:>' .

THE ROLE OF TEARS IN CONTACT LENS

21
PERFORMANCE AND ITS

MEASUREMENT

f.-P. Guillon and M. Guillon

21.1 INTRODUCTION formation and drainage with particular refer­

Contact lenses do not make direct contact
with the ocular tissues but are fully covered
by tears. This close interaction between con­
tact lenses and tears impart to tears a particu­
larly important role in achieving successful
long-term contact lens wear. This interaction
has several disparate aspects. First, contact
lenses are very thick, irregular, and perma­
nently moving foreign bodies placed within
a much thinner tear film; the net effect of this
is to destabilize the tear film. Second, contact
lenses selectively attract various components
of the tear film. This attraction, which is
highly material and lens-type-dependent,
imports to contact lenses their on-eye wet­
ting properties. These in tum determine the
physical acceptance of contact lenses.
The previous introductory remarks point
to a very complex physical and chemical
interaction between contact lenses and tears.
In order to fully understand this interaction
and its evaluation in contact lens practice we
will consider both the tear film before the
insertion of contact lenses, and during con­
tact lens wear. For the tear film in the
absence of contact lenses we refer to the
pre-ocular tear film (POTF), and we will
briefly summarize its functions, production
Contact Lens Practice. Edited by Montague Ruben and Michel Guillon.
ence to contact lenses. We will describe the
various techniques available to us to study
both the POTF and the pre-lens tear film
(PLTF) and evaluate the wettability of contact
lenses on the eye. Finally we will describe
the interaction between contact lenses and
tears by studying the characteristics of the
PLTF.
21.2 PRE-DCULAR TEAR FILM
CHUUlACTERJSTICS
21.2.1 TEAR FILM FUNCTIONS
Introductory remarks
Maurice (1990) attributes three functions to the
tear film; one optical, the second protective
and the third lubricative. He argues that the
functions of supplying nutrients to the epithe­
lium, which is widely accepted as the fourth
function of the tear film, is debatable. These
functions and, in particular their relevance to
contact lens wear, are summarized below.
Provision of an optical surface
The POTF provides a perfectly smooth opti­
cal surface to the strongest refracting compo­
nent of the eye by forming a continuous film

Published in 1994 by Chapman & Hall, London. ISBN 0 412 35120 X

454 The role of tears in contact lens performance and its measurement
that compensates for the micro-irregularities
of the anterior epithelial surface (see Chapter
(0). The PLTF similarly compensates for the
irregularities such as scratches and/or depos­
its that rapidly appear at the surface of both
rigid gas permeable (RGP) (Allary et al.,
1989a,b), and hydrophilic contact lenses
(Allary et al., 1989b; Guillon et al., 1992)
during use.
Protective action
Removal of foreign bodies
There are two aspects to the removal of
foreign bodies. First, there is the well known
removal of airborne particles and/or chemi­
cal irritants that takes place by the flushing of
the anterior ocular surfaces via reflex lacri­
mation, but also as important is the action of
the basal lacrimation that removes the
necrotic epithelial cells from the anterior ocu­
lar surface (Lemp, 1976), via the normal
blinking action and the specific role of the
mucous component of the tear film (Holly &
Lemp, 1977). In fact this latter role is the key
to successful contact lens wear, in particular
for extended wear. For that modality of wear
it has been shown that unless all epithelial
metabolic debris, that may be trapped
between the contact lens and the cornea, are
totally flushed within four hours of· eye
opening, adverse ocular reactions will most
likely take place (Mertz & Holden, 1981).
Antimicrobial activity
Both the basal and reflex tear compositions
reveal a wide range of proteins (Fullard &
Snyder, 1990). Amongst these, lysozyme
gives the tear film its main bacteriolytic
activity. This action is enhanced by several
other proteins, such as transferrin (Ford et
al., 1976), lactotransferrin (Liotet et al., 1980),
immunoglobulin (McOellan et al., 1973) and
possibly betalysin Gansen et al., 1984) which
are normally found in the tear film. The
second antimicrobial activity is mechanical
and associated with the mucus system that
forms a strand that traps small particles such
as bacteria and eliminates them (Holly &
Lemp, 1977).
The presence of a contact lens alters the
tears' antibacterial activity. Several studies
have shown that the conjunctival flora is
altered by the presence of a contact lens
(Rehim & Samy, 1988), usually with a reduc­
tion in antibacterial activity. Recently, how­
ever, studies have suggested no effect
(Elander et al., 1992), and at least one study
(Boles et al., 1991) has shown that ionic lenses
that attract high levels of lysozyme during
wear offer an enhanced antibacterial activity.
Lubrication
The presence of relatively large amounts of
mucin along the lid margins and the sponta­
neous mucin spread over the whole corneal
surface during blink (Lemp et al., 1970)
ensures that no direct solid-to-solid contact
takes place during blink. This lubricating
action is essential for an efficient, trauma­
free blink action. Similarly, when a contact
lens is worn the mucin coating contributes to
ensuring a trauma-free contact lens move­
ment. In fact, variation in the nature of the
lens coating during overnight wear leads to a
highly viscous PLTF at waking and reduces
contact lens movement at that time of day
(Guillon, 1991; Guillon & Guillon, 1991).
Maintenance of ocular integrity
The tears ensure the maintenance of ocular
integrity by creating a moist surface at the
anterior epithelial surface, any failure leads
to keratinization and loss of transparency
(Tiffany & Bron, 1978). It is via the tears that
the atmospheric oxygen during the day and
the palpebral vascular oxygen at night reach
.the epithelium. It is also via the tears that the
carbon dioxide that builds up during the
epithelial metabolic activity is eliminated.

The role of the tear film, however, is only a
passive one; no effect takes place during either
the passage of oxygen or carbon dioxide.
Similarly, whereas one often thinks of the
tear film as a source of nutrients for the
epithelium, Ehlers (1965) has put forward
information suggesting the contrary. He
showed that most nutrients, which are
hydrophilic components, cannot penetrate
the epithelial surface.
21.2.2 TEAR FILM STRUCTURE AND
GEOGRAPHIC DISTRIBUTION
Tear film structure
General description
The classic description of the tear film is a
basic trilaminar structure (Wolff 1946, 1954),
with a basal mucous layer spread over the
corneal surface, an intermediate aqueous layer
and a superficial lipid layer. That basic struc­
ture has been refined to include supplemen­
tary aqueous mucous interface and aqueous
lipid interface regions with slightly different
mixed compositions (Fig. 21.1) (Holly & Lemp,
1971). It is that model that we briefly describe
and will use to explain the interaction of con­
tact lenses with the tear fibn.
LIPID MUCIN
INTERFACE
MICROVILLI
MICROPLICAE
SURFACE OF CORNEAL EPITHELIUM
Figure 21.1 Schematic representation of modified
trilaminar tear structure.
Pre-ocular tear film characteristics 455
Mucous layer
The inner mucous layer is thought to be
extremely thin (0.02 to 0.04 urn) (Holly,
1973a) and have a complex mucoglycopro­
teinic structure (Holly 1973a, Greiner et al.,
1980, Van Haeringen, 1981). The glycopro­
tein part of the layer is surface active,
producing a hydrophobic segment that
attaches to the cornea, and a hydrophilic
one on which is formed the aqueous film.
That active role explains the extreme
importance of this very thin layer in main­
taining a stable tear film.
Aqueous layer
The intermediate aqueous layer accounts
for over 90% of the tear film thickness and
is made of 98% water and of 1.8% solids
(Ridley & Sorsby, 1940). The solids present
are both organic components, mainly high
molecular weight proteins such as
lysozyme, albumin and globulin (Fullard &
Snyder, 1990) and inorganic electrolytes
such as sodium, potassium, calcium, chlo­
ride and bicarbonate. These inorganic com­
ponents give to the tears their chemical
characteristics. Sodium (145 mg/ml), potas­
sium (16 to 24 mg/ml) and chloride (128 to
144 mg/ml) regulate the osmotic pressure
(Bothelo, 1964; Guilhard et al., 1968). The
osmotic pressure of the tears is approxi­
mately 305 mosmllkg, equivalent to 0.95%
sodium chloride (Guilhard et al., 1968;
Terry & Hill, 1978). The tear osmotic pres­
sure varies with the ocular location and is
known to be affected by contact lens wear
in non-adapted patients. Bicarbonate
(26 mg/ml), involved with pH regulation,
has a buffering action keeping the pH near
tonicity (7.45) with ranges between 7.14
and 7.82 (Carney & Hill, 1976). Both diurnal
(Carney & Hill, 1976) and contact-lens­
induced variations have been observed.
Calcium is found in low concentration (0.4
to 1.1 mg/ml) and seems not to have any
particular role.
456 The role of tears in contact lens performance and its measurement

Lipid layer the black line because of its appearance

when fluorescein is instilled in the eye (Fig.
The outer lipid layer, which is relatively thin
21.3). That junction zone of minimal thick­
(0.01 to 1.5 urn), is composed mainly of choles­
ness corresponds to the zone of the tear film
terol esther and other esther waxes, some free
with the greatest instability. Its effect has
cholesterol and very few free fatty acids
been demonstrated in various ways in con­
(Furukawa & PoIse, 1978, Nicolaides, 1986). Its
tact lens practice. Several studies have shown
main role is to prevent evaporation and, as for
that the film, whether pre-ocular (Guillon &
the mucous layer, the lipid layer plays a key
Guillon, 1988a, 1989a), pre-lens soft (Guillon
role in maintaining a stable tear film. Because
& Guillon, 1988c, 1989b) or RGP (Cuillon &
its structure is highly variable, the lipid layer
Guillen, 1988d) first breaks in that region.
gives different properties to the tear film. It is
those differences in structure that are studied
during the clinical evaluation. 21.2.3 THE LACRIMAL SYSTEM

Introductory comments
Geographic tear distribution
The lacrimal system can be divided into
The tear volume that totals approximately three components: secretory, distributional
7 111 (Mishima et al., 1%6) to 8.5 111 and excretory. The secretory component is
(Furukawa & Polse, 1978) is best described in made up of a series of glands distributed
two parts: the exposed tear volume (ETV), throughout the anterior ocular surface. The
which is in direct contact with the air, and distribution relates to the distribution of
the unexposed tear volume (UTV) (Port & tears over the ocular surface. The excretory
Asaria, 1990). The exposed part of the lacri­ component refers to the elimination of tears
mal fluid that constitutes just under half the from the eye.
total volume (Mishima et al., 1966) is the
most significant one as far as contact lens
wear is concerned. The E1V is divided into
the preocular part, a thin continuous layer
covering the cornea and exposed conjunctiva
and a marginal part, called alternatively lid
tear meniscus or lid tear prism, situated
along the upper and lower lids. It is esti­
mated that between 72.5 and 90% (Mishima
et al., 1966; Holly, 1981; Kwok, 1984; Bron,
1985; Guillon & Guillen, 1988a; Port &
Asaria, 1990) of the ETV is found within the
lid tear meniscus. On average the lid tear
meniscus has a volume of 5.25 111 and the
pre-ocular part a volume of 1.75 111 (Mishima
et al., 1966). The most critical part of the tear
film is the junction between the lid tear
meniscus and pre-ocular tear. At that point
the surface tension forces present make the
formation of a continuous film near impos­ Figure 21.2 Schematic representation of junction
sible (Holly, 1978) (Fig. 21.2). The result is a between tear meniscus and pre-ocular tear film
line of minimal thickness, often referred to as (by courtesy of McDonald, 1968).

Figure 21.3 Tear fluorescein coloration showing
the 'black' junction line of highest tear film insta­
bility between the tear meniscus and the pre­
ocular tear film.
Tear production
The secretory component is responsible for
both the basal and reflex tear secretions. The
various glands responsible for producing the
tear film (Adler, 1965) (Fig. 21.4) are:
1. The lacrimal gland proper, located in the
upper temporal quadrant of the eye,
which is divided into a main and acces­
sory part (Allansmith et al., 1976). Both
parts of the lacrimal gland proper are
seromucous glands (Ruskell, 1968;
Jensen et al., 1969; Allen et al., 1972) and
are responsible for producing the basal
and reflex aqueous parts of the lacrimal
fluid Gordan & Baum, 1980).
2. The accessory lacrimal glands of Krause,
which are situated in both fornices, but
mainly in the upper one, and the glands
of Wolfring near the tarsus. These glands
also contribute in a minor role to the
production of the aqueous tears.
3. The goblet cells or Crypts of Henle,
found in the fornices, produce the ocular
mucus which appears as a complex gel,
made up mainly of mucin (Fo1ch et al.,
1957). This part of the lacrimal fluid is
also produced by the conjunctival epi­
Pre-ocular tear film characteristics 457
GI8nds
of Kr.u••
Mar. GI8nda /'
Figure 21.4 Distribution of the various glands
producing the lacrimal fluid. (a) frontal view; (b)
section through eyelid (by courtesy of Tiffany &
Bron, 1978).
thelial cells (Greiner et al., 1980; Dilly,
1986) and the lacrimal gland proper
(Allansmith et al., 1976).
4. The glands of Meibomius, which are
numerous and situated within the tarsal
plates, with their orifices at the lid mar­
gin immediately posterior to the lashes
line, are responsible for the lipidic part
of the lacrimal fluid.
5. The glands of Zeis and Moll, both with
their orifices situated at the lid margin,
are also responsible for a minor part of
the lipidic component of the lacrimal
fluid.
Tear distribution
The tears are redistributed over the ocular
surface at every blink, or 5 to 12 times a
minute in a normal situation. The formation
458 The role of tears in contact lens performance and its measurement
of the pre-ocular tear film is therefore a very
dynamic phenomenon due to the physico­
chemical interactions taking place during the
blinking process, that lasts on average 0.3 s
(Doane, 1980). Holly (1973a) was the first to
describe this process fully, and a summary of
this description is of help to explain contact
lens on-eye wettability and the relevance of
the various clinical tests. The closing of the
lids has three effects (Forst, 1982):
1. It eliminates the aqueous part of the
tears.
2. It redistributes the mucin over the ocular
surface, to render it highly wettable.
3. It squashes the lipids between the upper
and lower lid edges.
During lid clusure the lipids are prevented
from migrating under the lids due to the lid
edge mucous and fonn a thick film in the
narrow space between the two eyelids
(Holly, 1980).
The opening of the eyelids redistributes
the aqueous tear immediately, along with a
monomolecular lipid layer at its anterior sur­
face (Holly, 1973b). A secondary upper lipid
motion accompanied by a slight increase in
the aqueous layer follows. The process
results in a stable tear film less than Is after
eye opening.
In between blinks, the tear film destabi­
lizes relatively rapidly, leading to the forma­
tion of dry spots that trigger the next blink.
Dry spots are thought to be due to the
migration of the superficial lipids towards
the ocular surface, rendering it hydrophobic
by contaminating the mucous coating (Fig.
21.5) (Holly 1973a). The rapidity of the con­
tamination is increased by the local thinning
of the aqueous tear film when, as during
contact lens wear, the overall tear film is
thinner than normal. The latter is a very
important determining factor in producing a
low tear film stability.
In between blinks, a vector flow also exists
which is limited to the upper and lower tear
prisms (Holly & Lernp, 1977) and does not
EVAPORATION DIFFUSION
b k t t
b 4l> I> ~ suPERFICIAL L1PIO LAYER
:.: .;: _: _: • TEAR FLUID
£~!!~II;;t'i~ ADSORBED MUCIN LAYER
r "
I l( I CORNEAL EPITHELIUM
STABLE TEAR FILM
BREAK UP
~~ pff)
'§gJ/,:yj?g
DRY SPOTS FORMED BY RECEDING
TEARS
Figure 21.5 Diagrammatic representation of the
mechanism of dry spot formation (by courtesy of
Holly, 1973a).
affect the pre-ocular tear film (Ehlers, 1965).
Tear Excretion
The tears leave the ocular surface via three
mechanisms: (1) the exchange of tears across
the conjunctival surface: (2) loss due to
evaporation; and (3) tear drainage at the
puncti. In humans it has been estimated that
between 8% (Schirmer, 1903) and 20% (Mau­
rice, 1973) of the tear film is eliminated each
minute by exchange across the conjunctival
surface. The amount of tears lost by evapora­
tion depends greatly upon environmental
conditions, in particular, relative humidity
and turbulent air flow (Holly, 1973b). ;\
decrease of the first and an increase of the
second contribute towards increasing the
evaporation. A recent study indicates that
evaporation could eliminate tears at a rate of 10
to 15% per minute (Tomlinson et al., 1991).
Finally during blinking, tears are pushed
towards the puncti at the inner canthus, where
they are passed in the nasolacrimal duct.
21.3 CLINICAL EVALUAnON TECHNIQUES
21.3.1 INTRODUcrORY REMARKS
Numerous routine and/or research clinical
techniques have been used to study the tears
of the contact lens wearer (Guillon, 1990).

Initially the techniques used were those that
had been developed to study patients with
pathological dry eye, such as the Schirmer
test (Schirmer, 1903). Such tests proved to be
of limited use for the evaluation of contact
lens wearers. More recently, clinical tech­
niques have been either modified and/or
developed with the prime objective the con­
tact lens wearer (Guillon, 1990). Some of the
techniques developed are limited to the
research environment. In this category are all
the techniques that aim to measure tear
evaporation, using evaporometers with dif­
ferent levels of invasiveness (Hamano et al.,
1981; Cedarstaff & Tomlinson, 1983; Rolando
& Refojo, 1983) and techniques to measure
tear flow rate using modified fluorophotom­
eters (Benedetto et al., 1984; Occhinpinti et
al., 1988). Also in this category are the tech­
niques that use biodifferential interference
microscopy (Hamano et al., 1979) to study the
structure of the tear film. These techniques
will not be discussed in the current chapter.
This chapter is limited to research and/or
routine techniques that can be used or
easily introduced in general clinical rou­
tine. These techniques can be divided into
two groups based upon the instrumenta­
tion used. The majority are based around
the slit lamp biomicroscope and include
easier, alternative ways of using the instru­
ment or special attachments. The second
group of techniques are those that stand
alone (e.g. Schirmer) or use other instru­
ments such as the keratometer. The
approach adopted in this chapter has been
to group the techniques into three catego­
ries according to their aim: (1) evaluation
of the tear film structure; (2) evaluation of
the tear volume; and (3) evaluation of the
tear film stability.
The same techniques are directly appli­
cable to the evaluation of both the pre-ocular
and pre-lens tear films, and therefore
described as one; when minor differences
are present they are highlighted.
Clinical evaluation techniques 459
21.3.2 EVALUATION OF THE TEAR FILM
STRUCI1JRE AND ADJACENT STRUCI1JRES
Lid edge anomalies
Introductory remarks
Anomalies of the lid border, where the
exposed tear film comes into contact with the
complex ocular structures present at the lid
edge, must be considered when evaluating
the tears of the contact lens wearer (Guillon
& Guillon, 1989b). This assessment is carried
out under diffuse lighting and involves the
assessment of both the upper and lower lid
margins. The structures of particular interest
are the lashes and meibomian gland orifices.
Observations and classifications
Lashes The lashes are a potential source of
contamination of the tear film because of
their close proximity to the tear meniscus.
Scaly lashes associated with epidermic prob­
lems and contamination associated with
make-up are often encountered. The level of
contamination of both the lower and upper
lashes can be classified into five categories:
l. Clean lashes.
2. Scaly lashes.
Light make-up contamination.
4. Medium make-up contamination.
5. Heavy make-up contamination.
Any contamination present or scales due to
epidermic problems should be eliminated
before contact lens fitting is undertaken or
during any refitting process. In the latter
case, if symptoms are present, elimination of
these problems is an essential requirement.
Lid margin
Foam Abnormal meibomian secretion pro­
duces bubble-like formations mostly at the
canthus and, in more severe cases, along the
lid margins. The appearance of these forma­
460 The role of tears in contact lens performance and its measurement
tions, referred to as 'foam' are classified into
seven categories according to their location:
O. None.
1. Upper lid.
2. Lower lid.
3. Both lids.
4. Canthus.
5. Canthus and lower lid.
6. Canthus and both lids.

Droplets The lid area within the lashes line

becomes wettable only when contamina­
tion occurs. This lid edge contamination is
revealed by the presence of tear droplets
covering the contaminated area. These
'droplets' are classified into five categories
according to the number of droplets seen:
1. None.
2. 1 droplet.
3. 2-3 droplets.
4. 4-5 droplets.
5. > 5 droplets.
The presence of 'foam' along the lids, in
particular when both are affected and/or the
presence of four or more 'droplets', is a
source of concern and the underlying cause
for these anomalies should be ascertained
and remedied before contact lens fitting is
undertaken.
Meibomian gland blockage Abnormal mei­
bomian secretions tend to solidify at normal
lid temperature and block the meibomian
glands, especially when associated with mei­
bomian gland dysfunction. The state of the
meibomian glands for each lid is classified
into four categories according to the number
of glands affected (Fig. 21.6):
1. None.
2. 1-2 glands.
3. 3-5 glands.
4. > 5 glands.
The lid border contamination is more com­
mon in females. This is associated with the
Figure 21.6 Blocked meibomian glands.
use of eyeliner and mascara (Guillon & Guil­
Ion, 1988a,b). In that context, the following
classification of make-up use is helpful to
ascertain the potential risk of contamination:
1. None.
2. Slight make-up.
3. Moderate make-up.
4. Heavy make-up.
It is pertinent to ascertain whether the pencil
eyeliner is applied within or outside the line
of the lashes. The former practice is always a
major source of contamination and potential
infection. This practice must be avoided by
all contact lens wearers. If the meibomian
gland dysfunction is not make-up related,
the underlying cause must be determined.
and remedied. Often a lid scrub treatment is
very effective at helping to unblock the rnei­
bomian glands.
Palpebral tear menisci
The tear menisci situated along the upper
and lower lids, as indicated earlier, hold
most of the ETV. Their structure is therefore
of great clinical interest (McDonald, 1969;
Holly & Lemp, 1977; Taylor, 1980; Guillon &
Guillon, 1989a,b; Port & Asaria, 1990). All the
techniques mentioned involve the use of the
slit lamp biomicroscope. Because of anatomi­
cal limitation the lower meniscus is easier to

examine and, as similar conclusions are
reached following the examination of both
the upper and lower tear menisci (Guillon et
al., 1988; Guillon & Guillon, 1989a), we sug­
gest limiting the routine clinical evaluation
to the latter. Four characteristics of the tear
menisci have been evaluated: height, width,
regularity and curvature. The latter two
parameters are of particular diagnostic inter­
est with regard to the tear meniscus struc­
ture.
The regularity of the lower tear menisci is
best observed under medium magnification
(X20) under diffuse lighting or with a broad
(3-4 mm) focal light (Fig. 21.7). Various crite­
ria have been given as to an abnormal tear
meniscus:
1. Holly and Lemp (1977) have suggested
that a scanty meniscus appearance or the
presence of an area of discontinuity
were signs of an aqueous tear deficiency
and/or lipid abnormality.
2. Taylor (1980) suggests classifying the
tear menisci as intact (no zone of irregu­
larity) for a normal patient, as intermit­
tently non-intact (presence of zone(s) of
irregularity at times) or permanently
non-intact (permanent zones of irregu­
larity) as abnormal menisci.
3. Guillon and Guillon (1988; 1989a) have
Figure 21.7 Tear prism irregularity observed by
slit lamp biomicroscopy under diffuse lighting.
Clinical evaluation techniques 461
described a simple clinical technique
(see page 000) and compare the height of
the tear prism immediately under the
centre of the pupil and both 5 mm
nasally and temporally. They suggest
that a large difference between the cen­
tral measurement and either of the
peripheral measurements is a sign of
irregularity.
The curvature of the tear meniscus is best
studied by lighting up the meniscus with a
thin vertical slit (McDonald, 1969) and
observing it under medium magnification
(X20 to X30). The normal meniscus should
be convex near the cornea, concave cen­
trally and convex at its contact with the
eyelid.
Pre-ocular tear film structure
General Remarks
The pre-ocular tear film is transparent, which
makes the observation of its component
structures very difficult. However, basic
optics indicate that, at any interface where a
difference in refractive index exists, a small
percentage of the incident light is specu1arly
reflected. The light reflected at the air lipid
interface constitutes the first Purkinje image
visible during biomicroscopy (Fig. 21.8).
Because the refractive index of the lipid layer
is higher than that of the aqueous layer, there
is a second interface, between the two layers,
which renders that surface visible in specular
observation. The reflection taking place
between the aqueous layer and the corneal
epithelium should be the third interface of
relevance. However, we have shown that the
surface of the epithelium, due to the pres­
ence of microvilli, is highly irregular and
does not produce a smooth regular reflecting
surface (Guillen, 1986). We know that such a
regular surface is neutralized due to its cov­
erage by mucin. When the mucin layer is
fully hydrated, the difference in refractive
462 The role of tears in contact lens performance and its measurement
index between the mucin and the aqueous
layer is so low that no useful specular reflec­
tion takes place. It is the observation and
measurement of these specular reflections
that permit the evaluation of the pre-ocular
tear film structure.

Narrow field slit lamp technique

The observation of the pre-ocular tear film in
specular reflection with a biomicroscope is not
recent (Marx, 1921; Vogt, 1921; Koby, 1924;
Meesman, 1927; Fisher, 1928; Fisher, 1940, Figure 21.9 Tearscope hand-held cold diffuse
Wolff, 1946, Edmund, 1951; Ehlers, 1965; light source for biomicroscope.
Guillon, 1982; Josephson, 1983; Forst, 1990).
The observation is very easy to carry out.
One simply locates the bright reflection
produced by the slit beam and focuses the
biomicroscope in that region. The observa­
tions are usually made at a medium to high
magnification (X30 to X40). The technique
has, however, two main drawbacks. First,
the light source of the biomicroscope sub­
tends only a small angle. The specular

Figure 21.10 Tearscope used in conjunction with

biomicroscope.

reflection only allows, at the most, the

observation of a 1 mm X 2 mm zone at any
one time. Second, because the slit lamp
biomicroscope is a heat source, it artifi­
cially dries up the tear film and alters its
structure in time. Two simple steps to
minimize these drawbacks are to use a
diffuser in front of the light source to
defocalize the light and increase its angular
subtend, and to decrease the light output of
the slit lamp with the rheostat.

Wide field slit lamp technique

The first solution to the main drawback of
Figure 21.8 First Purkinje image visible during the limited field of useful reflection, inherent
slit lamp biomicroscopy. to the conventional slit lamp technique, was

MICROSCUECTIVE
REFLECTING
OCULAR SURFACE
Figure 21.11 Schematic diagram of wide field lighting system for tear film observation.
Figure 21.12 Tear film appearance under low
magnification when lit up by wide field lighting
system.
introduced by McDonald (1968, 1969). He
positioned a hemispherical close examina­
tion medical lamp in front and slightly to the
temporal side of the subject's eye and
observed, with the biomicroscope, the large
reflection produced by the front surface of
the tear film. This led to important new
understanding, and inspired various work­
Clinical evaluation techniques 463
~
<,
ers to develop different new lighting sys­
tems, including a retro-illuminated cone of
light (Haberick & Lingelback, 1981), a modi­
fication of the standard Bausch and Lomb
keratometer to produce a diffuse light source
(Knoll & Walters, 1985) and the development
of a special hand-held light source for the
observation of the tear film with the biomi­
croscope (Guillon, 1986, 1990). Whereas the
former two did not evolve with time, the last
one has lead to many publications, the ensu­
ing device being the tearscope.
The tearscope is a hand-held instrument
(Fig. 21.9) that is used in conjunction with
the biomicroscope (Fig. 21.10). The slit
light source of the biomicroscope is posi­
tioned nasally to the patient and not
switched on. The tearscope acts as the light
source for the biomicroscope, which is
used at all magnification settings. The tear­
scope lighting system is a diffuse hemi­
spherical light source with a central hole to
allow viewing (Fig. 21.11). The key feature
of the system is the use of a cold cathode
light source that does not create any artifi­
464 The role of tears in contact lens performance and its measurement
cial drying of the tear film during its exami­
nation. One point to remember is that the
light source is diffuse and does not have to
be in focus with the tear surface to obtain a
clear image of the tear film (Fig. 21)2), only
the biomicroscope is required to be in
focus. The aim is to keep the tearscope as S
close to the eye as possible to produce the
largest illuminated zone possible. The
observations of the patterns are made at
X20 to X40 magnification to study the
various details of interest.
General physical interpretation of the
observations
The initial observations made revealed the
presence of interference fringes (Marx, 1921;
Vogt, 1921; Meesman, 1927) and the occa­
sional presence of surface particles (Koby,
1924). These interference fringes were of dif­
ferent colours, due to the light source's wide
spectrum; all were from the first order of
Figure 21.13 First order interference fringes pro­
duced by lipid layer and visible within the first
Purkinje image.
Air .. ~1
n2 .. plate refractive index
d ., plate thickness
S = source
SA = incident ray
Al, = partial reflection
AS = partial refraction
BC =partial reflection
Cl2'" partial refraction
d
AL, and Cl2 will produce interference fringes on
plate P after recombination by lens l
At A: there is a change of phase due to
reflection at a denser medium
Figure 21.14 Optical diagram depicting the prin­
ciple of the formation of constructive interference
fringes (Guillon, 1989).
interference (Fig. 21.13). The reconstructive
interferences observed are produced by the
reflected light at the air-lipid and lipid­
aqueous interfaces (McDonald, 1969) (Fig.
21.14). For a conventional biomicroscope
with non-monochromatic light, the colours
most often visible are brown, indigo and
blue. These correspond respectively to a lipid
layer thickness of 143 nm, 196 nrn and 221 nm
if we take the average refractive index of
lipids to be 1.5. The observation of the tear
film by various workers (Hamano et al., 1979,
1980; Nom, 1979; Guillon 1986; Guillon &
Guillon, 1988c) have shown that most com­
monly the lipidic reflection produces a
colourless pattern (Fig. 21.15) because its
thickness is below the minimal thickness to
produce interference fringes. In that case
 Clinical evaluation techniques 465
Nom (1979) has suggested a semi-qualitative
technique to estimate the lipid thickness.
Nom takes advantage of the phenomenon
described earlier, whereby eyelid closure
squeezes the lipid layer within the' inter­
palpebral aperture and thickens it inversely
proportionally to the palpebral aperture. The
patient is asked to produce a slow voluntary
closure, during which it is possible to
observe the position when the first fringes
appear. The ratio between the full aperture
and the aperture when the first fringes
appear enables us to estimate the thickness Figure 21.16 Increasing order interference fringes
of the lipid layer for that subject. produced by thinning aqueous layer and visible
Early on, during the study of these fringes, within the first Purkinje image.
it was noticed (McDonald, 1969) that these
fringes broke and that, at times, particularly
therefore most visible when the lipid layer is
in front of the contact lens, a second series of
very thin and semi-transparent
interferences became visible; these interfer­
ence fringes, contrary to the lipid fringes,
were of increasing order (Fig. 21.16). The Clinical classifications and interpretation
thickness involved led to the conclusion that
those were produced within the thinning Lipid layer patterns Three aspects of the
aqueous layer (McDonald, 1969; Guillon, lipid layer have been classified: its pattern,
1990). thickness and contamination by particles.
The aqueous pattern is, however, not vis­
Forst (1990) proposes a simple three category
ible most of the time. This is due to the fact
classification (Table 21.1):
that the lipid layer is totally reflective in
specular reflection, and hence hides the 1. Grainy, flowing pattern. This pattern is
underlying pattern. The aqueous pattern is considered as the normal pattern,
present in approximately 70% of the
population.
2. Irregular, yellow-brown pattern. This pat­
tern is considered to be transitional
between the physiological and patho­
logical patterns and encountered in
approximately 27% of the population.
3. Highly coloured pattern. This pattern is

Table 21.1 Lipid pattern classification (after Forst,

1990)
Description Incidence (%)
Grainy/flowing 70
Figure 21.15 Colourless pattern produced by the Irregular/yellow-brown 27
lipid layer and visible within the first Purkinje Highly coloured 3
image.
466 The role of tears in contact lens performance and its measurement
thought to be pathological, affecting
approximately 3°k of the population.
Guillon and co-workers (Guillon, 1986; Guil­
Ion & Guillon, 1988b), basing their investiga­
tions upon the work of several' groups
(McDonald, 1969; Hamano et al., 1979, 1980),
arrived at a six-category classification (Table
21.2). These patterns are listed in order of
increasing thickness:
1. Open meshwork (open marmoreal).
Appearance: the grey, marble-like pat­
tern is due to thicker local lipid areas
found over a thin, lighter colour main
layer. The pattern or meshwork is open
and fairly sparse (Fig. 21.17). This pat­
tern corresponds to the thinnest lipid
layer visible.
Clinical implications: the main clinical
implications are possible contact lens
drying problems due to high evapora­
tion rate associated with very thin lipid
layer.
2. Closed meshwork (closed marmoreal).
Appearance (Fig. 21.8): it is a grey,
marble-like pattern, as previously
described, but with closed meshwork
and tight pattern. The pattern corre­
sponds to a thicker, more stable, more
visible layer than the open meshwork.
Clinical implications: this pattern cor­
responds to a stable POTF and those
subjects are good candidates for both
rigid and soft contact lenses.
3. Flow pattern (Wave pattern). Appearance
(Fig. 21.19): it is a wavy, constantly
Figure 21.17 Open meshwork (open marmoreal)
lipid pattern.
changing pattern during the interblink
period; the most commonly encountered
pattern. The cause of this pattern is poor
mixing of lipids of varying classes. The
differential diagnosis from a marmoreal
pattern is the constantly changing aspect
of the flow pattern and its more round
shape.
Clinical implications: it is generally
a stable tear film, contact lens fitting is
possible with these subjects. One
should however, be aware of the possi­
bility of occasional excess lipid deposi­
tion.
4. Amorphous pattern, Appearance (Fig.
21.20): the pattern has a blue/whitish
appearance due to a thick, well mixed
lipid layer. It is the nonnallipid pattern
amongst non-contact lens wearers.
Clinical implications: it is a highly

Table 21.2 Lipid pattern classification

Description lncidence(%) Estimated thickness (nm)
Open meshwork 21 =15
Closed meshwork 10 =30
~w ~ 3O~~
Amorphous 24 =80
Colour 15 80 to 370
Other 7 variable
 Clinical evaluation techniques 467

Figure 21.18 Closed meshwork (dosed mar­

moreal) lipid pattern.

Figure 21.20 Amorphous lipid pattern.

Figure 21.19 Flow (wave) lipid pattern.

stable tear film, usually good for contact

lens wear with very occasional greasing
problem due to the high volume of lipid
present.
5. Colour fringe pattern. Appearance (Fig.
21.21): the pattern is formed of interfer­
ence colours that spread over different
discrete areas and are confined to yel­ Figure 21.21 Colour fringe lipid pattern.
low, brown, blue and purple. These
coloured Parts are the thickest zones of
the lipid layer with the grey background Oinical implications: it is a very thick
being slightly thinner and not produc­ .stable lipid pattern, contact lens wear is
ing an interference pattern. possible. However, contamination of the
468 The role of tears in contact lens performance and its measurement
contact lens surface by the large amount
of lipids may lead to a destabilization of
the PLTF.
6. Other patterns. Lipid patterns that are
difficult to classify are also encoun­
tered. Usually highly variable coloured
patterns (Fig. 21.22) with possible
mixing of mucous strands. These pat­
terns can be considered as pathological
and a contraindication to contact lens
fitting.
Often at low magnification, when the whole
cornea is viewed at once, more than one
pattern is visible. A particularly common
combination is a main closed meshwork pat­
tern combined with areas of flow pattern
(Fig. 21.23). Another combination that is
often found is that of an amorphous pattern
and a coloured fringe pattern (Fig. 21.24).
Here the interference colours are of first
order yellow and brown and occasionally
blue, which correspond to lipid layer thick­
nesses of 90, 140 and 220 nn, respectively.
Figure 21.22 Abnormal colour fringe lipid pat­
tern.
The properties of any combination lipid
layer are a combination of its two compo­
nents.
Lipid layer thickness evaluation The lipid
layer pattern appearance and visibility give
some indication as to its thickness. The open
meshwork marmoreal pattern is usually
associated with a thin lipid layer, which can
be as thin as 15 nm. Its visibility under X20
to X30 magnification is very poor and is
usually recognizable only by its post-blink
movement. As the lipid layer thickness
increases, the meshwork becomes denser,
changing successively to a closed meshwork
and to a wave pattern for thickness approxi­
mating 80 nm. Above that thickness an
amphorous pattern appears with no distin­
guishable details, followed by colour fringe
pattern indicating usual thicknesses from 90
to 220 nm. Occasionally this layer is much
thicker, exhibiting interference fringes corre­
sponding to a lipid layer thickness of
600 nm.
If one wishes to evaluate the thickness
more precisely, the technique first described
by Nom (1979) is recommended. The thick­
ness can be estimated as:
Figure 21.23 Meshwork/flow combination pat­
tern visible at low magnification.

Figure 21.24 Amorphous/coloured fringe pattern
visible at low magnification.
Lipid layer thickness (nm) =
Palpebral aperture at appearance
200 nm X of first red colour fringe (mm)
Normal palpebra! aperture (mm)
Lipid layer contamination classification The
contamination of the superficial lipid layer
must be assessed regardless of the pattern
observed. The presence of contaminants
within the lipid layer always destabilizes
the tear film. The classification of lipid
contamination should be carried out
according to the types of contaminants and
their severity. One such classification
(Table 21.3) has proved useful. The clinical
Table 21.3 Lipid layer contamination classification
Type
1 = Epithelial/atmospheric debris
2 = Mucous strands
3 = Make-up
Clinical evaluation techniques 469
implications of moderate or severe con­
tamination depends upon the types of con­
taminants.
Regardless of the lipid pattern present it is
essential to assess the level of the tear surface
contamination by mucus strands, epithelial
or atmospheric debris and make-up.
1. Mucus and other surface debris create
localized tear film instabilities, which
reduce the break-up time and favour
deposit formation. Great care should be
taken in fitting those patients and the
use of in-eye rewetting agents is recom­
mended. Daily wear soft contact lenses
should be changed regularly, possibly
every month as part of a planned
replacement programme. Extended wear
should be avoided unless a regular
replacement programme is implemented
or a disposable lens system (e.g. Acu­
vue) is used. Rigid lenses should be
changed regularly, preferably every six
months.
2. Contamination by make-up products
such as oily removers or creams com­
pletely destabilizes the lipid layer (Fig.
21.25) and produces areas of non­
wetting at the contact lens surface.
Patient habits and make-up products
must be changed before contact lens
fitting is undertaken.
Aqueous layer The aqueous layer is only
visible in the pre-lens tear film. Two aspects
of the aqueous layer have been evaluated, its
visibility and estimated thickness.
1. Aqueous layer visibility. The visibility
Severity
0= Absent
1 = Scant
2 = Moderate
3 = Heavy
470 The role of tears in contact lens performance and its measurement
Figure 21.25 Heavy lipid layer contamination by
make-up.
of the aqueous layer, especially the
interference fringes that form within it,
depends upon the reflectivity of the
lipid layer as indicated earlier. The
rating of the visibility of the aqueous
layer (Table 21.4) is therefore an assess­
ment of the lipid layer. The less visible
the aqueous layer, the more reflective,
hence the thicker the lipid layer.
2. Aqueous layer thickness. When visible,
the fringes formed within the aqueous
layer (Fig. 21.26) are simply counted or
their number estimated. This enables us,
assuming a refractive index of 1.337 for
Figure 21.26 Interference fringes formed with the
aqueous layer.
%
45
40
35­
30
25
20
15
10
5
0
0.01 0.03 0.10 0.22 0.40 0.50
PRtSU HEIGHT lmml
Figure 21.27 Lower tear prism height distribution
(by courtesy of Guillon & Guillon, 1989).
the aqueous layer, to estimate its thick­
ness (Table 21.4).
21.3.3 TEAR FILM VOLUME EVALUATION
General remarks
The investigators that have attempted the
assessment of the human tear volume in
clinical practice have all opted for the mea­
surement of the tear prism height (Wolff,
1946; Holly & Lernp, 1977; Lamberts et al.,
1979; Terry, 1984; GuiIlon & Guillon, 1988a;
Port & Asaria, 1990). The techniques used
vary and influence the results obtained.
Port and Asaria (1990), for example, have
described the most sophisticated tech­
nique. They modified a corneal pachometer
to carry out accurate measurements of the
tear prism height. However, they obtained
the lowest values of all investigators; it is
thought that this was due to the relative
drying of the tear prism height by the slit
lamp light.
Proposed clinical technique
We have used a very simple clinical tech­
nique to assess the tear prism height, while
avoiding artificial drying up of the tear
prism. Using the slit lamp biomicroscope,
one sets the slit vertically, in alignment
with the lid margin immediately adjacent

Table 21.4 Aqueous layer property classification
(A) Visibility
Classification
High
Moderate
Poor
Not visible
(B) Fringe number
Classification
Less than 5 fringes
5-10 fringes
More than 10 fringes
Present, not visible fringes
to the tear prism, and alters the slit width until
it apparently matches the height of the tear
prism. In order to obtain a value in milli­
metres, it is only necessary to calibrate once
the rotation of the knob that controls the slit
width using a microscope scale.
In the proposed routine the tear prism
height is measured in three positions:
(1) immediately below the pupil centre;
(2) 5 mm nasally; and (3) temporally. This
approach enables us not only to evaluate
the tear volume, but also to quantify the
regularity of the tear prism. The results
obtained on a unselected population of 121
patients aged 17 to 82 years show the lower
tear prism height to be normally distrib­
uted (Fig. 21.27)/ peaking at 0.22 mm and
giving widely ranging values from a mini­
mum of 0.1 mm to a maximum of 0.8 mm.
The evaluation also shows that, overall,
men had a greater tear prism height than
women and that, in both cases, the tear
prism height decreased with age.
21.3.4 EVALVATION OF THE TEAR FILM
STABILITY
General remarks
The evaluation of the stability of the tear film
is possibly the most important test to evalu­
Clinical evaluation techniques 471
Implication
Very thin/absent lipid layer
Thin lipid layer
Normal
Normal to thick lipid layer
Estimated thicknesstum)
< 1.0
1.0-1.8
1.8-3.5
> 3.5
ate tears in vivo. Whereas the test does not
identify the origin of any anomaly that may
affect the tears, it is the single quantitative
evaluation that indicates whether or not the
tears are maintaining an efficacious wettabil­
ity, with or without contact lenses. The con­
ventional way of measuring tear film stability
has been to measure the tear film break-up
time (BUT). The BUT is defined as the elapsed
time in seconds between eye opening follow­
ing a full blink and the appearance of the first
break within the tear film.
The tear film is not normally visible; tradi­
tionally the BUT has been measured after the
instillation of fluorescein. Fluorescein stains
the tears green; the breaks within this film
appear as black spots. However, as pointed
out by authors who have used the technique
recently (Hamano et al., 1982; Mengher et al.,
1985a; Patel et al., 1985; Guillon & Guillon,
1989a), the results obtained are not reliable.
The main drawback of the technique is its
invasive nature. A drop of 1 or 2% fluores­
cein is instilled in the lower canthus gener­
ally/ or impregnated paper is applied to the
bulbar conjunctiva.
In order to colour the tears, the fluorescein
must break through the lipid layer and totally
disrupt that layer, with the tendency of desta­
bilizing the tear film. At the same time, the
instilled fluorescein introduces a large volume
472 The role of tears in contact lens performance and its measurement

of liquid in relation to the pre-ocular tear
volume, and has the tendency momentarily to
increase the stability of the tear film. Because
the relative influence of the two effects is
highly variable from patient to patient, and
even from time to time, the results obtained
with the technique are unreliable. The values
obtained are not well correlated with the BUT
measured by non-invasive techniques (Meng­
her et al., 1985a; Patel et al., 1985; Guillon &
Guillon, 1989b). The fluorescein BUT therefore
cannot be used, even as a challenge test, and
has the further drawback of being unsuitable
for use while hydrogel lenses are being worn.
The tests of interest are therefore the avail­
able non-invasive tests. The following is a
description of these tests.
Non-invasive break-up time measurements
Introductory remarks
The instruments used to measure the non­
invasive break-up are, to our knowledge,
seven in total. They fall into two categories;
those with a small measurement field and
those with a wide measurement field (Table
21.5).
The narrow field techniques are of limited
use as they involve only a small part of the
cornea. In general, the smaller the field, the
lower the correlation with the full field mea­
surements. A recent study involving the
non-invasive break-up time (NIBUT) mea­
surements by conventional slit lamp specular
reflection; keratometry and hand-held kera­
toscopy, and with the Tearscope (Guillon et
al., 1992), showed that the best prediction of
the wide angle measurements was with the
hand-held "keratoscope. Hence this instru­
ment and the modification to the keratom­
eter target designed by Hirji and Callender,
and known as the IR-CAL modiciation (Hirji
et al., 1989), are the most useful of the narrow
field instruments.
The NIBUT instruments, both narrow and
wide field, also differ according to the nature
of the target. Some have a dark background.

Table 21.5 Non-invasive instruments used to measure the break-up time

Name
Narrow field instruments
Keratometer
Hand-held keratoscope
Slit lamp specular reflection
IR-CAL modified
keratometer
Wide field instruments
Modified bowl perimeter
External illuminator
Tearscope
Comment
Measurement in three posi­
tions (central, nasal, inferior)
Modified, enlarged kerato­
metric mires
Modified lighting system
and additional target
External bilateral illuminator
used with slit lamp biomicro­
scope
External monocular illumina­
tor for slit lamp biomicro­
scope
Reference
Patel et al., 1985
Guillen et al., 1992
Guillen et al., 1992
Guillon et al., 1992
Hirji et al., 1989
LambIe et al., 1976
Mengher et al., 1985b
Young & Efron, 1991
Guillon, 1986

with a bright grid (keratometer, hand-held
keratoscope, IR-CAL modified keratometer,
bowl perimeter), while others have a white
background (slit lamp specular reflection,
external illuminator, tearscope). Not surpris­
ingly, the results obtained vary with the differ­
ent techniques. In fact, it has been argued that
the dark-field instruments do not measure the
break-up time at all, but the time when the tear
film starts to destabilize or thin down (Patel et
al., 1985; Hirji et al., 1989). Also, the problem
with the dark-field systems is that they allow
only BUT measurements, and not evaluation of
the tear film structure.
Measurement techniques
The measurement techniques fall into two cat­
egories, depending upon the type of target
used. For the dark-field background instru­
ments, the practitioner observes the appear­
ance of any deformation of the target or grid.
The time measured has been referred to as the
non-invasive tear thinning time (NITIT); this
is the elapsed time recorded between a full
blink and the appearance of any distortion of
the target or grid. For the white background
instrument and the slit lamp, the practitioner
observes the apparition of any black spots
within the tear pattern. The time measured in
seconds between a full blink and the appari­
tion of a dark spot is the NffiUT. All the
techniques mentioned can be used with and
without contact lenses. The white background
instruments have the further advantage of
enabling the observation of the aqueous thin­
ning up to the apparition of the contact lens
surface. The measurement, in seconds, of the
time elapsed between a full blink and the
appearance of the dried contact lens surface,
for RGP lenses, is called the non-invasive
drying-up time (NIDUT).
Measurement values
The intrinsic values obtained by any practi­
tioner is technique-dependent, as indicated
earlier, but even for a given technique, there
Effects of contact lens wear 473
may be variations due to differences in envi­
ronmental conditions in the consulting
room, such as heat, humidity and air flow,
that offset the results. For this reason we
suggest that, whichever technique is used,
records of the first 50 or so patients tested
should be kept and the practitioner should
establish his/her own mean value and distri­
bution. With the two wide-field techniques
most commonly used the results are as fol­
lows:
1. The modified bowl perimeter (Mengher
et al., 1985b) records, for a normal popu­
lation, a mean value of 47.9 s with a
standard deviation of 5.3 (range 4-214 s)
for the right eye, and 35.1 ± 3.3 s (range
4-150 s) for the left eye. When compar­
ing normal patients and patients with
dry eye symptoms, Mengher et al. found
that 67% of the normal patients, versus
only 37% of the patients in the dry eye
group, had a NIBUT greater than 20 s.
2. For the tearscope, Guillon and Guillon
(l989b) advise stopping any measure­
ment after 45 s of the eye opening, even
if no break-up takes place, in order to
avoid undue discomfort. Studying a
group of 121 subjects (Guillon & Guillon,
1988a) they found that 28.6% had a
break-up time at least equal to 45 s (Fig.
21.28). They also found that the distribu­
tion had another peak at 15 s. This led
them to conclude that a NIBUT of the
pre-ocular tear film of at least 20 s should
be taken as a minimum for problem-free
contact lens fitting. In this study they
also demonstrated that a shorter NIBUT
was associated with a greater incidence
of staining.
21.4 EFFECTS OF CONTACT LENS WEAR
21.4.1 INTRODUCTION
Verv few studies have considered in detail
the effect of contact lenses on the structure
and stability of the tear film. It is our recom­
474 The role of tears in contact lens performance and its measurement
%
40...,....------------------,
35
30
25
20
15
10
5 trast to the POTF lipid layer, which most
o commonly has a thicker flow or amorphous
5 10 15 20 25 30 35
NIBUT IMe)
Figure 21.28 Non-invasive break-up time distri­
bution (by courtesy of Guillon & Guillon, 1989).
mendation that the pre-lens tear film should
be evaluated carefully for all contact lens
patients both at the time of fitting and dur­
ing aftercare. The interaction is complex and
the evaluation of the pre-ocular tear film
alone is not sufficient to predict contact lens
wettability for individual subjects. Also, the
pre-lens tear film (PLTF) changes are precur­
sor to other contact lens surface changes, that
lead to adverse effects such as decrease in
comfort and tear related problems. Monitor­
ing the PLTF during aftercare permits us to
decide whether a conventional soft or rigid
contact lens, or a regularly replaced contact
lens, needs to be changed (Guillon et al.,
1992).
21.4.2 SOFf LENSES
Pre-lens tear film structure
The structure of the PLTF is different to that
of the pre-ocular tear film (POTF) for the
same group of patients, and also differs with
different lens types and wear situations.
Whereas one would like to generalize from
simple short-term experiments as to the
effect of the various parameters, such an
approach is not possible. In particular, the
suggestion that the thickness of the lipid and
aqueous layers are greater with high water
content materials (Young & Efron, 1991), is
too simplistic.
For daytime measurements, a recent study
carried out with hyperthin (0.035 mm), 38%
HEMA lenses (03' 04) (Guillon et al., 1989;
Guillon et al., 1992) shows that, both at issue
and after one week of extended wear, the
PLTF lipid layer is most commonly absent or
very thin (Fig. 21.29); this is a marked con­
40 >45
pattern. Another study has shown that with
new, high water content lenses of conven­
tional thickness, Prima from Igel (67%) and
Bausch & Lomb 70 (70%), the PLTF lipid
layer is predominantly a wave pattern (Fig.
21.30), and hence only marginally thinner
than the POTF lipid layer. It would be easy to
conclude from these two studies that a high
water content contact lens has a thicker lipid
layer. We prefer to limit oar conclusions to
the fact that thick high water content contact
lenses hold a thicker lipid layer than hyper­
thin, low water content contact lenses.
The visibility of the aqueous fringes is
regulated by the relative intensity of the light
reflected at the interfaces of that layer. This is
influenced by a combination of factors,
mainly the lens surface refractive index, the
thickness of the aqueous phase, and the
presence and thickness of a superficial lipid
layer. The visibility of these interference
fringes is at its lowest when a thick, highly
reflective lipid layer is present (as in the
pre-ocular tear film), thus limiting the
amount of transmitted light available for
interference fringe formation in the aqueous
layer. The visibility of the interference
colours produced by the aqueous layer will
also be low when the aqueous layer present
is thick, thereby inducing a further decrease
in the visibility of its fringes by spatial
narrowing and by intensity loss through
successive reflections and by destructive
recombination of successive orders of inter­
ference. When the surface refractive index of
the contact lens material is near to that of
water, such as in high water content contact
lenses, the visibility is also low (Fig. 21.31).
The visibility of the underlying interference
 Effects of contact lens wear 475
60 _Baseline
50 01 Week
40
'# 30

20

10

0 ....- --­
None Spot Band Surface Uds edge
Prelens tear film breakup type at
issue and after 1 week wear

Figure 21.29 Pre-lens tear film lipid layer distribution with hyperthin low water content contact lenses
(Bausch & Lomb 03,04) by courtesy of Guillon et al., 1992).

55
50
45
40

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20
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Do
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Ul
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52 0 E
0
z
Q.
0 u ~ <l: u a
Meshwork fringes

Figure 21.30 Pre-lens tear film lipid layer distribution with conventional thickness high water content
contact lenses (Igel Prima and Bausch & Lomb 70) for both open eye wear 0 and immediately (3 min)
following overnight closed eye wear ~ (by courtesy of Guillon & Guillen, 1989b).

fringes will be maximized when the water
content is low, such as in HEMA lenses. The
surface also plays a part; when of poor qual­
ity the interference fringes will be minimal.
Because of the relative visibility, the thick­
ness of the aqueous fringes can be assessed
principally with low water content contact
lenses (Fig. 31.32), where a thick, invisible
aqueous layer is still the most common fea­
ture.
A significant change in contact lens wetta­
bility takes place during overnight wear. In
an early study with high water content lenses
(Igel, Prima, and Bausch & Lomb 70) (Guillon
476 The role of tears in contact lens performance and its measurement
100

90

80

70

;e 60
!..
eo
g
eo 50
~
'0
E. 40

30

20

10

High Medium lew Not visible

Visibility

Figure 21.31 Pre-lens tear film aqueous layer visibility distribution with conventional thickness high
water content contact lenses (Igel Prima and Bausch & Lomb 70) for both open eye wear 0 and wear
immediately (3 min) following overnight closed eye wear ~ (by courtesy of Guillon & Guillen, 1989b).

60 _Baseline
50 01 Week
40
<fl. 30
20
10
o '-----I:=L..­
Absent <5 5-10 >10 Thick not
Fringe no visible
Prelens tear film aqueous layer
at issue and after 1 week wear

Figure 21.32 Pre-lens tear film aqueous layer fringe distribution with hyperthin low water content
contact lenses (Bausch & Lomb 03,04) (by courtesy of Guillon et al., 1992).

& Guillon, 1989c), we have shown that
approximately 3 min after eye opening, a
thicker lipid (Fig. 21.30) was present than
during open eye wear; at that time the aque­
ous layer was essentially invisible (Fig.
21.31). In addition, soon after eye opening, a
much thicker mucous coating was also vis­
ible. A recent study (Guillon & Guillon,
1991), with disposable lenses (Acuvue and
NewVues) involving both the evaluation of
the PLTF immediately upon eye opening and
3 min later, has greatly increased our under­

standing of the change in wettability during
overnight wear. Immediately upon eye open­
ing the aqueous,layer is usually absent and
the tear film is a very thick, lipid-coated
mucin layer. With the initiation of reflex
blinking, the aqueous part of the tear film
quickly reforms but, because the mucous
coating was better than normal, a thick aque­
ous layer forms within a few blinks, hence
the observations made in the first study were
confirmed in the second, more extensive
study. A clinical implication of those find­
ings is the reduced contact lens movement
present at waking compared to pre-closed
eye wear. This phenomenon is due to the
viscous tear film that reduces movement and
not to the physical tightening of the lens fit
due to water loss and lens steepening.
Pre-lens tear film stability
Young and Efron (1991), in addition to find­
ing a change in PLTF structure associated
with lens water content, also found a connec­
50
45
40
35
15
10
ou...o--~~,-
0<5 5 <1010 <1515 <2020<2525 <30
PLTF NIBUT Seconds
Figure 21.33 Pre-lens tear film non invasive break-up time distribution (0 open eye; ~ closed eye) (by
courtesy of Guillon & Guillon, 1989b).
Effects of contact lens wear 477
tion between water content and PLTF stabil­
ity. This study, however, did not consider
other factors, such as contact lens thickness
and the nature of lens surface characteristics.
Our studies have shown that the PLTF
stability measured by the NIBUT with the
tearscope is lower than that of the POTF,
before contact lens insertion, for the same
group of patients (Guillon & Guillon, 1988c).
In this investigation the difference was
highly significant, with only 2% of eyes with
a PLTF NIBUT of 45 s or more versus 60% for
the POTF NIBUT. Also, the PLTF NIBUT,
both with conventional thickness high water
content lenses (Guillon & Guillon, 1988c) and
with low water content lenses (Guillon et al.,
1992), peaked between 5 and 10 s. The lens
geometry also affects the PLTF for HEMA
lenses. Lenses with a standard thickness and
the ultra-thin lenses such as Z6 (Hydron) and
U3 (Bausch & Lomb) have a thicker, more
stable PLTF than the hyperthin lenses such
as Z4 (Hydron) and 03-04 (Bausch & Lomb),
where the lipid layer at times may become
<45 45>
478 The role of tears in contact lens performance and its measurement
invisible. In association with the changes in
tear film structure that take place overnight,
the PLTF stability is greatly altered. Immedi­
ately upon eye opening the PLTF NIBUT is,
in the majority of cases, extremely short (less
than 1 s), but, within a few minutes, becomes
longer than the PLTF found during normal
open eye wear (Fig. 21.33).
An important aspect of the measurement
of the break-up time is the classification of
the position and type of breaks that take
place within the tear film. We classified the
types of break in five categories: none, spot/
band, surface and lid edge breaks. Spot/
band and surface breaks are increasing levels
of break severity. Most commonly a 'band' or
'surface' break takes place (Fig. 21.34); a high
incidence of the latter is an indication of poor
in vivo wettability, whereas a high incidence
of spot break is usually associated with a
stable pre-lens tear film.
The location of the initial break is an
important piece of clinical information. Most
often the initial break takes place in the
upper and/or lower quadrants, and very
rarely in the nasal and temporal quadrants
(Fig. 21.35). The reason for this is the destabi­
lization of the tear film at the junction
between the lid tear meniscus and the pre­
ocular tear film. This factor has been shown
to be associated with corneal desiccation
(Guillon et al., 1990). Another aspect of the
location of the initial break is its carity in the
central part of the contact lens (approxi­
mately SOlo). The implication is that all the
narrow field instruments will fail to detect
the initial break, and hence fail to measure
the true NIBUT, in the majority of cases.
Finally, with regard to hydrogel lenses, we
have shown (Guillon et al., 1992) using the
NIBUT measurement as a means of deter­
mining when a lens needs to be changed,
a phenomenon that is highly patient­
dependent. Our recommendation is to change
a contact lens if the NlBUT is decreased by >
25% lower than the base line value and is less
than 10 s.
21.4.3 RIGID LENSES
Pre-lens tear film structure
Lipid layer
Contrary to the hydrogel lenses, the charac­
teristics of the PLTF over rigid contact lenses
are more affected by the lens geometry and
associated lens movements than by the

50

40
~
z;
Q) 30
o
c:
Q)
"0
'0 20
E
10

0
Cent Nas Inf Temp Sup >1 Zone

Incidence of pre-lens tear film initial break

position appearance for overall study

Figure 21.34 Distribution of different types of break that take place at the front of hyperthin low water
content contact lenses (Bausch & lomb 03,04) (by courtesy of Guillon et al., 1992).

50
40
30
~
o
20
10
o Flow
Figure 21.35 Location of initial Pl.TF break for high wat-er content contact lenses (Igel 77) (by courtesy
of Guillon et al., 1990).
nature of the material (Madigan & Holden,
1986). This, however, does not imply that
material differences have no influence on
wettability (Benjamin, 1987). Typically, in
front of PMMA or RGP lenses, the lipid layer
is absent or so thin that it is neither visible
nor effective in preventing rapid destabiliza­
tion of the PLTF. Therefore, in addition to
classifying the lipid pattern when visible, we
rate the amount of the lens surface covered
by lipids (Guillon et al., 1989):
O. Lipid coverage absent.
1. Lipid coverage> 0% and ~ 25%.
2. Lipid coverage> 25% and ~ 50%.
3. Lipid coverage> 50% and ~ 75%.
4. Lipid coverage> 75% and ~ 100%.
Typically the pre-lens lipid layer on poly­
(methyl methacrylate) (PMMA) lenses is
invisible and the aqueous layer forms a con­
tinuously thinning wedge, the thickness of
which can be measured by the photography
of the interference fringe pattern and the
determination of the orders of interference.
In the case of PMMA lenses, the intensity of
the coloured fringes formed within the aque­
ous phase is at its maximum due to the
absence of lipid layer interference, the thin­
ness of the aqueous layer, and the high
refractive index of the contact lens material.
The lipid layer is either totally absent or
Effects of contact lens wear 479
• BaseUne
01 Week
Amor Colour Other
phous
only partially covers the PLTF of rigid contact
lenses. This absence of lipid Stems to be
independent of the material used, as it has
been observed in approximately the same
percentage (45%) of new lenses with materi­
als as different as PMMA, silicon acrylates
and fluorosilicon acrylates. Furthermore, as
these lenses are worn, the incidence of cases
showing no lipid coverage increases, sug­
gesting a more abnormal pre-lens tear film
with long-term wear. When present, the
lipid layer is always thin, as demonstrated by
the observed PLTF lipid patterns.
With RGP contact lens wearers, the ocular
surface away from the lens is covered by a
normal POTF with the superficial lipid layer
visible. We believe that the edge of the
contact lens acts as a barrier to the propaga­
tion of the superficial lipid layer over the
surface of the thin, unstable, aqueous pre­
lens tear film.
Aqueous layer
PLTF aqueous thicknesses of up to 2.5 urn
have been measured in front of PMMA cor­
neal lenses. These thicknesses increase to up
to 3.5 urn with the administration of one
drop of wetting solution containing 5% poly­
vinyl pyrrolidine. However, even over this
aqueous film of increased thickness, no vis­
480 The role of tears in contact lens performance and its measurement
ible lipid layer has been observed.
The aqueous layer in front of RGP lenses is
also thin, and has been estimated to be
between 1 and 4 urn, most commonly 2 to
3 urn with silicon acrylates and fluorosilicon
acrylates. The aqueous layer thickness seems
to be patient-dependent but not material-,
lens-care- or time-dependent over a six­
month investigation. The mucous coating
found on the lens front surface of lenses that
show good aqueous coverage and good wet­
tability is always slight to moderate.
Two studies have recently confirmed the
above statement: (1) in a daily wear study of
six-months duration with Boston IV, Parap­
enn EW and Equalens I, the lipid layer was
absent in 44% of cases and covered the
whole contact lens surface in 22% of cases.
The mean aqueous thickness was estimated
at approximately 2 JA.m in that study; (2) in an
extended wear study with Equalens 2 and
Fluoropenn, also of a six-month duration,
the lenses generally supported a thin lipid
layer and aqueous layer of approximately
4~.
Tear film stability
The tear film stability is indicated by the
break-up time of the tear film at the front
surface of the contact lens recorded by the
non-invasive technique (PLTF NlBUT).
PLTIF NlBUT measurements for rigid
lenses show that the pre-rigid lens film is far
more unstable than the pre-ocular tear film.
For example, a group of subjects with a POTF
NlBUT of 26.3 s had a PLTF NlBUT of 4.7 s
with Excel 02 lenses (Guillon & Guillon,
1988b), which are reported to have good
wetting characteristics and a zero degree
wetting angle. In fact the average PLTF
NlBUT of rigid lenses is approximately 4 to
6 s, hence even shorter than that of hydrogel
lenses (Guillon & Guillon, 1988c). Small
material differences have been reported. A
significantly longer PLTF NlBUT was
observed with modified PMMA and a low
Dk RGP materials, with similar in vitro wet­
ting angle, than with conventional PMMA
lenses (Lydon & Guillon, 1986). Similarly the
PLTF NlBUT of fluorosilicon acrylate
(Equalens 1) has been reported to be longer
than the PLTF NlBUT of two silicon acrylate
materials (Boston IV and Paraperm EW)
(Guillon & Guillon, 1988d). The latter con­
firms a previous report indicating also a low
incidence of deposits with fluorinated poly­
mers (Feldman et al., 1987). However, more
importantly than the average response, it is
interesting to note that some individuals do
perform better with certain RGP materials,
and therefore an extended trial fitting with
different materials is useful in problem cases.
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