right away. Some practitioners like to start the patient with 9 hours
the first day and add = hours each day until the lenses are worn for all waking
hours if desired.

/ot contact lens care

It is the goal of every contact lens
care system to remove foreign
matter and microorganisms from
the surface of the lens, and to
neutrali+e or kill any remaining
microorganisms on the lens. This
is usually called .cleaning. and
.disinfection.. 6are systems use
various combinations of daily
cleaners, rinsing agents, and
disinfectants.

"aily cleaners work well only if combined with mechanically cleaning the lens.
This is accomplished by putting a drop of cleaner on the lens and rubbing the lens
gently with a finger in the cupped palm of the other hand. The lens can be flipped
inside out so that the other surface can be cleaned.

rinsing agent is used to wash the daily cleaner and other matter from the
surface of the lens. rinsing agent should be used whether or not a daily cleaner
is used. *insing the lens will obviously be much more effective if a daily cleaner
is used.

"isinection can be accomplished by storing the contact lenses overnight in a
disinfecting solution.

#nzymatic cleaners are used to remove tear protein deposits from the surface of
the contact lens. These are deposits that may not be removed with a daily
cleaner. These cleaners are for the patients who are more susceptible to these
deposits than other patients. E"cessive protein deposits can block o"ygen
transmission through the lens and they may trigger a hypersensitivity reaction
under the eyelids. (ore fre$uent replacement of the lenses also reduces this
problem.

!ll.purpose sot contact lens care systems are currently popular for contact
lens care. &ne solution is used for cleaning, rinsing, and for disinfection #storage
in the case%. The idea is to encourage better compliance with a more simple
system. Enfortunately, many patients think all they have to do is remove the
lenses and place them in the solution overnight. 5e sure to encourage the patient
to rub and rinse the lenses as described above.

The allApurpose solutions are e"pensive. The cost for the patient can be reduced
if the allApurpose solution is only used as the cleaning agent and the disinfecting
agent #storage%. much less e"pensive contact lens saline solution can be
purchased to rinse the lens during cleaning and to rinse the lens before insertion.

Some patients may become hypersensitive to the preservatives in chemical care
systems. Symptoms may include soreness, stinging, foreign body sensation,
redness of the conjunctiva, redness of lids. swelling of the conjunctiva and/or lids,
and punctate staining of the cornea. major offender has been the preservative
thimerosal. It is best to avoid care systems with this preservative. Switching the
patient to a chemical care system with a different preservative may solve the
problem. lternatives to chemical care systems are daily disposables or a
hydrogen pero"ide care system as discussed below.

hydrogen pero'ide based care system re$uires more steps for the patient,
but it may be the only choice for the patient who is hypersensitive to the
preservatives in other care systems. The pero"ide is an efficient antimicrobial and
it has some protein cleaning activity as well. The system re$uires an e"posure
step of about <; minutes and a neutrali+ation step that lasts from =; minutes to a
few hours, depending on the system.

-eneral instructions to the patient should include@
&nly use products that are compatible with your lenses. 6heck with your
doctor?s office.
2o not mi" care product brands unless recommended by the doctor?s
office.
,ash hands before handling lenses.
2o not skip steps in your lens care routine, as instructed by the doctor?s
office.
7eep the lens care environment clean #case, counter, storage bag, etc.%.
7eep care product bottle tops from touching any surface.
,ork over a clean surface. Ese paper towels if in a public restroom.
If you drop your lens prior to insertion, rinse the lens well before insertion.
4otify your doctor?s office if you e"perience eye or lid redness and/or
irritation.
/ot Lenses or the astigmatic patient

"oes the patient really need astigmatic correction1

4ot all low astigmats #M<.=: 2% re$uire astigmatic correction. 4ot all of them want
astigmatic correction, particularly if the dominant eye does not have significant
astigmatism. If in doubt, trial fit with spherical soft lenses and overArefract. Show
the patient the difference between astigmatic correction and correction with the
spherical e$uivalent. Toric lenses are more e"pensive to replace, although the cost
differential has come down significantly in recent years. Toric lenses generally are
not as comfortable as spherical lenses. The difference in vision may not outweigh
these other factors. The trial contact lens that you use may make a difference in
this determination. Thicker, lower water content soft lenses tend to .mask. low
amounts of astigmatism better than thin lenses.

Toric sot lenses vs6 hard gas permeable lenses

To be able to offer the astigmatic patient the best lens for his/her eyes, we need an
understanding of the options in terms of lens design and the advantages and
disadvantages of each type.

The patient with significant astigmatism #generally L .:2% can be fit with toric soft
contact lenses or hard gas permeable #!1'% contact lenses. lthough !1' lenses
can efficiently fit almost any degree of astigmatism, many astigmats less than =.:;
2 are fit with toric soft lenses because of the initial comfort factor.

Toric soft contact lenses correct astigmatism by providing a cylinder correction in
the lens itself. The correction is similar to a glasses correction. 8or this to work,
the lens must not rotate significantly on the cornea.

*otational stability is
accomplished with a
variety of lens designs,
including weighting the
bottom of the lens
#prism ballast, top
image% and/or flattening
the bottom edge of the
lens so that it rests
against the lower lid
#truncation, bottom
image%.








The conventional !1'
lens corrects
astigmatism with a .tear
lens.. This rigid,
spherical lens is fit to
one curve of the cornea
#picture on the left%.
5ecause of astigmatism,
the lens does not fit the
other curve perfectly,
but the space between
the lens and cornea is
filled in with tear fluid
#picture on the right%,
which acts as a
refracting surface to
correct the astigmatic
error. The tear lens is
represented by the
black area in the picture
on the right.

8or the conventional !1' design, lens rotation does not affect the astigmatic
correction. The conventional !1' lens works well only for low to moderate
amounts of astigmatism. !1' lenses can also be designed to fit the cornea e"actly
for higher amounts of astigmatism #bitoric design%. bitoric !1' design is more
complicated and more costly.

The toric soft contact lens must maintain little or no lens rotation on the eye for
ma"imum acuity. The regular !1' lens does not have this problem. 8or this
reason, it is best to determine the patient?s cylinder power and a"is .sensitivity.
before a lens type is recommended. If the patient notices a decrease in vision with
a small a"is rotation, she may be better off with an !1' lens fitting.

Cylinder /ensitivity testing

t the completion of the manifest refraction, have the patient view a line on the
chart one line above the line of best corrected visual acuity #56F%. sk the
patient to let you know when she notices the letters blurring. Slowly rotate the
cylinder a"is away from the refracted a"is. Stop when the patient notices blurring.
The a"is sensitivity is the degree of rotation from the refracted a"is. 8or e"ample@
suppose the refracted a"is is >; and the patient reports blurring at a"is <;;, then
the a"is sensitivity would be <; degrees. Esually, the greater the cylinder power is,
the more sensitive the patient is to a"is rotation.

If the patient has an a"is sensitivity of : degrees, and the best fitting soft toric lens
fre$uently rotates <; degrees off a"is, then the patient may be better off wearing
!1' lenses.

How much astigmatic correction does the patient need1

similar procedure can be followed for cylinder power. The cylinder power is
reduced by .:; 2 while simultaneously changing the sphere .=: 2 to keep the
spherical e$uivalent. 8or e"ample@ change a B<.:; 2 cylinder power to B<.;; 2,
and at the same time change the sphere power .=: 2 in the plus direction. gain,
the patient reports when blurring occurs. The distance traveled on the cylinder
power wheel is the measure of cylinder power sensitivity. 8or e"ample@ suppose
the refracted cylinder power is <.: 2. The patient reports blurring at <.;; 2. The
cylinder power sensitivity is thus .: 2.

(ost patients do well with an automatic .: 2 reduction in cylinder power in the S63
prescription. 2epending upon the cylinder power sensitivity, a greater reduction
may be possible.

7sing a trial toric sot lens

diagnostic or .trial. set of soft toric contact lenses #torics% should be used. Some
practitioners have one or two favorite lens designs, and they fit these from
inventory. Evaluating a lens with the e"act parameters needed decreases the
.chair time. needed to fit torics. !owever, many manufacturers have liberal return
policies that allow you to fit from a limited trial set and return an ordered lens that
may not be optimum when worn by the patient.

Toric lens parameters vary from brand to brand. Fariables include the following@
base curve
diameter
range of sphere powers
range of cylinder powers
range of a"is alignments
fle"ible wear, planned replacement, or daily wear
s you can imagine, fitting torics form inventory re$uires a lot of lenses. To help
you sort things out, there are publications that organi+e all this information for you
#e.g. Tyler?s Nuarterly%. &bviously, you will be spared some frustration by
beginning your fitting with a brand that includes the parameters that you need for a
particular patient.

Choosing a trial lens

To begin your toric lens fitting, you will need the manifest refraction and the
keratometry readings. Toric lenses usually have a large diameter to aid stability, so
measuring the patients cornea is usually not necessary.

Hust as with spherical soft lenses, the glasses lens power #or manifest refraction%
will need to be adjusted for verte" power. Toric verte" adjustment is a little tricky
because you may have to adjust both the sphere power and the cylinder power.
3et?s look at an e"ample@

(* K A0.;;B=.;;I<0;

8irst of all, we convert to contact lens language #minus cyl.%.

(* K AC.;;A=.;;I>;

8rom the optics modules, you may #hopefully% remember that we are really dealing
with two different lenses. &n an a"is cross, the powers convert to@

AC.;; 2 at <0; degrees
A0.;; 2 at >; degrees

If we look up each of these powers on a verte" conversion chart, AC.;; 2 at a verte"
distance of <=mm converts to A:.C= 2 at +ero verte" distance, and A0.;; 2 converts
to A/.=: 2. Therefore, our 63 *" will be A:.C=A<.CDI>;. )ou can also use the
optics calculator to arrive a the same answer. &ur ideal toric trial lens power would
be A:.:;A<.:;I>;. *emember that you want to start with a cylinder power that is
less than the refracted power. (any manufacturers offer A<.=: and A<./: cylinder
powers and do not offer a A<.:; cylinder power. If this is the case, you would want
to start with the A<.=: cylinder power.

Hust as with a spherical contact lens fitting, you will follow the manufacturers
recommendation for the starting base curve. (ost lenses come in .medium.,
.steep., and .flat. base curves.

E"ample@

v. 7 reading 5ase 6urve

M 9D.;; >.< #flat%
9D.;; A 9:.;; 0./ #medium%
L 9:.;; 0.9 #steep%


#valuating the it

The same basic evaluation criteria used with spherical soft lenses also applies to
toric lenses.

8or best vision, the a"is of the contact lens cylinder correction should line up with
the a"is as determined by the manifest refraction. ll is well if the contact lens
rotates to the correct position after insertion, and it should stay in the correct
orientation throughout the day. This, of course, is not always the case.

ll toric soft lenses have some type of markings that assist in the evaluation of lens
rotation. It might be a single mark at the C o?clock position, marks at D and >
o?clock, three marks at :, C and / o?clock, or some other marking scheme. The
marks are viewed with a slit lamp to determine the degree of rotation of the lens.
The rotation of the lens should not be evaluated until the lens has had time to
stabili+e on the eye. Ten to <: minutes after insertion is usually sufficient time for
stabili+ation.

If a toric lens consistently rotates to the same position on the eye, then the
prescription can be adjusted to accommodate the rotation. 8or this adjustment, the
.3*S. system is used. L!(/ stands for .leftAadd, rightAsubtract.. If the lens is
rotating to the right, then the degree of rotation is subtracted from the refractive
a"is. If the lens is rotating to the left, then the degree of rotation is added to the
refractive a"is.

3et?s look at an e"ample@

This patient is wearing a toric soft lens #light blue color over a blue iris% with a C
o?clock rotational marker and two marks <: degrees to either side. Ideally, after the
lens has stabili+ed, the center marker should be at the C o?clock position as you
look at the lens with a slit lamp.


3et?s suppose that our lens stabili+es to a position with the lens rotated somewhat
counterclockwise, like this@


The arrow marks the C o?clock position, so our lens has not rotated enough for the
left <: degree marker to align with the C o?clock position. So, we will have to
estimate the degree of rotation. It looks like it has rotated about =/D of the way
toward the marker. ,e estimate that it has rotated <; degrees.

3et us say that the patient?s glasses prescription is A=.;;A<.=:"</;, and this is the
power of the lens that we have inserted. &ur lens has rotated to our right. The
3*S rule is@ left add, right subtract. Therefore, we will subtract <; degrees from
</; to get a contact lens a"is of <C;. This means that we will order the patient a
new lens with the a"is at <C;. Theoretically, the new lens should behave the same
way, rotating <; degrees to the right after stabili+ation. If so, the cylinder a"is will
be in the correct position for good vision, at a"is </;.

s with a spherical soft lens, the toric lens should center well and e"hibit some
movement, at least when pushed with the lower lid. loose fitting toric lens will
generally not be a successful fit, as the e"cessive movement contributes to lens
rotation and blurry vision.

&nce an acceptable fit has been achieved, with minimal rotation after being allowed
enough time to stabili+e, an overArefraction should be performed. 'erform the
refraction as you would with an eye not wearing a contact lens. In other words,
perform the normal refractometry routine, checking sphere, cylinder a"is, and
cylinder power. *ecord the results. To arrive at the final contact lens prescription,
place the trial contact lens power specifications #adjusted for rotation% into a trial
frame. Then place the overArefraction results into the same trial frame along with
the other lenses. 4ow place the overAloaded trial frame onto a lensometer and
read the final contact lens power *". This is the contact lens power that you will
order, along with the other specifications of the particular trial lens that was used. If
the results of the overArefraction were minimal, you can dispense with this final
e"ercise and simply order the specifications of the trial lens as adjusted, if
necessary, for lens rotation.

The insertion, care, and handling of toric soft lenses are very similar to that of
standard soft lenses. The patient need not pay particular attention to the
orientation of the insertion, as the lenses should rotate to the proper position in a
short period of time. The patient should, however, pay particular attention to
inserting the lenses so that they are not insideAout. This is usually not a problem as
most toric lenses give an obvious .taco test..

The patient should be seen back in a week or two for a review of the fit. (any soft
toric contact lens vision and comfort complaints originate from toric lens
dehydration. This may become apparent in the return visit, but may not show up
until much latter. If the symptoms are relieved by regular use of reAwetting drops,
then the patient will need to make this a part of his routine.

If the patient complains of intermittent blurring, then the lens may be too loose,
allowing for e"cessive rotation upon blinking. steeper base curve may be
necessary.

If the patient complains of constant blurring, the lens may be constantly misaligned,
or the prescription may be wrong. If the fit seems ade$uate #not too steep or flat%, a
predictable a"is misalignment can be again adjusted with the 3*S principle. The
prescription can be rechecked with overArefraction if necessary. ,hen evaluating
vision complaints, always keep in mind that the patient may have switched the
lenses. If all else fails, the fit can be started from scratch before soft lenses are
abandoned for *1' lenses. Some would argue, why put up with this nonAsense-
Simply fit *1' lenses in the first placeO To be fair, many patients are successfully
fit with soft toric lenses the first time.

'resbyopia is the term for difficulty focusing at near due to the aging lens of the
eye. Symptoms usually first occur between the ages of 9; and :;, with most
patients needing some degree of near compensation by age 9:. 4ear
compensation means more plus power, which brings the near point closer
/ot lenses plus readers

There is no ideal contact lens correction for 'resbyopia. The presbyopic contact
lens wearer must compromiseP therefore, motivation is a key factor in successfully
fitting the presbyope with contact lenses. 5efore modifying the contact lenses for
near vision, be sure that your patient understands that readers can be worn over
distance powered contact lenses. This is not always obvious to them, and it is the
most simple solution. &f course, not everyone wants .simple., some do not want
glasses, even for near vision.

Over.plusing the contact lens power

!elping the new presbyope who already wears contact lenses may be as simple as
overAplusing the correction in both eyes. &verAplusing means changing a B<.:;
correction to B=.;; or changing a AD.;; correction to A=.:;. !yperopes usually
tolerate this better than myopes. The idea is to overArefract binocularly in the plus
direction until the distance vision is unacceptable, and then back off a little until it is
acceptable. If overplusing is not acceptable, then monovision may be tried.


2onovision

(onovision is a techni$ue that corrects only one eye for near vision, while leaving
the other eye for distance vision. 4ot everyone can tolerate having one eye blurry
all the time. The success rate is enhanced by keeping the dominant eye the
distance eye, and by minimi+ing the power difference between the two eyes.

There have been many methods described for determining the dominant eye,
and some of them don?t work very well. Try first asking the patient which eye is
dominant, (any patients already know what you are talking about and can give
you the information. (y personal e"perience has been that the vast majority of
right handed people are also right eye dominant. (y e"perience has also been that
many left handed people are also right eye dominant. There are some people who
seems not to have a dominant eye.

If the patient is not aware of eye dominance, there are two methods that may work
to determine dominance@

The camera method@ 7eep an old camera handy and have the patient take a
picture. ,hichever eye is used to look through the viewfinder is the dominant eye.

3ook through the hole method@ The patient e"tends both arms and holds the hands
together so that a hole is formed through which the patient views a distant object.
)ou cover one eye at a time and ask if the object can be seen. ,hichever eye it is
that can see the object is the dominant eye.

7eep in mind that most people are right eye dominant, including almost everyone
who is right handed. 5ut, this is not always the case. That?s why we check.

,hen adjusting the contact lens power for monovision, the distance eye is given as
much plus power #or as little minus power% as the patient will tolerate before
complaining about blurry distance vision. This narrows the power difference
between the two eyes and improves the intermediate and near vision. The near
eye is given the minimum additional plus power to do the job. 7eep in mind that,
because of the verte" distance change, less plus power will be needed than what is
given in the glasses bifocal correction. In other words, a B;./: add with contact
lenses is e$uivalent to a B<.;; add power in a glasses bifocal. ,hen in doubt, give
less power and have the patient try it for a few days.

E"amples@

9: year old right eye dominant presbyope with a distance contact lens correction
of AD.;; &2 and AD.;; &S might end up with a monovision contact lens correction
of@

&2 A=./:
&S A=.=:

&ur patient tolerates a .=: reduction in the minus correction for the right eye, which
focuses at distance. !e can read well enough with a B;./: 2 .add. for his left eye,
which is the reading eye.

C; year old right eye dominant presbyope with a distance contact lens correction
of B<.:; &2 and B<.:; &S might end up with a monovision contact lens correction
of@

&2 B=.;;
&S BD.=:

This hyperopes can tolerate a .: 2 increase in the correction for the right eye,
which is the distance eye. !e can read well enough with a B<./: 2 .add. for his left
eye, which is the reading eye.

8rom the above you might surmise that the 9: year old will have the greater chance
of success because there is less power difference between the two eyes. If your
patient does not tolerate monovision, bifocal contact lenses may be considered.

Biocal sot lenses

5ifocal contact lenses offer the possibility of success #compromised% for some of
your contact lens patients who do not want to wear glasses for anything. The
downside for the fitter is increased .chair time.. The downside for the patient is
increased e"pense.

The are several design types of bifocal contact lenses. The simultaneous view
bifocal design uses concentric circles of different powers that project focused light
from two different distances simultaneously on the retina. The aspheric bifocal
design is a type of progressive power design. The translating or alternating bifocal
design is similar to the bifocal in a pair of glasses. The optics of these designs are
comple" and are beyond the scope of this module. They are mentioned in order to
familiari+e you with the vocabulary.

The fitting techni$ues and characteristics of bifocal contact lenses are very specific
to the brand. 'roper alignment on the cornea is usually critical, and pupil si+e plays
a role. (any practitioners prefer to begin with a .modified monovision., meaning
one eye is fit with a conventional contact lens and the other eye is fit with a bifocal
contact lens