Contact lens fitting

Optimal fitting

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There is little or no relationship between the radius of curvature of the central cornea and the back
optic zone radius (BOZR) of the best fitting lens. The fit of a soft lens is affected by tear quality, lid
tightness, palpebral aperture and the total diameter of the cornea.
Eyes with large, steep corneas are likely to need a steeper lens than expected whereas eyes with
small, flatter corneas are likely to need a flatter lens. This is because the overall sag of cornea plus
sclera is greatest in steep, large corneas and least in small, flat corneas.
An optimal fitting lens should have complete corneal and limbal coverage in all positions of gaze,
with approximately 1mm of overlap onto the sclera. The lens should be well centred in primary
gaze and retain complete coverage on eye version.
Adequate movement is required for tear exchange and debris removal, and should be assessed on
blinking and by how much the lens 'lags' behind on lateral excursions. A well-fitting lens should
move between 0.2mm and 0.4mm post-blink and should move laterally between 0.3mm and 0.5mm.
This movement can be compared to the overlap onto the sclera. A well fitting lenes will move less
than one half of the amount overlap on blink.
The push-up test measures the tightness of a lens and is conducted by using the index finger or
thumb to manipulate the lower lid and dislodge the lens. Compare the ease with which the lens
displaces with the recovery speed to record the resistance to decentration and the re-centration
movement. In an optimal fit, this is 50%.

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Loose fitting

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When a contact lens is placed on an eye, the tear film is split into two parts; a pre-lens tear film and
a post-lens tear film. Both are approximately 2 microns thick. It is the post-lens tear film that
reduces the friction between the lens and the ocular surface. So a lens with a thicker post-lens tear
film is likely move more. Higher modulus lenses exert a bigger "squeeze pressure" on the post-lens
tear film between blinks, which is advantageous for tear exchange but can also limit lens
movement.
Conversely, a thin pre-lens tear film may increase friction between the lens and the palpebral
conjunctiva. This may lead to increased movement on blink.
A truly loose soft lens will normally provide complete corneal coverage in primary gaze, but
centration is likely to be poor. In up gaze a loose fit will usually display inferior sag. Movement will
be in excess of 0.4mm on blinking and more than 1.5mm on up-gaze. Patients usually report poor
comfort as a result.
The push up test will reveal a very easily dislodged lens with erratic recovery, that doesn't re-centre
well. A loose lens will often have a push-up ratio of 100%.
Some loose lenses, especially those with a high modulus, may appear to have a wavy lens edge, like
there is an excess amount of material.

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Tight fitting
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It is well known that the fitting characteristics of hydrogel soft lenses changes depending on the
duration of wear. The biggest change occurs during the first few minutes of wear. The fit tightens
after the first five minutes of wear, with the movement on blink reducing to a minimum at 20-25
minutes before recovering again to a more consistent level for the rest of the wearing time.
Recent research has shown similar results for silicone hydrogel lenses. It is not clear why this
happens but it does have an effect on when lenses should be assessed. It is best to wait more than 20
minutes for the lenses to settle before assessing the fit, but assessing the fit in the first 5 minutes is
likely to be a better predictor of overall fit than between 5 and 20 minutes, when the fit will appear
tighter than reality.
In tight-fitting soft contact lenses, the coverage and centration are usually good but the lens will
have poor movement, usually less than 0.2mm, on blinking. The lens will resist the push up test and
a tight lens will be recorded as 0%. The lens will be difficult to dislodge recovery will be slow.
Over a period of time, the ens edge of a tight lens may indent the conjunctiva. It may also cause
blanching of the fine superficial vessels under the lens margin.
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Toric lens fitting

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A well fitting soft toric lens will fit like an optimal fitting spherical soft lens. Toric lenses tend to
have larger diameters which tend to enhance stability but may make it more difficult to find a lens
that fits small corneas well.
Good centration and stability on blink are important, as is the stability and position of the toric lens
location markings. Locating the laser toric axis marking and recording clockwise or anticlockwise
rotation in degrees allows adjustments to be made for stable rotation of the lens. Use the notation
CAAS (clockwise add, anticlockwise subtract) to add or subtract the lens rotation to the spectacle
prescription to obtain the ideal toric meridian for the contact lens.
Ultimately, the visual acuity will indicate the stability of the toric lens. On blink, excursions and
push up, the lens should exhibit good stability and return to the desired position rapidly.

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Module 2: RGP Contact Lens Fitting

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A Review of Contact Lens Fitting & Aftercare

Module 2: RGP Contact Lens Fitting

Rigid Gas Permeable (RGP) contact lenses account for 10% of new contact lens fits and up to 15%
or refits in the UK. While this represents a small minority of fits, RGP fittings have recovered in the
last two or three years after a long period with almost no use. This may be accounted for by an
increase in specialist rigid lenses including scleral and semi-scleral lenses.
Rigid gas-permeable (RGP) contact lens fitting is often regarded as more complex than soft lens
fitting, but in reality the judgements made to fit either lens are very similar and despite the relatively
small volume of fits, there is still a wide range of RGP lens designs available to cover every
application.
In this module we will review the characteristics of a well fitting lens.

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Optimal fitting
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Ideally, RGP lenses should be assessed using white light and with cobalt blue light using fluorescein
and a Wratten 12 yellow filter. White light assessment allows the centration and dynamic fit to be
assessed, while cobalt blue light with fluorescein allows the practitioner to assess the alignment of
the lens with the cornea.
An optimally-fitting RGP lens centre over the pupil in primary gaze and remain within the limbal
area without overlap in any direction of gaze. The goal of RGP centration is to ensure that the visual
axis always remains within the back optic zone diameter (BOZD) of the contact lens to maintain
clear vision without flare. When the lids are separated, the lens may drop slightly but it should
promptly return to a central position post blink.
Lens movement is a key component of an RGP fit. Movement is required to pump tears from
behind the contact lens. This clears debris as well as enabling oxygen exchange. Optimum
movement is between 1.0mm - 1.5mm with each blink.
In blue light, a thin layer of fluorescein should be visible under the lens, indicating alignment with
the cornea. Alignment of the back surface of the lens with the cornea allows the force of the lens to
be distributed across the corneal surface. Slight apical clearance can enhance lens centration.
The edges of the lens should display adequate edge clearance (approximately 0.5mm - 1.0mm) to
enable tear exchange and facilitate lens removal.
An optimal lens fit will result in stable, clear vision and improved lens comfort. However, initial
comfort will depend on the patient and it will be much less than with a soft lens.

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Steep fitting

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A steep lens will display less movement than an optimal fit, usually less than 1mm and will often
remain centred around the corneal apex when the lids are separated. An immobile lens can feel
initially comfortable but it causes tears to stagnate beneath its surface, leading to staining and
corneal distortion.
During blinking a steep lens may move rapidly, though it will take a bit more effort to dislodge from
its centred position. Steep lenses often centre low because the edge clearance is too little to allow
the lens to attach to the top lid.
On fluorescein assessment with cobalt blue light a steep fitting lens will have a narrow band of edge
clearance and pooling of fluorescein centrally. Fluorescein will be absent where the lens touches the
cornea in the mid-periphery. In very steep lenses air bubbles may also be present at or near the
corneal apex.
Aspheric lenses often require a flatter fitting than multi-curve designs to provide proper alignment
across the corneal surface. Therefore Aspheric lenses chosen to fit the corneal curvature are more
likely to appear steep.

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Flat fitting

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A flat-fitting RGP lens will have poor centration and increased movement, more than 1.5mm. It will
often overlap the limbus during versional movements.
When the lids are separated, the lens will drop quickly, often falling sideways and pivoting around
an area of corneal touch in a semi-circle.
The fluorescein pattern will be unstable, displaying central touch, a wide mid-peripheral band of
fluorescein and a wide band of edge clearance, possibly with some edge lift.
Flat fitting lenses are uncomfortable and often cause reflex tearing. However, an excess of tears can
also make a well-fitting lens appear flat. Choosing a lens which is slightly steeper (0.05mm) than
would be expected from the corneal curvature can be a good starting point for this reason.

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Module 3: Contact Lens Aftercare

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A Review of Contact Lens Fitting & Aftercare

Module 3: Contact Lens Aftercare

Advances in contact lens materials, designs and care systems mean that more people than ever
before can wear lenses successfully. Many 'contact lens complications' have been consigned to the
history books. Comprehensive follow up remains, however, a key component of ongoing success.
As many as 50% of new wearers drop out of contact lens wear, most citing discomfort and dry eye
as the reason for doing so. Most of these symptoms are avoidable and simple changes to care
systems, materials and designs can prevent many of these drop-outs. So the role of the eye care
practitioner in delivering comprehensive aftercare is as important as ever.
In this module we will review some of the more common aftercare issues as well as common ocular
pathologies which can affect contact lens wear.
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Blepharitis

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Blepharitis is a very common inflammation of the eyelids and can vary in severity from
asymptomatic to extreme discomfort. Symptoms include ocular discomfort, burning and itching.
Patients may complain of reduced wearing time and reduced vision with contact lenses.
Anterior blepharitis affects the front of the eyelids around the base of the lashes and is most
commonly due to a bacterial staphylococcal infection, though can also include seborrheic dermatitis
or demodex blepharitis.
Posterior blepharitis affects the meibomian glands. Meibomian gland disease (MGD) can be caused
by bacterial infection. The chemical and physical secretion of the glands is altered, making it thicker
and blocking the glands. The lipid layer of the tear film becomes unstable and there is increased
evaporation of the tears and consequently dry eye.
Blepharitis is more common in long term contact lens wearers. It is also a condition which should
be controlled before fitting contact lenses or, if seen at aftercare, should be managed to allow
contact lens wear to continue. The presence of bacteria on the lid margins makes corneal
infection/inflammation more likely and the associated dry eye symptoms make the contact lens less
comfortable.
Treatment for blepharitis usually involves lid hygiene as part of a daily routine. Artificial tears may
also be beneficial. More severe cases may require antibiotic ointment or even oral antibiotics.
Treating MGD is vital to contact lens comfort. Heat application helps to soften and liquefy the
blockages which can then be manipulated by lid massage to remove the blocked debris.
It is often not possible (especially in older patients) to completely eradicate blepharitis. Instead,
regular treatment should be used to control the condition, reducing symptoms and minimising the
number and severity of relapses.

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Contact Lens Peripheral Ulcer

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A contact lens peripheral ulcer (CLPU) is an inflammatory condition caused by a response to
contact with gram positive bacteria (commonly staphylococcus). CLPU is not an infection, rather it
is inflammation caused by the exotoxins produced by bacteria on the lids or trapped under a contact
lens.
CLPU can occur at any time but it is more commonly associated with poor lens hygiene, contact
lens deposits and lid margin disease (blepharitis). It is also more common in overnight wear of soft
lenses.
In many cases (up to 50%) CLPU is asymptomatic and it is common to see resolved CLPUs at
aftercare with no corresponding history from the patient. Symptomatic patients often report contact
lens intolerance, foreign body sensation and photophobia. The symptoms usually subside
significantly when the lens is removed.
CLPU is self limiting on removal of the contact lens (and the source of the bacterial exotoxin). The
condition usually resolves in 48 hours. However, a it is important to differentiate CLPU from
microbial keratitis as the initial symptoms are very similar. The patient should be instructed to
return or seek help if the symptoms do not subside or get worse in the first 12-24 hours post lens
removal.
In severe cases, ocular lubricants or oral analgesics may be given to reduce discomfort. Any
blepharitis should be treated with lid hygiene before lens wear is re-started

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Lid Wiper Epitheliopathy (LWE)

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The lid wiper is located on the marginal conjunctiva of the upper lid. During blinking, it passes over
and rubs against the ocular surface or contact lens.
An unstable or thinning pre-corneal tear film or a poorly wetting contact lens is thought to increase
friction, causing patients to complain of discomfort. While the cause of LWE is not fully understood
it is thought that the lack of lubrication damages the epithelium of the lid wiper, causing it to stain
with lissamine green. LWE occurs on both the upper and lower lid margins. Upper LWE has been
noted in 67% to 80% of symptomatic contact lens wearers, 13% to 32% of asymptomatic lens
wearers and 76% of non-lens wearers who have dry eye symptoms.
The staining length and width in mm are both considered when grading this condition on a 0-3 or 0-
4 severity scale.
Initial management requires an improvement to contact lens comfort, either by changing the lens
material for one with a lower coefficient of friction and/or increasing lubrication by using artificial
tears. Underlying causes such as MGD or aqueous deficiency, should be treated before re-fitting.

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Subconjunctival Haemorrhage
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Subconjunctival haemorrhage is caused by a ruptured blood vessel under the conjunctiva. It is

commonly associated with coughing, sneezing or vomiting. Mild trauma to the eye may also be a
cause. It is more common in patients taking anticoagulants such as aspirin and warfarin. The patient
is usually asymptomatic and no treatment is required. The condition will resolve in 7-14 days
depending on the size of the bleed.
Recurrent subconjunctival haemorrhage may be indicative of underlying cardiovascular disease and
should be referred to a GP.
Whilst haemorrhage under the conjunctiva look spectacular it does not affect contact lens wear at
all. Patients can be fitted with and continue to wear their soft contact lenses.

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