UNIT 0 CONTACT LENS: HISTORICAL REVIEW

CL vs Glasses

Why do we use CLs?

• Mostly to neutralize refractive errors

• Therapeutic CLs

• Cosmetic CLs

Sir JOHN HERSCHEL (1845) FIRST CL (all CLs are made of glass until 1930): Correction of
irregular corneal astigmatism (effect of the tear film). Shape of the CL is determined by
creating a mould made of clay

PRIMERA CL (todas las CL son de cristal hasta 1930): Corrección del astigmatismo corneal
irregular (efecto de la película lagrimal). La forma de la CL se determina creando un molde
hecho de arcilla.

DA VINVI: The first idea: to replace the anterior corneal surface with another surface of known
radius, with a liquid between both surfaces (Da Vinci does not manufacture any CL, only
presents the idea)

La primera idea: sustituir la superficie anterior de la córnea por otra de radio conocido, con un
líquido entre ambas superficies (Da Vinci no fabrica ninguna CL, sólo presenta la idea)

Keratometer invented by Helmholtz (1885) & Javal (1881)

Fick (1888): Eugène Kalt (1888):

Müller (1889): Zeiss (1920):

In 1930 the first plastic CLs are manufactured. First, of PMMA

PMMA for scleral CLs

• William Fleinbloom (1936): CLs with a part of glass, a part of PMMA

• Ernest Mullen (describes the refractive effect of the tear film under the CL) and
Theodore Obrig (uses sodium fluorescein to stain the tear film and assess CL fit)

• Kevin M. Tuohy (1946)

Hydrogel CLs

• Otto Wichterle & Drashoslav Lim (1954)

• HEMA (38% WC)

• Spin casted

First commercially available hydrogel CLs

• FDA approval. Bausch & Lomb. Soflens (1971)

• Purely silicone CLs: Silsoft (Bausch & Lomb, 1981).

First Rigid Gas Permeable CLs

Gaylord, Polycon (1972)

– Allows oxygen to pass through

– Commonly known as RGP (now only rigid: corneal, scleral, etc.)

Disposable CLs

• Vistakon (1988) (Acuvue)

• Bausch & Lomb (1988) (Seequence)

• Ciba Vision (1988) (NewVues)

(Not daily disposable at first)

Silicone-hydrogel CLs

• High oxygen permeability (2000):

– Night and Day/ O2Optix (Ciba)

– PureVision (Bausch & Lomb)

– Acuvue Advance/OASYS (Johnson & Johnson)

– Biofinity (Cooper Vision)

– Many others….

UNIT 1 CONTACT LENS: Corneal keratometry and

topography
Anterior corneal radius

• Mean anterior corneal radius 7.8 mm

• In general:

– Children: spherical

– Youth: with the rule astigmatism

– Adults: spherical

– Elderly: against the rule astigmatism

Corneal eccentricity / asphericity

• Shape factor: p = 1-2

• Eccentricity: 

• Asphericity: Q = - 2
Mean value of  = 0.47

• So, to describe the corneal shape we should always provide a value of apical radius (or
2 if astigmatic) + a value of  to show how this apical radius changes as we move from
the center.

Por lo tanto, para describir la forma de la córnea debemos proporcionar siempre un

valor de radio apical (o 2 si es astigmático) + un valor de e para mostrar cómo cambia
este radio apical a medida que nos alejamos del centro.

• A single value of  may not even be enough, as the rate of change may change towards
the periphery.

Un único valor de e puede no ser suficiente, ya que la tasa de cambio puede cambiar
hacia la periferia.

• In some instruments it is possible to obtain values of  for different corneal diameters

and meridians.

Posterior corneal radius

• Mean posterior corneal radius 10% less than anterior corneal radius

– For a 7.8 mm anterior radius: 7.8 – (0.78) = 7.02 mm

– OMG!! The cornea in air is a negative lens!

• Therefore it is thinner towards the center and thicker towards the periphery

Total corneal power

• P total = P ant + P post + effect thickness (negligible)

• P = (n’ – n) / R

• n cornea (average) = 1.376

• n aqueous = 1.336

Keratometry

• Useful to determine the two main anterior radii of the central (3.6 mm in diameter
approx.) of the cornea

The cornea acts like a convex mirror and creates a virtual image, upright and smaller than the
object (First image of Purkinje, P1)

• Corneal radius (R) is determined from the distance between

keratometer and the cornea (d), the separation between the
reflected keratometer mires (image: h’) and the actual
separation of the mires (object: h).

El radio corneal (R) se determina a partir de la distancia entre el

queratómetro y la córnea (d), la separación entre los mires del
queratómetro reflejados (imagen: h') y la separación real de los
mires (objeto: h).
 • So, it is very important to see the image in focus (to be at the right distance). R=2dh’/h

• Provides corneal power derived from R ant and nk = 1.3375

• AND assuming that R post = R ant – 10% R ant

• Therefore, only valid for normal corneas!

• Which corneas are not normal?

• Keratoconus

• Refractive surgery

• Normal patients not located near the average!

Keratometer types

• Helmholtz: Measures both meridians at the same time. Fixed mires. Internal mobile
prism system. Move far back and approach slowly until “something is seen in focus”.
Move horizontally and vertically until mires are centered on the central cornea. Adjust
distance precisely. Inferior right mire must be single. The black cross of the eyepiece
must be inside the inferior right mire. Approach or separate mires to measure
horizontal and vertical at the same time. May need to rotate the body of the
instrument if astigmatism is not at 90° or 180°.

Mide ambos meridianos al mismo tiempo. Muros fijos. Sistema de prisma móvil
interno. Mover lejos y acercarse lentamente hasta que "se vea algo enfocado". Mover
horizontal y verticalmente hasta que los mires estén centrados en la córnea central.
Ajustar la distancia con precisión. El mires inferior derecho debe ser único. La cruz
negra del ocular debe estar dentro del mires inferior derecho. Aproximar o separar los
mires para medir la horizontal y la vertical al mismo tiempo. Puede ser necesario girar
el cuerpo del instrumento si el astigmatismo no está a 90° o 180°.

• Javal-Schiötz: Measures a meridian at a time. Mobiles mires. Non-mobile prism

system. Move far back and approach slowly until “something is seen in focus”. Move
horizontally and vertically until mires are centered on the central cornea. Adjust
distance precisely. Mires must be in sharp focus. The black oblique line of the eyepiece
must cross over the center of the image. First horizontal meridian, then vertical (after
rotating 90 degrees)

Mide un meridiano a la vez. Muros móviles. Sistema de prisma no móvil. Muévete

hacia atrás y acércate lentamente hasta que "se vea algo enfocado". Mover horizontal
y verticalmente hasta que los mires estén centrados en la córnea central. Ajustar la
distancia con precisión. Los mires deben estar bien enfocados. La línea oblicua negra
del ocular debe cruzar sobre el centro de la imagen. Primero el meridiano horizontal,
luego el vertical (después de girar 90 grados)

The keratometer must be calibrated with calibration spheres of know radii. Adjust the
eyepiece (very important to ensure the mires are seen in sharp focus at the correct (d)
distance. Adjust de position of the patient. The patient must fixate the light or fixation point
(so that the instrument is aligned with the corneal apex).
El queratómetro debe calibrarse con esferas de calibración de radios conocidos. Ajustar el
ocular (muy importante para asegurarse de que los mires se ven bien enfocados a la distancia
(d) correcta. Ajustar la posición del paciente. El paciente debe fijar la luz o el punto de fijación
(para que el instrumento esté alineado con el ápice corneal).

Notation

• RE: 7.80 mm (43.25 D) @ 180° // 7.90 mm (42.75 D) @ 90°

• LE: 8.20 mm (41.00 D) @ 10° // 8.25 mm (41.25 D) @ 100°

• Corneal astigmatism: - |subtract values| x meridian of less power

• Corneal astigmatism RE: -0.50 x 90°

• Corneal astigmatism LE: -0.25 x 10°

Types of astigmatism

• With the rule: maximum power at 90 ± 20°

• Against the rule: maximum power at 180 ± 20°

• Oblique: maximum power at 45° ± 25°

• Corneal astigmatism RE: -0.50 x 90° -- against the rule

• Corneal astigmatism LE: -0.25 x 10° -- with the rule

• x 90° denotes the direction of the axis, therefore the meridian with the highest
curvature (maximum power) is at 180°

• We are saying the same as in Optometry, but in CLs we prefer to talk about corneal
“topography” instead of refractive power.

• Refractive astigmatism = Corneal astigmatism + Internal astigmatism

• In CLs we will not be using Javal’s rule because: It refers to keratometry astigmatism,
and we know that this is valid only for “normal corneas”. It is based on “statistics”.
Useful in general, not very useful for a particular patient. We can actually measure
posterior corneal astigmatism now!

Corneal Topography

Based on the Placido Disc, and the keratometry principle. The software of the topographer
determines radii from the distance (h’) between two consecutive reflected circles at different
degree intervals.

• Larger corneal area (up to 8 mm in topography and up to 12 mm in tomography, e.g.,

Pentacam)

• Radii at each point. Therefore, we can know local changes, eccentricity, etc.

• Some instruments provide information of both corneal surfaces, corneal thickness,

anterior chamber depth, anterior chamber angle, etc
Curvature maps: axial or tangential

• Axial (or sagittal) map: radius of a point is “averaged” from that point to the visual axis.
Not good at showing local abrupt changes, smoother.

El radio de un punto se "promedia" desde ese punto hasta el eje visual. No es bueno
para mostrar los cambios locales abruptos, más suaves.

• Tangential map: radius of a point is compared to next point (from next ring). Very good
at showing local changes, such as exact position and shape of a keratoconus.

El radio de un punto se compara con el siguiente punto (del siguiente anillo). Es muy
bueno para mostrar cambios locales, como la posición exacta y la forma de un
queratocono.

Elevation map

Distance (vertical) between the cornea of the patient and a

known surface of reference, usually an sphere

Pentacam (corneal tomography)

– Scheimpflug imaging technique (camera

rotation of 180°, from 130° to 310°)

– Blue LED at 475 nm

– Over 500 real data elevation points

– Good reproducibility and repeatability

– Additional camera to compensate for small deviations of fixation.

Ocular and corneal aberrations

– Many topographers provide corneal aberrations (anterior, posterior or total

corneal aberrations).

– These aberrations are not measured, but determined mathematically from

elevation data.

– All aberrometers provide ocular aberrations, including corneal and lens

aberrations.
 – Only if they include a topographer will they provide corneal aberrations as
well.

UNIT 2 CONTACT LENS: CORNEAL, CONJUNCTIVAL AND

EYELID ANATOMY AND PHYSIOLOGY
Cornal Innervation

• Long posterior ciliary nerves from the ophthalmic branch of the trigeminal nerve

• These nerves enter the cornea at anterior half of the stroma and ascend towards the
surface of the epithelium. They “normally” do not have myelin (from 1.5 mm of
limbus).

Estos nervios entran en la córnea en la mitad anterior del estroma y ascienden hacia la
superficie del epitelio. "Normalmente" no tienen mielina (a partir de 1,5 mm del limbo).

Corneal vascularization

• The cornea is an avascular tissue. Capillaries reach the limbal area and do not enter
the cornea (in normal conditions).

• When there is hypoxia (e.g., caused by a CL), capillaries may cross the limbus and enter
the cornea.

Layers of the cornea

• Epithelium (and basal membrane)

• Bowman membrane (now known as Anterior limiting lamina)

• Stroma

• Descemet membrane (now known as Posterior limiting lamina)

• Endothelium

Corneal epithelium

• 10% of corneal thickness (50 µm)

• Approx. 5 cellular layers

• Anterior surface not regular (microvilli and plicae)

• Stem cells at the limbus able to regenerate the whole epithelium (important for
certain types of refractive surgery)

• Three types of cells:

 Basal cells (mitosis, adhered to the basal membrane through

hemidesmosomes)
 Wing cells
 Surface cells
 • The whole epithelium renews all cells approx. every 10 days. At a given time, about 4%
of the cells of the epithelium are undergoing mitosis

Stroma

• 90% of corneal thickness (470 µm)

• Composition:

– Collagen: type I

– Keratocytes: wound healing function, matrix generation

– Matrix

• Collagen fibers form about 250 collagenous lamellae (about 300 at the central cornea,
500 at the periphery).

• Collagen fibers are separated about 57 nm at the center of the cornea, about 62 nm at
the periphery.

• 66% of fibers follow a nasal-temporal or superior-inferior orientation.

• These fibers and lamellae provide biomechanical properties to the cornea (resist IOP).

• Anterior and posterior stroma are very different:

– Anterior: the anterior 100 µm of the stroma has 50% more lamellae than the
posterior stroma. Lamellae are thinner but intertwined. More resistant. Very
compact, no spaces. Highest density of keratocytes.

los 100 µm anteriores del estroma tienen un 50% más de laminillas que el
estroma posterior. Las láminas son más finas pero están entrelazadas. Más
resistentes. Muy compacto, sin espacios. Mayor densidad de queratocitos.

– Posterior: lamellae are thicker but disposed one upon the other with little
intertwining. Less resistant. It contains spaces where water from the aqueous
humor may enter.

Las láminas son más gruesas pero están dispuestas una sobre otra con poco
entrelazamiento. Es menos resistente. Contiene espacios por donde puede
entrar el agua del humor acuoso.

– This difference is very important when considering refractive surgery. Most

procedures remove anterior stroma (surface ablation procedures, LASIK,
SMILE…).

Corneal endothelium

• Single layer or cells without mitosis (does not regenerate if cells are lost)

• Natural cell lost of 0.6% per year

• Minimum of 2800 cells /mm2 to implant a IOL of anterior chamber (and 3200 µm of
anterior chamber depth)
What is required for the cornea to be transparent?

• Collagen fibers at the correct distance from one another

– Traumatism to stroma, anterior or posterior limiting laminae does not

regenerate and may leave permanent scar and loss of vision if central

• Absence of blood vessels

• Regularity of corneal surface (provided by tear film)

• Absence of myelin in corneal nerves

Corneal Physiology Oxygen in open eye and closed eye conditions

How do we measure corneal oxygen uptake?

• Polarographic technique.
• Sensor with a known volume of oxygen in contact with the anterior corneal surface.
• Oxygen moves from the sensor to the cornea. Volume / time.
• Epithelium, stromal, endothelium consumption: 2:2:1 ratio
• Stromal consumption only when keratocytes are active, otherwise ratio is 4:0:1

Why does the cornea require energy?

• Epithelium: to regenerate through mitosis of basal cells.

• Stroma: to repair in case of trauma through activation of keratocytes and matrix

formation (however, if collagen distribution is disrupted, permanent scar is possible)

• Endothelium: to return water entering the posterior cornea to the aqueous humor
through the ion pump (the ion pump moves ions, not water: water follows along out of
the stroma to reduce and equilibrate concentration of ions).

• Remember: the cornea does not have blood vessels to bring oxygen and nutrients!

Corneal oxygen metabolism and energy pathways

• Minimum O2 level at corneal epithelium: 10% (Holden et al)

• Metabolized at the epithelium through three pathways:

 – Anaerobic pathway:

• Embden-Meyerhof anaerobic glycolysis (2 ATP)

• Hexose monophosphate Shunt (1 ATP)

• Products: lactate, which migrates towards posterior cornea and

anterior chamber

– Aerobic pathway:

• Tricarboxylic acid cycle, also known as the Krebs cycle (36 ATP)

• Products: CO2 and water, which migrate towards corneal surface and
tear film

Alterations to the corneal environment when inserting a CL

• Oxygen restriction

• Difficulty expelling the remnants of metabolism (although CL transmissibility to CO2 is

higher than to O2)
Slight increase (1.5°C) in eye temperature, leading to higher rate of metabolism
(corneal mean temperature 32°C)

• Changes in tear chemistry: increase in CO2 (acidification), decrease in osmolarity (less

water evaporation)

Oxygen restriction

• Oxygen reaching the cornea will depend on:

– Diffusion through the lens (oxygen transmissibility: Dk/t)

– CL diameter (RCL smaller than the cornea, soft CL cover the whole corneal
surface)
Tear exchange underneath the CL:

• RCL: 10 to 20% tear exchange with each blink

• Soft CL: 1% tear exchange with each blink

• This depends on type of CL fit (steep, flat, etc.)

Physiological edema

• Closed eye: 8% of oxygen at the epithelium, but 10% needed for correct aerobic
metabolism….
• RESULT: corneal physiological (normal) edema of 2 to 4% on opening the eyes in the
morning. Water has entered the cornea at the endothelium / aqueous humor interface
 and accumulated at the posterior stroma, leading to slight swelling (increase in corneal
thickness).
• Water tends to enter the cornea when there is hypoxia, leading to anaerobic
metabolism and lactate migration towards posterior cornea. Water from aqueous
humor enters to equilibrate concentration of ions (osmotic equilibrium). This happens
precisely when the endothelium has less energy for the ion pump!
• Energy reserve: 30 minutes
• Maximum edema on eye closure: at 4 hours
• Increased oxygen demand during the first 10 minutes after eye opening

Corneal edema (non physiological)

• If thickness increases over 8%, it may cause:

 Slight blurred vision
 Contrast sensitivity reduction
 Photophobia, halos, glare…
• Why does edema increase over physiological values?

 Using a CL with low Dk/t at night (oxygen available on the cornea will be even
less than 8%)

 Inserting a CL immediately after eye opening (without respecting the 10

minute high oxygen demand period)

 Endothelium not functioning properly (due to previous or current

Other consequences of hypoxia: Microcysts

• Disorganized cellular material

• They originate at the level of the basal cells of the epithelium (abnormal mitosis due to
lack of energy)

• They show a characteristic shadow when seen on the slit-lamp

• They may show fluorescein staining when they reach the corneal surface

Other consequences of hypoxia: Neovascularization

• Growth of vessels from the limbus towards the cornea.

• Caused directly by hypoxia or by hypoxia mediated inflammation.

• Once resolved, ghost vessels may remain that could refill very fast if hypoxia occurs
again
CONJUNCTIVA

Alterations to the conjunctiva

• CONJUNTIVAL HYPEREMIA

– Mechanical irritation: CL edge lift

– Reaction to surface deposits in CL

– Hypoxia, hypercapnia (increased CO2)

– Toxicity to solution

• Papillary conjunctivitis

– Reaction to surface deposits in CL (mainly denaturalized lysozyme), increased

with overnight wear.

– Mechanical friction of the CL

– Allergic reaction (not necessarily related to CL).

• Superior limbic keratoconjunctivitis

– Commonly related to CL fit and movement (too step)

• Lid-parallel conjunctival folds (LIPCOF)

– Commonly related to dry eye and CL discomfort, and to LWE (see later)

– CL wearers and non wearers

Limbus

• Annular zone from 1.5 to 2 mm

• Corneal epithelium forms conjunctival epithelium. Corneal stroma forms conjunctival

connective tissue. The rest of the corneal layers disappear.
 • Site of growth of new vessels (hypoxia)/neovascularization.
Stem cells.

Eyelids

Blinking

• Temporal inhibition of Levator muscle

• Activation of orbicular muscle

• Blinking is needed to:

– Correctly distribute tear film over the ocular surface: on eye closure, it
compresses the tear film like a curtain.

– Secrete lipids from Meibomian glands.

– Drain tear film through the lachrymal puncta at the nasal canthus.

• Frequency: Blinks per minute

• Amplitude: Complete or incomplete

• Distribution: Blinking regularity or blinking clusters

Visual suppression and blinking

• Each blink is associated with a loss of visual information of 400 ms: Blink suppression.
We are not aware of closing the eyes!

• There is a synchronization of blinks to minimize information loss

Cognitive and attentional aspects

• Nerve terminals (cold) detect ocular surface dryness.

• Internal “pacemaker” associated with attentional and cognitive factors. This

mechanism may inhibit normal spontaneous blink (we forget to blink because we are
paying too much attention to something else).

Marcapasos interno asociado a factores atencionales y cognitivos. Este mecanismo

puede inhibir el parpadeo espontáneo normal (nos olvidamos de parpadear porque
estamos prestando demasiada atención a otra cosa).

Saccades and blinks

• Saccadic suppression: similar to blink

suppression during saccadic eye
movements.

• Blinks with large amplitude saccades

Displays: Ocular dryness

• Ergonomic factors and other:

– Distance to the screen, light and unwanted reflections, ambient illumination,

type and size of font, contrast, etc.

• Ocular dryness

– Related to a reduction in blinking frequency, incomplete blinks and loss of

regularity.

– Increase in inter-palpebral distance: related to screen position. Laptop,

handheld device versus desktop PC.

– Both factors lead to: increase in tear film evaporation.

– More relevant at the inferior part of the cornea/conjunctiva

– Localized contact lens dehydration

• Ocular dryness: prevalence

 Between 30 and 70% of computer users, with more severe symptoms in

women, users older than 30 years and in those using their devices more than 4
hours per day.
 Symptoms increase towards the end of the day
 More on dry eye in T3!

MGD (Meibomian Gland Dysfunction)

• Insufficiency in lipid production.

• Altered lipids.
• Increased tear film evaporation.

UNIT 3 CONTACT LENS: TEAR FILM

The tear film is useful for…

• It presents the most significant refractive transition of the eye: n H2O=1.336 vs n

cornea=1.376 vs n air=1).

• It gives uniformity to the corneal surface, covering the microvilli and plicae of the
surface epithelial cells. This facilitates corneal transparency.

• It provides O2 to the cornea and eliminates CO2, dead cells, dust particles....
Atmospheric O2 first diffuses to the tear film before reaching the cornea.

• It provides lubrification to the anterior surface, offering comfort during and between
eyeblinks.
 • It contains antimicrobial agents to prevent
anterior ocular surface infection and provide
stability to natural ocular microbiome.

• Stabilizes pH and osmolarity of the ocular

surface.

• Regulates and maintains overall anterior

ocular surface homeostasis.

Tear film secretion

How thick is the tear film?

• The thickness of the tear film depends on the time since the last blink and on the
position on the cornea:

– Maximum stability at 2 seconds after blink (approx.)

– It is recommended to carry out measurement 2 second after the last blink (for
example for corneal topography).

– Total thickness: 5-10 microns

Lipid layer

• Thickness of 1% of the total.

• Composed basically of cholesterol and phospholipids.

– Polar internal layer with hydrophilic part in contact with the aqueous layer

– Non-polar hydrophobic external layer

• Main function: to prevent the evaporation of the tear film.

• Secreted by meibomian glands (less by Zeiss and Moll).

– Complete and regular blinking is needed.

Aqueous layer

• Composition:
  Water: 98%
 Electrolytes: K+, Ca2+ & Mg 2+
 Vitamins A & C
 Dead epithelial cells
 About 2000 types of proteins, amongst which many bactericidal agents:
• Lysozyme: 25% of tear proteins. Decreases in chronic eye conditions. It
is synthesized in the epithelial cells of the main and accessory lacrimal
glands. It destroys mucopolysaccharides in the bacterial wall.
Lactoferrin: provides a boost to immunologic system
• IgA: prevents bacterial adhesion to epithelial cells
• Beta-lysine

Mucin layer

• It is produced by conjunctival goblet cells (soluble mucin) or by corneal epithelial cells

(transmembrane mucin):

• It offers viscosity to the tear (soluble mucin mixed within the aqueous layer, MUC
5AC).

• It converts the corneal surface into an hydrophilic surface and prevents tear rupture by
coating precipitated lipids (transmembrane mucin, glycocalyx, MUC 1, 4, 16).

Chemical properties of tear film

• pH: (7.14 - 7.82), with an average of 7.45.

• Osmolarity of 300-310 mOsm/l (mean of 308). Varies with:

‒ Blink frequency, completeness and regularity

Tear volume

‒ Pathological alterations
CL wear (it may decrease osmolarity at the post-lens tear film but increase it at
the pre-lens tear film): related to evaporation.

Tear distribution

• Upper eyelid movement: mainly vertical.

• Movement of the lower eyelid: mainly nasal.

Elimination of the tear film

• Evaporation

• Drainage through the lacrimal puncta towards the lacrimal sac.

TEAR FILM EVALUATION

• Clinical case history

 – Use of standardized questionnaires in the diagnosis of dry eye and marginal
tear film deficiency:

• McMonnies Dry Eye Questionnaire, developed by McMonnies y Ho.

• Contact Lens Dry Eye Questionnaire, developed by Begley et al.

– 36 items.

– Some questions are specific for contact lens related dry eye

– 9 symptoms subscales, exploring frequency, intensity and

duration of symptoms throughout the day

– Short version: CLDEQ-8

• Ocular Surface Disease Index (ODSI): probably the most commonly

used

Clinical case history

• Signs and symptoms

– 30% of patients requiring ophthalmic assistance complain of dry eye related

symptoms

– Signs and symptoms show a weak association

– Many authors recommend a symptom based diagnosis and treatment plan

Observation of the tear film meniscus

• Normality values:

– 0.18 mm in normal eyes.

– Values <0.1 mm indicate dry eye.

– It is necessary to check the continuity and regularity of the meniscus along the
whole the eyelid, especially in the temporal zone.

Schirmer test

– Very invasive test

– Schirmer I: without anesthesia

– Schirmer II and III: with anesthesia and external stimulation of tear secretion
Osmolarity evaluation

TearLab Osmolarity System

• Dry eye: Over or equal to 308 mOsm/l or a difference of more than 8 mOsm/l between
eyes

Tear Break-up time (BUT)

• Most common technique of tear film evaluation. Normal >10 s

• Fluorescein absorption 465 - 490 nm (cobalt blue light)
• Fluorescein emission 520 - 530 nm: yellow filter for better observation Wratten #12
(cutoff point at 495 nm)
• Invasive technique: Up to 50 μl of fluorescein can be administered in an initial tear
volume of only 10 μl. It depends on the surface of the strip of paper used.
• It requires the right volume of fluorescein. Adding more to “improve staining” may
produce the opposite effect (quenching)

Non invasive break-up time (NIBUT)

• It does not employ fluorescein

• Mires of the Helmholtz keratometer or Placido disc: time until the appearance of
distortions in the image following a blink.

• Tearscope

• Based on the observation of interference patterns on the lipid layer of the tear film
(estimation of thickness of the lipid layer).

• Keratograph 5M, MYAH,

Ocular Thermography

• Temperature = Blood vessels.

• Corneal vascularization: limbus.
• Corneal center: avascular.
• Tear film = Heat conductor.
• Therefore, if tear film is OK, there will be less difference in temperature between the
central cornea and the limbus

Staining of the ocular surface

Rose bengal and Lissamine green staining

• Staining of dead cells

• Areas of surface exposure and desiccation
• Frequent at the lower areas of cornea and conjunctiva in incomplete blinking
Ocular surface exposure

Types of tear film secretion: Reflex versus Basal

DRY EYE

• Loss of homeostasis of the tear film: loss of equilibrium of the various components,
structures, etc.
• Ocular symptoms (e.g., OSDI ≥ 13)
• Tear film instability (e.g., reduced BUT < 10 s)
• Hyperosmolarity (≥ 308 mOsm/l)
• Ocular surface inflammation and damage
• Neuro-sensory abnormalities (reduced corneal sensitivity, disruption of nerve
terminals, etc.)

DRY EYE (aqueous)

• Sjögren syndrome:
 Inflammatory, autoimmune alteration of all mucous production glands, leading
to dryness of eyes, mouth...
• Normal reduction in tear production with age (ARDE, age-related dry eye):
 Reduction of 50% at 50 years
 Reduction of 75% at 80 years

DRY EYE (evaporative)

• MGD (Meibomian gland disfunction)

 Reduction in lipid expression
 Modification of lipid composition
DRY EYE (treatment)

• Change your environment conditions

• Lid hygiene in MGD
• Heat in MGD
• Lachrymal puncta occlusion
• Anti-inflammatory agents
• Tear substitutes (refer to Pharmacology course to understand types of artificial tears
and form of administration to the ocular surface, preservative-free solutions,
hyaluronic acid, etc.).

DRY EYE AND CONTACT LENSES

• Contact lens surface

– Contact lens/tear film interaction (pre-lens):

• Ionic surface attracts water in wearers with good tear film, but attracts
proteins (mainly lysozyme) in dry eye

• Blinking

• Contact lens material

– Water content:

• All contact lenses restore their water content from their environment,
i.e., tear film

• If the tear film is altered, further reduction occurs

• Contact lens material

– Silicone-hydrogel: good Dk but lower wettability

– Rigid materials: best option

– Materials of high resistance to dehydration: they dehydrate slowly, but have a

fast rehydration cycle

• 3 & 9 o’clock staining

– Typical of rigid corneal CL, depends on corneal astigmatism (worse with

against the rule), CL diameter, edge lift…

– Caused by migration of tear film towards the horizontal meniscus under the
CL, leaving areas of corneal exposure and dryness

• Desiccation of lower portion of soft lens

– Related to incomplete blinking

 – Lens dehydrates: it tries to capture water from the ocular surface to
rehydrate: it dries ocular surface

UNIT 4: CORNEAL ESTHESIOMETRY

Historical development

• Von Frey (1894): Horse hairs of different longitude.

• Cochet-Bonnet: nylon filaments of 0.12 mm or 0.08 mm in diameter and different

lengths.

• Patel and Murphy (1994): Air non-contact esthesiometer of area 0.8mm2. Patients
refer “cold” sensation rather than “touch” sensation.

• Long posterior ciliary nerves from the ophthalmic branch of the trigeminal nerve

• These nerves enter the cornea at the anterior half of the stroma and ascend towards
the surface of the epithelium. They “normally” do not have myelin (from 1.5 mm of
limbus).

• In the epithelium the nerve axons loose their Schwann cells (corneal epithelial cells
function as Schwann cells, so changes in epithelial cells, e.g., CL wear, refractive
surgery, affect nerve axons).

Types of corneal nerves

• Mechano-nociceptors: Δδ fibers that describe the intensity of the stimuli but not their
duration.
• Polymodal nociceptors: C fibers that describe intensity and duration of stimuli.
Conduction velocity higher than Δδ.
• Cold: Δδ and C.
• There are about 7000 nociceptors (pain receptors) per mm2

Corneal esthesiometry

• Apply nylon filament perpendicular to the corneal surface and increase force until
flexure of filament or patient response.

• Start with maximum length at 60 mm and progressively shorten the filament until
patient response (objective: reflex blinking or subjective: e.g., hand raised).

• When filament is shortened, by applying the same force, more pressure is transferred
to the ocular surface, as filament flexure resistance is increased.

• For each length of filament, there is a corresponding pressure value at the ocular
surface, but normally results are written as length of filament at first patient response.

• It is important to always use the same diameter of filament. Thicker filaments will have
higher flexure resistance.
Physiological variations

• Location: maximum sensitivity at the center of the cornea and reduction towards the
periphery, being lower at the top.

• Overlap of the reception fields of the nerve terminals (greater density at the center of
the cornea).

• Neuronal adaptation to the mechanical touch of the eyelid on the upper part of the
cornea.

• Age: Constant from 10 to 50 years and reduced after 50.

• Intraocular pressure: lower sensitivity with increased intraocular pressure.

• Diurnal variations: lower in the morning (IOP is also higher in the morning).

CLs and corneal esthesiometry

• Lower corneal esthesiometry with RCL (rigid corneal lenses) than soft lenses
Greater decline with years of RCL use, and slower recovery
• Important for orthokeratology (reduction of up to 50% of corneal sensitivity) and for
refractive surgery (time without CLs prior to surgery to allow at least partial corneal
recovery)

Refractive surgery and corneal esthesiometry

• Reduced sensitivity during the first 3-6 months after the intervention. Abnormal
response to pain: allodynia and hyperalgesia

Other alterations to corneal esthesiometry

• Congenital corneal anesthesia.

• Diabetes: abnormal esthesiometry values.

• Postherpetic neuralgia: esthesiometry reduced by 50%.